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Tetrodotoxin Toxicity Treatment & Management

  • Author: Theodore I Benzer, MD, PhD; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Dec 28, 2015
 

Prehospital Care

Prehospital care includes the following:

  • Provide careful attention to the airway, breathing, and circulation (ABCs).
  • Patients may require endotracheal intubation for oxygenation and airway protection in the setting of muscle weakness and respiratory failure, which can occur soon after ingestion of the tetrodotoxin.
  • Cardiac dysfunction may require IV intervention with fluids, pressors, and antiarrhythmics.
  • Severely poisoned patients may be very weak, have difficulty speaking, and be unable to provide a history; thus, clues from the environment and bystanders are very important.
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Emergency Department Care

Emergency department (ED) management includes the following:

  • Focus initially on the ABCs.
  • Secure the airway before frank respiratory failure or aspiration occurs.
  • Establish an IV early in the event acute antiarrhythmics or vasopressors are needed.
  • Remove toxin from the intestinal tract by the usual toxicologic modalities. The use of nasogastric or orogastric lavage is theoretically beneficial but can be complicated by aspiration and damage to the esophagus. The administration of activated charcoal (with or without a cathartic) is recommended for all symptomatic patients.
  • If vomiting has occurred, gastric lavage is not indicated.
  • Carefully monitor vital signs and oxygenation in the ED because patients can decompensate suddenly. Treat all alterations in vital signs aggressively.
  • Further treatment should focus on supporting cardiovascular function until the toxin is eliminated from the body.
  • Neostigmine has been used to treat acute respiratory failure from tetrodotoxin poisoning; however, a systematic review concluded that the current literature contained insufficient data to provide an evidence base for or against this practice.[7]
  • No specific antidote has been tested in humans. An animal study using monoclonal antibodies against TTX has been done.[8] Monoclonal antibodies were shown to be life saving in mice treated both before and after the ingestion of a lethal dose of TTX. Further studies are needed to document the efficacy in humans.
  • In another animal study, 4-aminopyridine (a potassium channel blocker) was used in guinea pigs intoxicated with tetrodotoxin or saxitoxin.[9] A dramatic improvement in respiratory, cardiac, and CNS status occurred after administration of the drug. No human studies of this drug for use in tetrodotoxin poisoning are in progress.
  • Admit all patients with documented or suspected puffer fish ingestion to an intensive care unit; symptoms usually develop within 6 hours but may be delayed for 12-20 hours.
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Contributor Information and Disclosures
Author

Theodore I Benzer, MD, PhD Assistant Professor in Medicine, Harvard Medical School; Director of the ED Observation Unit, Director of Toxicology, Chair of Quality and Safety, Department of Emergency Medicine, Massachusetts General Hospital

Theodore I Benzer, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Michael J Burns, MD Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center

Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

Additional Contributors

Robert L Norris, MD Professor, Department of Emergency Medicine, Stanford University Medical Center

Robert L Norris, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, International Society of Toxinology, American Medical Association, California Medical Association, Wilderness Medical Society

Disclosure: Nothing to disclose.

References
  1. Nagashima Y, Matsumoto T, Kadoyama K, Ishizaki S, Taniyama S, Takatani T, et al. Tetrodotoxin poisoning due to smooth-backed blowfish, Lagocephalus inermis and the toxicity of L. inermis caught off the Kyushu coast, Japan. Shokuhin Eiseigaku Zasshi. 2012. 53(2):85-90. [Medline].

  2. Moczydlowski EG. The molecular mystique of tetrodotoxin. Toxicon. 2013 Mar 1. 63:165-83. [Medline].

  3. Lago J, Rodríguez LP, Blanco L, Vieites JM, Cabado AG. Tetrodotoxin, an Extremely Potent Marine Neurotoxin: Distribution, Toxicity, Origin and Therapeutical Uses. Mar Drugs. 2015 Oct 19. 13 (10):6384-406. [Medline].

  4. Padera RF, Tse JY, Bellas E, Kohane DS. Tetrodotoxin for prolonged local anesthesia with minimal myotoxicity. Muscle Nerve. 2006 Dec. 34(6):747-53. [Medline].

  5. San Diego Department of Environmental Health, FDA. Tetrodotoxin poisoning associated with eating puffer fish transported from Japan--California, 1996. MMWR Morb Mortal Wkly Rep. 1996 May 17. 45(19):389-91. [Medline].

  6. Cole JB, Heegaard WG, Deeds JR, McGrath SC, Handy SM, Centers for Disease Control and Prevention (CDC). Tetrodotoxin poisoning outbreak from imported dried puffer fish--Minneapolis, Minnesota, 2014. MMWR Morb Mortal Wkly Rep. 2015 Jan 2. 63 (51):1222-5. [Medline]. [Full Text].

  7. Liu SH, Tseng CY, Lin CC. Is neostigmine effective in severe pufferfish-associated tetrodotoxin poisoning?. Clin Toxicol (Phila). 2015 Jan. 53 (1):13-21. [Medline].

  8. Rivera VR, Poli MA, Bignami GS. Prophylaxis and treatment with a monoclonal antibody of tetrodotoxin poisoning in mice. Toxicon. 1995 Sep. 33(9):1231-7. [Medline].

  9. Chang FC, Spriggs DL, Benton BJ, et al. 4-Aminopyridine reverses saxitoxin (STX)- and tetrodotoxin (TTX)-induced cardiorespiratory depression in chronically instrumented guinea pigs. Fundam Appl Toxicol. 1997 Jul. 38(1):75-88. [Medline].

  10. Ahasan HA, Mamun AA, Karim SR, et al. Paralytic complications of puffer fish (tetrodotoxin) poisoning. Singapore Med J. 2004 Feb. 45(2):73-4. [Medline].

  11. U.S. Food and Drug Administration. Advisory on Puffer Fish. FDA. Available at vm.cfsan.fda.gov/~mow/chap39.html. January 17, 2014; Accessed: December 28, 2015.

  12. How CK, Chern CH, Huang YC, et al. Tetrodotoxin poisoning. Am J Emerg Med. 2003 Jan. 21(1):51-4. [Medline].

  13. Lange WR. Puffer fish poisoning. Am Fam Physician. 1990 Oct. 42(4):1029-33. [Medline].

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Puffer fish.
Chemical structure of tetrodotoxin.
 
 
 
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