Diagnostic Considerations and Management of Adult Botulism

  1. Immediate Management (first hour after presentation)
    1. Obtain complete clinical and epidemiologic history, specifically the food history in the previous week, history of ingestion of home-canned or commercially canned foods, and ingestion of spoiled food. Determine whether other persons have symptoms. Pursue the likelihood of alternative diagnoses such as wound botulism, drug use (phenothiazines, atropine, neomycin, kanamycin, gentamicin, polymyxin, bacitracin, dihydrostreptomycin, or colistin), tick paralysis, atypical Guillain-Barré Syndrome, carbon monoxide intoxication, or myasthenia gravis.
    2. Give an emetic if within 4 hr of the suspicious ingestion and a cathartic if within 36 hr of ingestion and the patient's bowel is not atonic.
    3. Consult with the local or state health department medical epidemiologist about the case and potential vehicles to determine clinical likelihood of botulism, arrange for release and shipment of trivalent antitoxin, and begin the epidemiologic investigation.
    4. Obtain serum and stool from the patient and, if available, the suspect food. These should be sent to the laboratory of the state health department or the CDC with the concurrence of the consulting epidemiologist at the state health department or CDC.
    5. Perform a tensilon test and lumbar puncture. Consider an EMG with rapid repetitive stimulation.
    6. Observe the patient in hospital, monitoring vital signs and vital capacity. Be prepared to intubate the trachea and provide mechanical ventilation.

  2. Early Management (1 - 24 hours after presentation)
    1. Ask for release of trivalent antitoxin from the nearest quarantine station by consulting medical epidemiologists at the state health department and CDC.
    2. Skin test before administering equine trivalent antitoxin.
    3. Administer antitoxin 1 vial im and 1 vial iv. This dose should be repeated in 4 hr if signs and symptoms progress.
    4. Ask that others who ate the suspect food be examined and purged. Obtain serum and stool from all exposed individuals, even if they are asymptomatic, and ship to the appropriate laboratory at the state health department or CDC.
    5. Consider treating asymptomatic persons who ate the suspect food with 2 vials of antitoxin after skin testing.
    6. If wound botulism is suspected, the wound should be thoroughly and widely debrided after administration of antitoxin.
    7. Wound aspirate or tissue obtained at surgery should be Gram stained and cultured anaerobically at an appropriate laboratory.
    8. If wound botulism is suspect, treat with high dose intravenous penicillin.
    9. The value of local injections of botulism antitoxin around a wound has not been evaluated. However, the experience with local instillation of tetanus antitoxin in treatment of tetanus suggests that local injection of botulism antitoxin may be useful.

  3. Intermediate and Long-Range Management
    1. Perform tracheostomy if long-term intubation is anticipated. Maintain good pulmonary hygiene.
    2. Provide nutrition either enterally via nasogastric tube or parenterally via central venous catheter.
    3. Consider low dose subcutaneous heparin for prophylaxis of deep venous thrombosis.
    4. Begin physical therapy and rehabilitation planning.

Quoted from Botulinum Neurotoxin and Tetanus Toxin edited by Lance L Simpson

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