Tetrodotoxin Toxicity Treatment & Management

  • Author: Theodore I Benzer, MD, PhD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Apr 14, 2011
 

Prehospital Care

  • Provide prehospital care with 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

  • 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.
  • No specific antidote has been tested in humans. An animal study using monoclonal antibodies against TTX has been done.[3] 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.[4] 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.
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Contributor Information and Disclosures
Author

Theodore I Benzer, MD, PhD  Assistant Professor in Medicine, Harvard Medical School; Director of Clinical Operations, 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 and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Robert L Norris, MD  Professor, Department of Surgery; Chief, Division of Emergency Medicine, Stanford University Medical Center

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

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart & 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, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and 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.

References

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

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

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

  4. 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. Jul 1997;38(1):75-88. [Medline].

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

  6. FDA/CFSAN resources page. Pufferfish poisoning. Food and Drug Administration Web site. Available at: http://vm.cfsan.fda.gov/~mow/chap39.html. Accessed January 20, 2005. [Full Text].

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

  8. Karalliedde L. Animal toxins. Br J Anaesth. Mar 1995;74(3):319-27. [Medline].

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

  10. Mills AR, Passmore R. Pelagic paralysis. Lancet. Jan 23 1988;1(8578):161-4. [Medline].

  11. Sims JK, Ostman DC. Pufferfish poisoning: emergency diagnosis and management of mild human tetrodotoxication. Ann Emerg Med. Sep 1986;15(9):1094-8. [Medline].

  12. Sun KO. Management of puffer fish poisoning. Br J Anaesth. Oct 1995;75(4):500. [Medline].

  13. Xu QH, Zhao XN, Wei CH, Rong KT. Immunologic protection of anti-tetrodotoxin vaccines against lethal activities of oral tetrodotoxin challenge in mice. Int Immunopharmacol. Jul 2005;5(7-8):1213-24. [Medline].

 
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Puffer fish.
Chemical structure of tetrodotoxin.
 
 
 
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