CBRNE - Botulism Treatment & Management

  • Author: Peter P Taillac, MD; Chief Editor: Robert G Darling, MD, FACEP   more...
 
Updated: Mar 23, 2010
 

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.
  • 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

  • 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  Associate 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, and 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

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

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

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert G Darling, MD, FACEP  Adjunct Clinical Assistant Professor of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine; Associate Director, Center for Disaster and Humanitarian Assistance Medicine

Robert G Darling, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, American Telemedicine Association, and Association of Military Surgeons of the US

Disclosure: Nothing to disclose.

References

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Bioterrorist Agents. Signs and symptoms. Chart courtesy of North Carolina Statewide Program for Infection Control and Epidemiology (SPICE), copyright University of North Carolina at Chapel Hill, www.unc.edu/depts/spice/bioterrorism.html.
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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