Tetrodotoxin Toxicity Treatment & Management

Updated: Aug 09, 2021
  • Author: Theodore I Benzer, MD, PhD; Chief Editor: Asim Tarabar, MD  more...
  • Print

Medical Care

Prehospital Care

Prevent others from eating until the source of tetrodotoxin exposure can be ascertained, in order to avoid more casualties. 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. 

Provide careful attention to the airway, breathing, and circulation (ABCs). Do not induce vomiting (emesis). 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.

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. Carefully monitor vital signs and oxygenation in the ED because patients can decompensate suddenly. Treat all alterations in vital signs aggressively. The administration of activated charcoal (with or without a cathartic) is recommended for all symptomatic patients.

If the patient/victim can be rapidly transported to an emergency department, gastric lavage may be considered after the airway has been secured. Gastric lavage is recommended only after ingestion of a life-threatening amount of tetrodotoxin and only if it can be done shortly after ingestion (generally within 1 hour). The risk of worsening injury to the lining of the gastrointestinal (GI) tract must be considered. [2] If vomiting has occurred, gastric lavage is not indicated.

Further treatment should focus on supporting cardiovascular function until the toxin is eliminated from the body. Heart function should be monitored, and the patient/victim should be evaluated for hypotension, dysrhythmias, and respiratory depression. The patient should be evaluated for hypoglycemia, electrolyte disturbances, and hypoxia. [2]

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.

Neostigmine has been used to treat acute respiratory failure from tetrodotoxin poisoning; however, a systematic review concluded that the literature contained insufficient data to provide an evidence base for or against this practice. [15]