Decision No. 354/2002/QD-BYT on issuing guidelines for diagnosing, treating, and preventing pufferfish poisoning.

Pursuant to …;

Regarding the issuance of guidelines for diagnosis, treatment, and prevention of pufferfish poisoning. Cá nóc.

THE MINISTER OF HEALTH

Pursuant to Decree 68/CP dated October 11, 1993 of the Government stipulating the functions, tasks, powers, and organizational structure of the Ministry of Health;

Upon the proposal of the Director of the Treatment Department and the Director of the Food Safety and Quality Control Bureau; 

DECISION:

Article 1. Now hereby promulgates with this Decision guidelines for diagnosis, treatment, and prevention of pufferfish poisoning.

Article 2. The guidelines for diagnosis, treatment, and prevention of pufferfish poisoning shall be applied in all state-owned, semi-state-owned, private, and foreign-invested medical facilities.

Article 3. This Decision shall take effect fifteen days from the date of issuance. All previous regulations that conflict with this Decision are hereby abolished.

Article 4. The Heads of the Office, Inspectorate, Treatment Department, other Departments of the Ministry of Health, Food Safety and Quality Control Bureau, Directors of provincial health services, directors of hospitals and institutes under the Ministry of Health, heads of health departments of various sectors, and heads of state-owned, private, semi-state-owned, and foreign-invested medical facilities are responsible for implementing this Decision./.

GUIDELINES

DIAGNOSIS, TREATMENT AND PREVENTION OF PUFFERFISH POISONING

(Annexed to Decision No. 354/2002/QĐ-BYT dated February 6, 2002 of the Minister of Health).

Pufferfish poisoning from consumption of pufferfish is currently a pressing issue. The number of people poisoned by consuming pufferfish is increasing, with a high mortality rate (up to 60%). Pufferfish poisoning most commonly occurs in central provinces such as Ha Tinh, Quang Binh, Quang Tri to Phu Yen, Qui Nhon, Quang Ngai... even in Hanoi and some non-coastal provinces due to consumption of dried and frozen pufferfish... To protect public health and lives, the Ministry of Health provides guidelines for diagnosis, treatment, and prevention of pufferfish poisoning as follows:

I. OVERVIEW

1- Pufferfish (also known as toadfish, sea goby, chicken thigh fish) with hundreds of species worldwide: called Pufferfish in the United States, Fugu fish in Japan... In Vietnam, there are nearly 70 different species.

- Pufferfish live more in saltwater than freshwater.

- The type of pufferfish that people usually eat has a body length of 4-40 cm, firm, short scales, large head, protruding eyes, white meat. The poison is concentrated in the skin, intestines, liver, abdominal muscles, testes, and especially in the eggs, thus female pufferfish are more toxic than males, particularly during spawning season. This poison is called TETRODOTOXIN (TTX).

2- Tetradotoxin (TTX) C11 H17 O8 N3 mentioned above: is a neurotoxin, extremely toxic, causing high mortality, this substance is also isolated from certain bacteria: Epiphytic bacterium, vibrio species, pseudomonas species (Yasumoto 1987), in the skin and organs of saury, salamander, blue-ringed octopus...

- Tetradotoxin is not a protein, soluble in water, not destroyed by heat, cooking, drying, or freezing, the toxin remains intact (it may be decomposed in alkaline or strong acidic environments).

- Tetradotoxin can be detected by biological testing with mice or fluorescence spectroscopy, thin-layer chromatography, high-pressure liquid chromatography.

3- Mechanism of TTX toxicity: inhibits sodium and potassium ion channel pump activity through the cell membrane of neuromuscular tissue, stops nerve-muscle transmission causing skeletal muscle paralysis, respiratory muscle paralysis...

- After consuming pufferfish containing TTX, the toxin is rapidly absorbed through the gastrointestinal tract within 5-15 minutes. The peak level of TTX in the blood is reached at 20 minutes and excreted via urine after 30 minutes to 3-4 hours. Consuming 4-7 grams of pufferfish containing TTX will cause symptoms of poisoning. According to the US Food and Drug Administration, the lethal dose for humans is 1-2 mg.

4- Cause of death from pufferfish poisoning is respiratory muscle paralysis and hypotension.

II- DIAGNOSIS

1- Epidemiology: Consumption of pufferfish (within 5 minutes to 3-4 hours prior).

2- Symptoms:

2.1- Mild symptoms: Appear early after consuming fresh, dried, or salted pufferfish within 5-10 minutes, later up to 3 hours:

- Tongue, mouth, lip, face numbness, finger and palm, toe and foot numbness.

- Headache, sweating.

- Abdominal pain, nausea, vomiting, increased salivation.

2.2- Severe symptoms:

- Speech disorder, loss of coordination, fatigue.

- Muscle weakness, progressive paralysis, respiratory failure, cyanosis, cessation of breathing, convulsions.

- Slow pulse, low blood pressure, coma.

Hypertension due to oxygen deficiency or pre-existing hypertension may occur.

3- Laboratory tests: Determine tetradotoxin (if conditions permit).

4- Differential diagnosis: Cases of allergic reactions or anaphylactic shock from consuming any marine fish or other food. These cases have the following symptoms: Asthmatic breathing difficulty, rapid pulse, low blood pressure, digestive disorders, red itchy skin immediately after eating.

III- GUIDELINES FOR TREATMENT

1- At the site of consumption:

As soon as the first signs appear: numb lips, hands (patient still conscious).

1.1- Induce vomiting, prevent choking (place patient in lateral position, head down).

1.2- Activated charcoal (powder or suspension):

Adults: Drink 30g mixed with 250 ml of clean water.

Children aged 1-12 years: Drink 25g mixed with 100-200 ml of clean water.

Infants under 1 year old: Drink 1g/kg mixed with 50 ml of clean water.

For adults and children over 12 years old, drink 1 bottle of activated charcoal suspension 30 ml.

Transport the patient to the hospital.

Drinking activated charcoal within 1 hour after consuming pufferfish is highly effective in removing toxins, contraindicated if the patient is already unconscious or disoriented.

1.3- If the patient exhibits altered consciousness, coma, weak or stopped breathing, cyanosis: perform mouth-to-mouth resuscitation or mouth-to-nose resuscitation or use a two-way Mayoy cannula.

2- On the ambulance:

2.1- Ensure respiration:

- Place the patient in a lateral position, head down to prevent choking.

- Administer oxygen and manual resuscitation bag (ambu) if the patient is cyanotic and has stopped breathing, intubate and use a bag valve mask (if available) to prevent choking.

2.2- Ensure hemodynamics:

- Maintain blood pressure above 90 mmHg: administer 0.9% Sodium Chloride or 5% Glucose intravenous fluid.

- If heart rate is below 60 beats per minute: inject Atropine sulfate 0.25 mg/ml intravenously, dosage 0.5-1.5 mg, repeat every 5-10 minutes until heart rate exceeds 70 beats per minute.

- If there is atrioventricular block: Adults: inject Atropine sulfate 0.25 mg/ml intravenously, repeat every 5 minutes. Children aged 1-12 years: inject 0.02 mg/kg intravenously, repeat every 5 minutes, total maximum dose 1 mg. Children over 12 years old: total dose 2 mg.

- If blood pressure is low and intravenous fluid administration does not improve blood pressure: Continue administering Dopamine hydrochloride 40 mg/ml in a 5 ml vial + 250 ml of 0.9% NaCl or 5% glucose at a dose of 3-10 mg/kg/min, or combine with norepinephrine (Noradrenaline) at a dose of 0.1-0.3 mg/kg/min to maintain blood pressure ≥ 90 mmHg.

- If blood pressure increases: Ensure oxygenation and ventilation, sedatives. If there is a sudden increase in blood pressure, it must be lowered using nifedipine (10 mg capsule) placed under the tongue with 5 drops (5 mg).

2.3- Absorbent drugs for poisoning.

- Activated charcoal 30g + 250 ml of clean water, stir well and drink all at once (if not yet consumed and the patient is conscious). If the patient has altered consciousness, a gastric tube must be inserted before administering activated charcoal.

- Note: If the patient has seizures, before inserting a gastric tube to administer activated charcoal, inject diazepam (Seduxen 5 mg/1 ml vial, 10 mg/2 ml vial, Valium 10 mg/2 ml vial) intramuscularly at a dose of 5 mg to 10 mg.

3- In the emergency and antidote department:

The main focus is on resuscitation of respiratory and circulatory functions, ensuring vital functions.

3.1- If the patient arrives early within 3 hours, handle as follows:

3.1.1- Stomach lavage: preferably with a 2% or 1.4% alkaline solution, each time injecting 150 - 200 ml or 10 ml/kg in children < 5 years old, warm solution. The amount extracted should be equivalent to the amount injected, totaling 5-10 liters.

If signs of altered consciousness, cyanosis, slow breathing appear, intubate and inflate the balloon before performing stomach lavage.

3.1.2- Activated charcoal 30g mixed with 250 ml of clean water, children aged 1-12 years drink 25g mixed with 100-200 ml of water, children < 1 year old drink 1g/kg mixed with 50 ml of water.

3.1.3- Sorbitol 40g, if the patient does not have diarrhea. Children < 1 year old should not be given Sorbitol because they are prone to vomiting and electrolyte imbalance. Alternatively, use 30 ml of milk-activated charcoal.

3.2- If the patient arrives late after 3 hours, handle as follows:

3.2.1- Resuscitate respiratory function, ensure hemodynamic stability through fluid administration.

3.2.2- Continuously monitor vital functions for the first 24 hours.

3.3- Ensure ventilation:

3.3.1- Oxygen inhalation via nasal cannula or mask.

3.3.2- If the patient exhibits respiratory failure (cyanosis, respiratory muscle weakness, apnea, coma), intubate and use mechanical ventilation, duration of ventilation from 4-20 hours.

3.4- Maintain blood pressure:

Administer 0.9% NaCl solution, 5% glucose.

- If heart rate is slow < 60 beats/min: Atropine (as above), prepare defibrillator standby.

- If heart rate is fast, arrhythmia: Xylocaine, prepare defibrillator standby.

- If blood pressure continues to drop < 90 mmHg: administer dopamine 3-5 mg/kg/min or adrenaline, combined with dobutamine or norepinephrine (noradrenaline).

3.5- Acid-base balance: adjust based on clinical and laboratory findings (blood gases, electrolytes).

3.6- Electrolyte balance: Based on electrolyte test results.

If the patient survives > 20 hours, the chances of survival are high.

- There is currently no specific antidote for tetrodotoxin.

- Anticholinesterase drugs: Edrophonium intravenously slowly, or neostigmine intramuscularly or subcutaneously, may be used in patients with mild respiratory paralysis who arrive early, however, these cannot replace respiratory resuscitation methods (this drug has only been applied experimentally on animals).

IV- PREVENTION OF Fugu POISONING

1- The best measure is not to eat fugu fish.

2- When eating suspected fugu fish (with symptoms such as numbness of the lips and hands), induce vomiting and take antidotes immediately (activated charcoal and sorbitol) while rushing to the hospital's emergency and antidote department for treatment.

3- Fishermen should have a first aid kit including: milk-activated charcoal, two-way Mayo bag.

4- Do not dry fugu fish to make regular fish, do not make fugu fish paste or powder for sale./.