He's having a stroke!!!

[ERDoc]

The owner tells you that they ordered edamame, tuna-goma-ae and sunomono for appetizers. The main course consisted of hamachi sashimi, tekka maki, spicy tuna roll, fugu and california roll. For drinks they had sodas and some sake.

The pt denies any pain. He is not orthostatic. 12-lead is sinus with a rate consistent with the pulse. As you are sitting with him, he starts to tell you that he feels like he is having some trouble breathing.

[EMS-Cat]

BINGO! Fugu / Puffer Fish it is!

From a BLS level, this is still a dispatch ALS ASAP to the scene & support ABC's call. Also, if ALS is a ways out, be prepared to transport himself yourself if local protocols allow [there are places around here were ALS can be delayed up to 20 min. or so, but the nearest ER is 10 Min. away]. Also consider LifeFlight if needed. I'd package him and get him out to the rig so I've got a stable working area and if ALS is delayed, I'm one step up [And there's no need to have him fold up in the shop if you can safely move him]. Get ready to BVM the guy and manage his airway.

And *VERY* large doses of emotional support. If it is fugu poisoning, he's going to feel like he's been hit with sux/Pavuloned/insert paralytic of choice and he'll still be totally aware of everything and every word going on around him.

But, as always, follow the protocols dictated in your area, not mine.

And it's time for the restaurant to find a new chef...

[vs-eh?]

http://en.wikipedia.org/wiki/Pufferfish

http://en.wikipedia.org/wiki/Sashimi_fugu

http://en.wikipedia.org/wiki/Tetrodotoxin

The skin and certain internal organs of many Tetraodontidae are highly toxic to humans, but nevertheless the meat of some species is considered a delicacy in Japan (as fugu) and Korea (as boh-guh).

Tetrodotoxin (anhydrotetrodotoxin 4-epitetrodotoxin, tetrodonic acid, TTX) is a potent neurotoxin with no known antidote, which blocks action potentials in nerves by binding to the pores of the voltage-gated, fast sodium channels in nerve cell membranes. The binding site of this toxin is located at the pore opening of the voltage-gated Na+ channel

Puffers poisoning usually results from consumption of incorrectly prepared puffers soup, "chiri" or occasionally from raw puffers meat, "sashimi fugu." While chiri is much more likely to cause death, sashimi fugu often causes intoxication, light-headedness, and numbness of the lips, and is often eaten for this reason. Puffers (tetrodotoxin) poisoning will cause deadening of the tongue and lips, dizziness, and vomiting. These are followed by numbness and prickling over the body, rapid heart rate, decreased blood pressure, and muscle paralysis. Death results from suffocation as diaphragm muscles are paralyzed. Patients who live longer than 24 hours are expected to survive, although the poison can cause comas lasting several days.

Treatment consists of supportive care and intestinal decontamination with gastric lavage and activated charcoal. Case reports suggest that anticholinesterases such as edrophonium may be effective.

All of the above is referenced. And yes, I'm ashamed I used Wikipedia...

Nature's paralytic...since death essentially results from diaphragm paralysis, prep a tube and get all your airway/breathing stuff together, treat accordingly. This guy appears that he is quite sensitive/got a rather large dose. Patch and ask if the doctor wants activated charcoal given (if you carry it). I doubt anyone carries Acetylcholinesterase inhibitor's on their ambulance.

I would also be weary as to why he is the only one experiencing these signs and symptoms. Caution the other guests accordingly...

EDIT - Foiled again!

[irlemt]

BLS level reply. FOGU prepared even well can produce those symptoms or so I'm told. Fogu is pufferfish. Transport and inform ER of suspicions.

[Just Plain Ruff]

as a matter of fact Irlemt, some japanese businessmen order Fugu for that tingling feeling. They use it as a badge of manhood that they eat fugu and survive. I believe that anytime you eat fugu you will get a minimal feeling of numbness.

here's a great link I found.

http://www.cfsan.fda.gov/~mow/chap39.html

Everything you wanted to know about Fugu and pufferfish.

ALS response definately warranted. Prepare to intubate and rapid transport to the ER.

What will happen is that if this is a significant poisoning the ER will intubate this guy for a precautionary state and let the toxin clean itself out of the body.

Once the toxin is gone then the patietn can be extubated and will go on to lead a healthy and active live minus the FUGU.

Sorry Erdoc couldnt' resist helping out.

[EMS-Cat]

Great 'teaching case', ERDoc. Thanks.

[ERDoc]

Sorry Erdoc couldnt' resist helping out.

No problem. There is a Japanese says that goes something like this:

Those who eat fugu soup are stupid. But those who don't eat fugu soup are also stupid.

Care is basically supportive. Intubate and watch. Most statistics you find are from Japan, where people try to prepare them on their own. Mortality is fairly high because of this. Fugu is highly regulated here in the US. Any fugu that is sold in the US can oly be purchased from a single market in Japan (I don't remember the name, but it starts with an Sh). It is prepared there by chefs who have gone through 2-4 years of training exclusively on fugu. Their final exam is pretty simple, they have to eat a meal that they have prepared (pretty much pass/fail basis). It can only be flown into the US through JFK where it is inspected by trained inspectors (duh, who else would do some inspecting). It can then only be cooked by chefs in the US that have gone through the same training as those in Japan. Others have covered most of the pathophysiology so I will not go into the details. With a little modern medicine it is fairly survivable. Intubate, ventilate and let the tetrodotoxin clear out.

This scenario was a little too easy (damn those Simpsons). I'll have to come up with a more difficult one next time. :twisted:

[EMS-Cat]

Actually, ERDoc, the 'Simpsons' comment was an after thought. Think of it as a 'teaching aid'.

Seattle has at least one restaraunt that sells fugu so it's totally unheard of up here. But it's certainly a 'zebra' none-the-less.

Please keep these 'teaching cases' coming. I tend to forget to stop by forum, but when I do, I always check out this thread first. Good stuff is always turning up.

[ERDoc]

A restaurant in Chicago recently started serving it. Guess the Chicago medics should brush up on it, if they don't know it already. :wink:

[EMS-Cat]

This is one of those situations where *very* good history taking saves everyone time and frustration. It certainly gives the ER a 'heads up'.