DECISION

PROMULGATING THE WRITTEN GUIDANCE ON DIAGNOSIS, HANDLING AND PREVENTION OF PUFFER POISONING

THE HEAL MINISTER

Pursuant to the Government’s Decree No.68/CP of October 11, 1993 defining the functions, tasks, powers and organizational apparatus of the Health Ministry;
At the proposals of the directors of the Therapy Department and of the Department for Food Quality, Hygiene and Safety Control,

DECIDES:

Article 1.- To promulgate together with this Decision the written "Guidance on diagnosis, handling and prevention of puffer poisoning."

Article 2.- The written "Guidance on diagnosis, handling and prevention of puffer poisoning" shall apply to all State-run, semi-public, people-founded, private and foreign-invested medical establishments.

Article 3.- This Decision takes effect 15 days after its signing for promulgation. The previous regulations contrary to the provisions of this Decision shall all be annulled.

Article 4.- The office director, the chief inspector, the Therapy Department director, the directors of the Departments of the Health Ministry, the director of the Department for Food Quality, Hygiene and Safety Control, the directors of the provincial/municipal Health Services, the managers of hospitals and institutes with hospital beds under the Health Ministry, branch medical chiefs, heads of State-run, private, people-founded and foreign-invested medical establishments shall have to implement this Decision.

GUIDANCE

ON DIAGNOSIS, HANDLING AND PREVENTION OF PUFFER POISONING
(Issued together with the Health Minister’s Decision No. 354/QD-BYT of February 6, 2002)

The poisoning through eating puffer is being a burning issue now. The number of people poisoned through eating puffer fish has risen with high mortality rate (60%). Puffer poisoning has usually occurred in central provinces such as Ha Tinh, Quang Binh, Quang Tri, Phu Yen, Quy Nhon, Quang Ngai,… and even in Hanoi and non-coastal provinces, due to eating of dried and frozen puffer... In order to protect the people’s health and lives, the Health Ministry hereby guides the diagnosis, handling and prevention of puffer poisoning as follows:

I. GENERAL INFORMATION

1. Puffer fish (also called toadfish, sculpin, chicken thigh fish in some places) exist in hundreds of species in the world, called puffer fish in the United States, Fugu fish in Japan... There are in Vietnam nearly 70 different species.

- Puffer fish live in salt water more than in fresh water.

- The poisonous puffer fish often eaten by people have the body of 4- 40 cm long, firm, short scales, big heads, protruding eyes and white meat. The fish’s poison concentrates in their skin, intestine, liver, abdominal muscle, spermarium and largely in their eggs, hence, female puffers are more poisonous than male puffers, particularly in the egg-laying season. That poison is called TETRODOTOXIN (TTX).

2. Tetrodotoxin (TTX) C11H17O8N3 is a neurotoxin, which is extremely noxious, causing high mortality and may be also isolated from some types of bacteria such as epiphytic bacterium, vibrio species, pseudomonas species (Yasumoto 1987), found on skin and viscera of the smooth newt, salamander, green-circle octopus.

- Tetrodotixin is not proteine, dissolves in water, is not disintegrated by heat; when cooked or sun-dried, the toxin still exists (which can be disintegrated in the alkaline environment or strong acid).

- Tetrodotoxin is detected through biological test on mouse or by the method of fluorescent spectrum, thin-layer chromatography, high-pressure liquid chromatography.

3. TTX poisoning mechanism: suppressing Na+ and K+ channel pump through myo-neurocyte membrane, stopping myoneurocyte transmission, causing myo-osseous palsy, myo-respiratory lapsy.

- After eating puffer with TTX, this toxin is quickly absorbed through intestines and stomach within 5- 15 minutes. TTX will reach its peak in blood within 20 minutes and discharge through urea after 30 minutes, lasting for up to 3-4 hours. Eating puffer with 4-7 g of TTX will result in poisoning symtoms. According to the US drug and food control agency, a dose of 1-2 mg will cause human death.

4. The cause of death due to puffer poisoning is myorespiratory lapsy and hypotention.

II. DIAGNOSIS

1 Epidemiology: Eating puffer (5 minutes up to 3-4 hours before).

2. Symptoms

2.1. Light symptoms: appearing 5-10 minutes or possibly up to 3 hours after eating puffer (fresh, dried, pickled):

- Getting numbed in tongue, mouth, lips, face, fingers and hands, toes and feet.

- Getting headache, perspirating.

- Getting stomachache, feeling nausea and vomiting, accelerated salivation.

2.2. Serious symptoms:

- Rash talking, loss of coordination, feeling exhausted.

- Getting vasculo-weak, myoprogressive lapsy, respiratory failure, getting purple, breath stoppage, convulsion.

- Slow pulse, lowering blood pressure and getting comatose.

Possible occurrence: Higher blood pressure due to oxygen inadequacy or in high blood- pressure patients.

3. Test: Determining Tetrodotoxine element (if conditions permit).

4. Splitting diagnosis: For cases of allergy or reactive shock from eating any kind of sea fish or other sea food. These cases show the following symptoms: Getting difficulty to breath like suffering from asthma, quicker pulse, lowering blood pressure, digestive disorder, getting itchy red skin after eating.

III. TREATMENT GUIDANCE

1. At places where puffer are eaten:

Immediately after the first symptoms: numbed lips, numbed hands (victims are still conscious):

1.1. Making the patients vomit, avoiding chokes for patients (letting them lie on either side with low heads).

1.2. Active coal (flour or powder):

Adults: Orally taking 30g stirred slowly in 250 ml of clean water.

Children aged 1-12: Orally taking 12 g stirred slowly in 100-200 ml of clean water.

Under 1-year children: Orally taking 1g/kg, stirred slowly in 50 ml of clean water.

Adults and children of over 12 years old may orally take one 30 ml-bottle of active coal powder.

Taking the patients to hospitals.

Orally taking active coal within 1 hour after eating puffer will be highly effective, doing away with the toxin, contra-indication when the patients get coma or sense disorder.

1.3. If the patients get the sense disorder, coma, breathing decline or cessation, turn purple: giving resuscitation from mouth to mouth, mouth to nose or through two-way Mayo canun.

2. On the ambulance cars:

2.1. To ensure respiration:

- Letting the patient lie on either side with low heads to avoid choke.

- Giving oxygen breathing and ambu if the patients get purple and stop breathing, inserting windpipe, pumping chock vesticle (if conditions permit) to avoid choke.

2.2. To ensure blood circulation:

- Maintaining blood pressure at over 90 mmHg: Transfusing the solution of 0.9%- sodium chlorate or 5% glucose.

- If the heartbeat is recorded at under 60 beat/minute: Atropine sulfate, ampoule of 0.25 mg/ml, use dose of 0.5-1.5 mg, intravenous injection repeated at every 5-10 minutes, maintaining the heartbeat at over 70 beat/minute.

- In case of sans-systole: Adults: Intravenous injection with atropine sulfate ampoule of 0.25 mg/ml, repeated at every 5 minutes. Children aged between 1 and 12 years, intravenous injection, 0.02 mg/kg, repeated at every 5 minutes, the total dose of 1 mg. Children of over 12 years old, the total dose shall be 2 mg.

- In case of lowering blood pressure in spite of solution transfusion: Continuing transfusing dopamine hydrochloride 40 mg/ml, ampoule of 5 ml + 250 NaCl 0.9% or 5% glocose with a dose of 3-10 mg/kg/minute, or in combination with norepinephrin (noradrenalin), a dose of 0.1-0.3 mg/kg/minute in order to maintain HA ≥90 mmHg.

- If the blood pressure rises: Ensuring oxygen breathing, aeration, calmatives. If the blood pressure rises exacerbatedly, it must be lowered with nifedipin (capsule of 10 mg), kept under tongue 5 drops (5 mg).

2.3. Toxin absorbents:

- Active coal 30 g + 250 ml of clean water, stirring slowly and drinking once (if having not yet orally taken and the patients are still conscious. If the patients get sense disorder, the stomach probe shall be placed before pumping the active coal.

- Attention: If patients get convulsion, before the stomach probe is placed for active coal pumping, intramuscular injection of diazepam (seduxen ampoule of 5 mg/1 ml, ampoule of 10 mg/2 ml, valium ampoule of 10 mg/2 ml), use dose of between 5 mg and 10 mg.

3. At the Emergency and Anti-Poisoning Departments

Mainly to revive respiration, circulation, ensuring the revival of function.

3.1. If patients are hospitalized within 3 hours after getting poisoned, the treatment shall be as follows:

3.1.1. Cleaning stomach: It is best to use sodium solution of 2% or 1.4%, 150-200 ml of solution are pumped each time, or 10 ml/kg for children of under 5 years old, warm solution, the volume of pump-in solution is equivalent to the volume of solution taken out, with the total of 5-10 liters.

In cases where appear signs of sense disorder, purple, slow breathing, placing windpipe and pumping chock vesicle before cleaning the stomach.

3.1.2. Active coal with 30 g mixed in 250 ml of clean water, children aged 1-12 orally take 20 g mixed with 100-200 ml of water, children of under 1 year old, 1g/1kg mixed with 50 ml of water.

3.1.3. Sorbitol 40 g, if patients do not get diarrhoea. Children of under 1 year old, no sorbitol shall be given as it may easily cause vomiting, electrolysis water disorder. Or replacing it with 01 bottle of active coal powder of 30 ml.

3.2. If the patients are hospitalized after getting poisoned for more than 3 hours, the treatment shall be as follows:

3.2.1. Giving respiratory revival, ensuring blood circulation mainly through solution transfusion.

3.2.2. Monitoring surviving function incessantly within the first 24 hours.

3.3. Ensuring aeration:

3.3.1. Oxygen breathing through nose or mask sonde.

3.3.2. If patients get respiratory failure (purple, respiratory palsy, breathing cessation, coma) placing inside the windpipe device for mechanical breathing for 4-20 hours.

3.4. Maintaining blood pressure:

Fluid transfusion: 0.9% sodium chloride, 5% glucose

- If the heart beat is <60 beats/minute: Atropine (the above dose), placing devices to create pending beats.

- If the heart beat is fast, in disorder: xylocain, placing devices to create pending beats.

- If blood pressure continues to drop to under 90 mmHg: Transfusing dopamin of 3-5 g/kg/minute or adrenaline in combination with dobutamin or norepinephrine (Noradrenaline).

3.5. Acid- alkali balancing: Readjusting according to clinical symptoms and tests (gaseous substance in blood, electrolysis).

3.6. Electrolytic balancing: According to electrolytic test.

If patients can live for > 20 hours, the survival rate is high.

- No specific effective antidote for tetrodotoxin.

- Cholinesteraza antifermment: edrophonium, slow intravenous injection, or neostigmine, intravascular or under-skin injection, which can be used on patients with light respiratory palsy and early arrival, but cannot replace respiratory reviving means (this drug is only tested on animals)

IV. PUFFER POISONING PREVENTION

1. The best way is not to eat puffer.

2. When eating fish suspected to be puffer (with symptoms of numbed lips, numbed hands): causing emisis and immediately taking antidote orally (active coal and sorbitol) and quickly going to hospitals- Emergency and Anti-Poisoning Departments) for treatment.

3. For offshore fishermen, their families would prepare first-aid kits, each including active coal powder, two-way Mayo canun.

4. Not to sun-dry puffer for use as common fishes, not to make puffer barbecue, puffer powder for sale.