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.
Pediatric nutritional support: Intravenous feeding (hyperalimentation) is discouraged because of its potential for secondary infection and because of the success with nasogastric or nasojejunal tube feeding.
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.
Consultations
Botulism is a notifiable disease in the United States. 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.
Other consultations may include the following:
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Pulmonology for respiratory sequelae
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Surgery for wound care
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Infectious disease specialist for management issues
Prevention
Inform the public about the hazards of improperly preserved or canned foods. Inform expectant mothers not to administer honey to infants.
There is no vaccine against botulinum toxin, although the antitoxin may induce host immunity to the toxin and therefore may be efficacious when used as a vaccine. A program for vaccination of workers at high risk was ended by the CDC in 2011. [16]
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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.
