Pediatric emergency medicine trisk 3104 3104
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In patients with severe symptoms, treatment is directed toward ensuring
adequate ventilation and hemodynamic stability. The treatment is the same as that
of anaphylaxis, see Chapter 85 Allergic Emergencies . Fluids and vasopressor
support may be needed to treat hypotension. Pharmacologic treatment includes
administration of antihistamines, corticosteroids, and if necessary, adrenergic
agents. Both diphenhydramine and cimetidine have been used successfully to
treat the symptoms of scombroid poisoning. In the event of severe bronchospasm,
other bronchodilators, including inhaled β2 -agonists may be necessary adjuncts.
Ciguatera
Ciguatera is an illness endemic to the South Pacific but in the continental United
States it is largely confined to the lower Atlantic states. However, because it does
occasionally appear in the United States or may occur in recent visitors from
endemic areas, its clinical manifestations should be recognized.
Ciguatera results from ingestion of a toxin elaborated by the dinoflagellate,
Gambierdiscus toxicus. This parasite is ingested by small fish, which begin to
concentrate the toxin. As predators ingest those small fish, the toxin ascends the
food chain until ingested by humans. The fish that most commonly harbor
ciguatoxin include barracuda, grouper, red snapper, and parrot fish. The
physiologic actions of ciguatoxin are primarily neurologic. The toxin decreases
CNS concentrations of γ-aminobutyric acid (GABA) and dopamine. This action
occurs in conjunction with sodium channels being “locked open,” permitting
unrestricted sodium ingress.
The clinical picture of ciguatera poisoning begins 4 to 36 hours after ingestion
of contaminated fish. After a brief period of nausea and vomiting, patients
develop weakness or paresthesias, particularly perioral. A hallmark of ciguatera
toxin is the reversal of hot–cold sensation. In severe cases there may be coma.
Toxic manifestations may persist for days to months after significant exposure.
The diagnosis of ciguatera intoxication is clinical, based on the history of
ingestion of a fish known to carry this toxin. GI decontamination is ineffective
because symptoms appear many hours after ingestion of contaminated fish.
Management of ciguatera is supportive, with specific attention should to CNS
status and its effects on airway and ventilation. IV mannitol has shown great
promise in reversing many of the neurologic manifestations, particularly coma. It
is administered in a dose of 0.5 to 1 g/kg via an in-line filter.
Paralytic Shellfish Poisoning
