Prehospital Care
Initiate supportive care, including intravenous (IV) fluids and seizure control with pyridoxine and benzodiazepines.
Emergency Department Care
Initiate supportive care and decontamination as follows:
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ABCs (airway, breathing, circulation) and coma protocols
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Correction of fluid and electrolyte imbalances
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Antiemetics (if needed)
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Dextrose (if needed)
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Consideration of activated charcoal (although with typical delayed presentation of poisoning by Gyromitra species, benefit from this intervention is unlikely)
Administer intravenous fluids to maintain brisk urine output and prevent renal damage from hemolysis.
Treat seizures with both pyridoxine (vitamin B6) and benzodiazepines. [13] Although limited cases exist in which pyridoxine was used as an antidote for gyromitrin-containing mushroom poisoning, pyridoxine is the antidote of choice for isoniazid-induced seizures, which are due to hydrazine and hydrazone metabolites of isoniazid interfering with GABA synthesis.
Phenobarbital has been demonstrated to increase metabolism of hydrazines to toxic metabolites and should be avoided. Phenobarbital metabolism may be decreased if liver failure from gyromitrin toxicity has occurred.
Treatment of methemoglobinemia involves oxygen and methylene blue. Methemoglobin cannot transport oxygen; functional anemia results. Modest levels of methemoglobinemia may be tolerated with supportive care. With higher levels (eg, >20%) and associated symptoms, such as mental status changes, dyspnea, ischemic chest pain, or acidosis, consider treatment with methylene blue.
Anemia due to hemolysis may require blood transfusion.
Theoretically, folinic acid may be beneficial. Hydrazines inhibit metabolism of folic acid to tetrahydrofolate.
Admit all symptomatic patients in whom gyromitrin poisoning is suspected for further management and monitoring. Monitor patients for dehydration, neurologic toxicity, and liver or kidney failure. Consider intensive care unit admission for patients with seizures, coma, severe methemoglobinemia, or hemolysis.
Patients with gyromitrin ingestion who are asymptomatic 8 hours after ingestion and are without clinical or laboratory signs of toxicity may be considered for discharge. Early follow-up care for re-evaluation must be in place at the time of discharge. Instruct patients to return immediately if they become symptomatic. Instruct patients to keep themselves well hydrated.
Consultations
Consultation with a regional poison control center and toxicologist may be helpful. They may assist in contacting a mycologist for mushroom identification. Obtain a gastroenterology consultation if evidence of liver dysfunction is present.
