Tetrodotoxin Toxicity Treatment & Management

Updated: May 24, 2018
  • Author: Theodore I Benzer, MD, PhD; Chief Editor: Asim Tarabar, MD  more...
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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.


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. [9]

  • No specific antidote has been tested in humans. An animal study using monoclonal antibodies against TTX has been done. [10] 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. [11] 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.