eMedicine Specialties > Emergency Medicine > Toxicology
Toxicity, Tetrodotoxin: Treatment & Medication
Updated: Oct 2, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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.
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.
Medication
No drug has been shown to reverse the effects of tetrodotoxin poisoning. Treatment is symptomatic. Specific drug efficacy has only been documented anecdotally.
Anticholinesterase drugs (eg, neostigmine) have been proposed as a treatment option but have not been tested adequately.
GI decontaminants
Empirically used to minimize systemic absorption of the toxin. May only benefit if administered within 1-2 h of ingestion.
Activated charcoal (Liqui-Char)
Emergency treatment in poisoning caused by drugs and chemicals. Network of pores present in activated charcoal adsorbs 100-1000 mg of drug per gram of charcoal. Does not dissolve in water.
For maximum effect, administer within 30 min of ingesting poison. Generally mixed and given with a cathartic (eg, 70% sorbitol), except in young pediatric patients in whom electrolyte disturbances may be of concern.
Adult
1 g/kg (typically 50 g) PO; may repeat once at one-half original dose (0.5 g/kg) if large ingestion is suspected
Pediatric
<2 years: Cathartic not recommended
Administer as in adults (usually 15-30 g)
May inactivate ipecac syrup if used concomitantly; effectiveness of other medications decreases with coadministration; do not mix with sherbet, milk, or ice cream (decreases adsorptive properties)
Documented hypersensitivity; poisoning or overdose of mineral acids and alkalies; unprotected airway with absent gag reflex
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor for presence of bowel sounds to minimize risk of charcoal ileus; not very effective in poisonings of ethanol, methanol, and iron salts; induce emesis before administration; after emesis with ipecac syrup, patient may not tolerate activated charcoal for 1-2 h; can administer in early stages of gastric lavage; without sorbitol, gastric lavage returns are black
Cholinergic agents
May be useful in reversing the neurological complications of the venom; however, they should not be a substitute for airway management.
Neostigmine (Prostigmin)
Although not clinically proven, neostigmine has been used anecdotally to restore motor strength. Inhibits destruction of acetylcholine by acetylcholinesterase, which facilitates transmission of impulses across myoneural junction.
Repeat doses based on patient's response.
Adult
0.5 mg IM
Pediatric
0.02 mg/kg IV or 0.04 mg/kg IM
Atropine antagonizes muscarinic effects; effects of neuromuscular agents are increased
Documented hypersensitivity; GI or GU obstruction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in epilepsy, asthma, bradycardia, hyperthyroidism, cardiac arrhythmias, or peptic ulcer; anticholinesterase insensitivity can develop for brief or prolonged periods
More on Toxicity, Tetrodotoxin |
| Overview: Toxicity, Tetrodotoxin |
| Differential Diagnoses & Workup: Toxicity, Tetrodotoxin |
 Treatment & Medication: Toxicity, Tetrodotoxin |
| Follow-up: Toxicity, Tetrodotoxin |
| Multimedia: Toxicity, Tetrodotoxin |
| References |
| « Previous Page | Next Page » |
References
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].
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].
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].
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].
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].
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].
How CK, Chern CH, Huang YC, et al. Tetrodotoxin poisoning. Am J Emerg Med. Jan 2003;21(1):51-4. [Medline].
Karalliedde L. Animal toxins. Br J Anaesth. Mar 1995;74(3):319-27. [Medline].
Lange WR. Puffer fish poisoning. Am Fam Physician. Oct 1990;42(4):1029-33. [Medline].
Mills AR, Passmore R. Pelagic paralysis. Lancet. Jan 23 1988;1(8578):161-4. [Medline].
Sims JK, Ostman DC. Pufferfish poisoning: emergency diagnosis and management of mild human tetrodotoxication. Ann Emerg Med. Sep 1986;15(9):1094-8. [Medline].
Sun KO. Management of puffer fish poisoning. Br J Anaesth. Oct 1995;75(4):500. [Medline].
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].
Further Reading
Keywords
TTX, Japanese puffer fish, fugu, tetrodotoxin, tetrodotoxin toxicity, tetrodotoxin exposure, tetrodotoxin poisoning, tetrodotoxin ingestion, neurotoxin
