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CBRNE - Botulism Treatment & Management

  • Author: Peter P Taillac, MD; Chief Editor: Duane C Caneva, MD, MSc  more...
 
Updated: Apr 21, 2015
 

Emergency Department Care

Antitoxin should be administered as soon as the clinical diagnosis is established, as laboratory confirmation requires days. The early administration of antitoxin will not reverse the course of the intoxication but will prevent further progression of paralysis. This is the best method to prevent diaphragmatic involvement and the need for mechanical ventilation. Antitoxin can only bind neurotoxin free in the blood. Once in the neuron, it cannot be bound.

Food-borne botulism

Monitor asymptomatic individuals who have eaten food suspected of being contaminated for the appearance of neurologic signs and symptoms.

Enemas and cathartics or whole-bowel irrigation may be used (if no ileus is present) to purge the gut of toxin. If ingestion occurred within the past few hours, emetics or gastric lavage may aid in the removal of toxin.

In infant botulism, most cases progress to complete respiratory failure. Intubation is required for a median of 16-23 days. Tracheostomy usually is not required.

Wound botulism

Wound botulism requires thorough debridement of the wound site, even if it appears to be healing well. Follow this by injection of 3% hydrogen peroxide to produce aerobic conditions. Hydrogen peroxide itself is not innocuous to tissues, and some have advocated using hyperbaric oxygen therapy if available.

Antitoxin may be injected directly into the wound site.

Urinary retention may require use of a catheter.

Respiratory concerns

In adults, botulism results in pulmonary complications in 81% of patients, with ventilatory failure in one third.

Monitor spirometry, pulse oximetry, and arterial blood gas measurements, with particular attention placed on serial measurements of maximal static inspiratory pressure and respiratory vital capacity to help in predicting respiratory failure.

Strongly consider intubation and mechanical ventilation when vital capacity is less than 30% of predicted (or < 12 mL/kg), particularly when absolute or relative hypercarbia and rapidly progressive paralysis with hypoxemia are evident.

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Consultations

See the list below:

  • Medical care providers who suspect botulism in a patient should immediately call their state health department's emergency 24-hour telephone number. The state health department will contact the CDC to report suspected botulism cases, arrange for a clinical consultation by telephone and, if indicated, request release of botulinum antitoxin. State health departments should call the CDC 24-hour telephone number at 770-488-7100. The call will be taken by the CDC Emergency Operations Center, which will page the Foodborne and Diarrheal Diseases Branch medical officer on call.
  • Pulmonology for respiratory sequelae
  • Surgery for wound care
  • Infectious disease specialist for management issues
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Contributor Information and Disclosures
Author

Peter P Taillac, MD Clinical Professor of Surgery, Division of Emergency Medicine, University of Utah Health Sciences Center

Peter P Taillac, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Joseph Kim, MD Chairman, Department of Emergency Medicine, Western Medical Center; Clinical Instructor, University of California, Irvine, School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Barry J Sheridan, DO Chief Warrior in Transition Services, Brooke Army Medical Center

Barry J Sheridan, DO is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Duane C Caneva, MD, MSc Senior Medical Advisor to Customs and Border Protection, Department of Homeland Security (DHS) Office of Health Affairs; Federal Co-Chair, Health, Medical, Responder Safety Subgroup, Interagency Board (IAB)

Disclosure: Nothing to disclose.

Additional Contributors

Edward Bessman, MD, MBA Chairman and Clinical Director, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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Courtesy of Arnon SS, et al. Botulinum toxin as a biological weapon: medical and public health management. JAMA 2001 Apr 25;285:1059.
 
 
 
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