Botulism¶

VERSION: 1.1 CREATED: February 2, 2026 REVISED: February 2, 2026 STATUS: Validated per checker pipeline

DIAGNOSIS: Botulism

ICD-10: A05.1 (Botulism food poisoning — foodborne botulism), T48.1X1A (Poisoning by skeletal muscle relaxants, accidental — iatrogenic botulism), A48.51 (Infant botulism), A48.52 (Wound botulism), A48.59 (Other specified botulism — adult intestinal colonization, inhalational)

CPT CODES: 95907-95913 (nerve conduction studies), 95886 (needle EMG), 95937 (repetitive nerve stimulation), 87900 (bacterial toxin assay — mouse bioassay, sent via public health), 80053 (CMP), 85025 (CBC), 71046 (chest X-ray), 93000 (ECG), 70553 (MRI brain), 72156 (MRI spine), 94010 (spirometry/PFTs), 94726 (FVC), 99291-99292 (critical care E/M), 31500 (intubation)

SYNONYMS: Botulism, botulinum toxin poisoning, Clostridium botulinum poisoning, food poisoning botulism, foodborne botulism, wound botulism, infant botulism, iatrogenic botulism, descending paralysis, botulinum intoxication, sausage poisoning, botulism food poisoning, adult intestinal toxemia botulism, inhalational botulism

SCOPE: Diagnosis and management of all forms of botulism: foodborne (toxin ingestion), wound (toxin produced in infected wound), iatrogenic (therapeutic botulinum toxin overdose), infant botulism (intestinal colonization in infants), and adult intestinal colonization. Covers acute recognition of descending flaccid paralysis, respiratory monitoring (NIF/FVC), antitoxin administration (heptavalent equine antitoxin via CDC), electrophysiologic diagnosis, differentiation from GBS/MG/stroke, and supportive ICU care. Excludes cosmetic botulinum toxin use without adverse effect and bioterrorism-specific protocols (notify public health).

PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting

═══════════════════════════════════════════════════════════════ SECTION A: ACTION ITEMS ═══════════════════════════════════════════════════════════════

1. LABORATORY WORKUP¶

1A. Essential/Core Labs¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
CBC with differential (CPT 85025)	STAT	STAT	ROUTINE	STAT	Baseline; infection screen; wound botulism may show leukocytosis	Normal; leukocytosis suggests wound infection
CMP (BMP + LFTs) (CPT 80053)	STAT	STAT	ROUTINE	STAT	Electrolyte abnormalities; renal/hepatic function; baseline for prolonged ICU course	Normal
Magnesium (CPT 83735)	STAT	STAT	ROUTINE	STAT	Hypomagnesemia worsens neuromuscular weakness; can compound paralysis	>1.8 mg/dL
Phosphorus (CPT 84100)	STAT	ROUTINE	ROUTINE	STAT	Hypophosphatemia can worsen respiratory muscle weakness	>2.5 mg/dL
Blood glucose (CPT 82947)	STAT	STAT	ROUTINE	STAT	Critical illness hyperglycemia management; autonomic dysfunction	Normal
Arterial blood gas (ABG) (CPT 82803)	STAT	STAT	-	STAT	Respiratory failure assessment; early CO2 retention precedes hypoxia	Normal pH, pCO2 <45 mmHg; rising pCO2 indicates impending respiratory failure
PT/INR (CPT 85610), aPTT (CPT 85730)	STAT	ROUTINE	-	STAT	Coagulation status before procedures; wound botulism may need surgical debridement	Normal
Blood cultures (aerobic/anaerobic) (CPT 87040)	STAT	ROUTINE	-	STAT	Wound botulism — rule out secondary bacteremia; exclude sepsis	No growth
Urinalysis (CPT 81003)	STAT	ROUTINE	ROUTINE	STAT	Baseline; UTI as complication in prolonged hospitalization	Normal
Pregnancy test (beta-hCG)	STAT	STAT	ROUTINE	STAT	Antitoxin is equine-derived — pregnancy category C; imaging considerations	Document result
Lactate (CPT 83605)	STAT	STAT	-	STAT	Assess tissue perfusion; distinguish from septic shock	<2.0 mmol/L
Type and screen (CPT 86900)	STAT	ROUTINE	-	STAT	Potential need for surgical intervention (wound botulism); ICU procedures	On file

1B. Extended Workup (Second-line)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Serum botulinum toxin assay (mouse bioassay) (CPT 87900)	STAT	STAT	-	STAT	Definitive diagnostic test; contact CDC/state health department for testing; sensitivity 33-44% in serum	Positive confirms diagnosis (negative does NOT exclude)
Stool botulinum toxin assay and culture	STAT	STAT	-	STAT	Higher sensitivity than serum (60%+ in foodborne); also identifies colonization (infant, adult intestinal)	Positive toxin or culture of C. botulinum
Wound culture (anaerobic)	STAT	STAT	-	STAT	Wound botulism — culture for C. botulinum; send tissue/exudate for anaerobic culture and toxin assay	C. botulinum isolation
Suspected food sample (for toxin testing)	STAT	STAT	-	-	Epidemiologic confirmation; send to state public health lab via CDC coordination	Toxin identified in food
Serum for toxin type identification (A-G)	-	ROUTINE	-	ROUTINE	Identifies toxin serotype to guide antitoxin selection; types A, B, E most common in humans	Type identified
ESR (CPT 85652) / CRP (CPT 86140)	URGENT	ROUTINE	ROUTINE	ROUTINE	Inflammatory markers; elevated in wound botulism	Normal in foodborne; elevated in wound botulism
TSH (CPT 84443)	-	ROUTINE	ROUTINE	-	Hypothyroidism can contribute to weakness (differential)	Normal
AChR antibody panel (binding, blocking, modulating)	-	ROUTINE	ROUTINE	-	Exclude myasthenia gravis (key differential)	Negative
Anti-MuSK antibody	-	ROUTINE	ROUTINE	-	Exclude MuSK-MG (bulbar-predominant MG mimic)	Negative
Creatine kinase (CK) (CPT 82550)	STAT	ROUTINE	ROUTINE	STAT	Elevated in some neuromuscular conditions; usually normal in botulism; rhabdomyolysis from prolonged immobility	Normal

1C. Rare/Specialized (Refractory or Atypical)¶

Test	ED	HOSP	OPD	ICU	Rationale	Target Finding
Anti-ganglioside antibodies (GM1, GD1a, GQ1b)	-	EXT	EXT	-	Exclude GBS variants if diagnostic uncertainty persists	Negative
Edrophonium (Tensilon) test	-	EXT	EXT	-	Differentiates from MG (positive in MG, negative in botulism); rarely performed now	No improvement (negative) in botulism
Heavy metals (lead, arsenic, thallium)	-	EXT	EXT	-	Toxic neuropathy differential; environmental exposure	Normal
Tick paralysis assessment (physical exam)	STAT	STAT	-	STAT	Ascending paralysis mimic; search skin/scalp for embedded tick	No tick found
Organophosphate/carbamate level (cholinesterase)	-	EXT	-	EXT	Cholinergic crisis differential (excess secretions + weakness); toxicology screen	Normal cholinesterase levels
CSF analysis (LP) — if diagnostic uncertainty	-	EXT	EXT	-	CSF normal in botulism; elevated protein with normal cells suggests GBS; pleocytosis suggests infection	Normal in botulism (protein normal, WBC normal)
Porphyrins (urine ALA, PBG)	-	EXT	EXT	-	Acute intermittent porphyria — motor neuropathy + autonomic dysfunction mimic	Normal

2. DIAGNOSTIC IMAGING & STUDIES¶

2A. Essential/First-line¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Nerve conduction studies (NCS) (CPT 95907-95913) / EMG (CPT 95886) with repetitive nerve stimulation (RNS) (CPT 95937)	-	URGENT	ROUTINE	URGENT	As soon as available (ideally within 24-48h); diagnostic cornerstone	Reduced CMAP amplitudes; normal sensory nerve action potentials (SNAPs); INCREMENTAL response (facilitation) at high-rate (20-50 Hz) repetitive stimulation (post-exercise facilitation); normal or mildly prolonged distal latencies; brief-duration, small-amplitude motor unit potentials (BSAPs) on needle EMG; fibrillation potentials in severe cases	None significant
Chest X-ray (CPT 71046)	STAT	ROUTINE	-	STAT	On admission	Aspiration pneumonia; atelectasis; baseline for ventilator management; mediastinal mass (differential)	None significant
ECG (12-lead) (CPT 93000)	STAT	ROUTINE	-	STAT	On admission and PRN	Sinus tachycardia; conduction abnormalities; autonomic effects on cardiac rhythm	None
CT head without contrast (CPT 70450)	URGENT	ROUTINE	-	URGENT	On admission if stroke in differential	Normal (excludes stroke, mass lesion)	Contrast allergy (if contrast used)

2B. Extended¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
MRI brain with and without contrast (CPT 70553)	-	ROUTINE	ROUTINE	ROUTINE	If brainstem pathology suspected	Normal in botulism; excludes brainstem stroke, demyelination, mass	Pacemaker, metallic implants
MRI spine with and without contrast (CPT 72156)	-	ROUTINE	ROUTINE	-	If myelopathy in differential	Normal in botulism; excludes spinal cord compression	Same as MRI
CT chest with contrast (CPT 71260)	-	EXT	-	EXT	If thymoma suspected (MG differential) or pulmonary complication	No thymoma; assess for aspiration pneumonia	Contrast allergy, renal impairment
CT abdomen/pelvis (wound botulism with IVDU)	-	EXT	-	EXT	If deep abscess suspected as source of wound botulism	Abscess identification for surgical drainage	Contrast allergy, renal impairment
Repeat NCS/EMG	-	ROUTINE	ROUTINE	-	At 1-2 weeks if initial study non-diagnostic or to assess recovery	Evolution of findings; improving CMAPs indicate recovery	Same as initial
Echocardiogram (CPT 93306)	-	EXT	-	ROUTINE	If hemodynamic instability or autonomic dysfunction	Cardiac function assessment	None significant

2C. Rare/Specialized¶

Study	ED	HOSP	OPD	ICU	Timing	Target Finding	Contraindications
Single-fiber EMG (CPT 95872)	-	EXT	EXT	-	If standard EMG non-diagnostic	Increased jitter and blocking (present in botulism but non-specific — also seen in MG, LEMS)	Anticoagulation (relative)
Pulmonary function testing (formal) (CPT 94010)	-	ROUTINE	ROUTINE	-	If borderline respiratory function during recovery	Quantify restrictive defect; guide weaning	Unable to cooperate

LUMBAR PUNCTURE¶

Indication: NOT routinely indicated in botulism. Perform only if GBS, meningitis, or other CNS infection is in the differential and cannot be excluded clinically. CSF is NORMAL in botulism.

Timing: URGENT only if diagnostic uncertainty — particularly if ascending weakness or CSF pleocytosis/protein elevation would change diagnosis

Volume Required: 10-15 mL (standard diagnostic)

Study	ED	HOSP	OPD	Rationale	Target Finding
Opening pressure	URGENT	ROUTINE	-	Rule out elevated ICP	10-20 cm H2O (normal in botulism)
Cell count (tubes 1 and 4) (CPT 89051)	URGENT	ROUTINE	-	Normal WBC distinguishes from GBS (albuminocytologic dissociation) and meningitis	WBC <5 cells/uL (NORMAL in botulism)
Protein (CPT 84157)	URGENT	ROUTINE	-	Normal in botulism; elevated in GBS	NORMAL (<45 mg/dL) — elevated protein favors GBS
Glucose with serum glucose (CPT 82945)	URGENT	ROUTINE	-	Normal in botulism; low in bacterial meningitis	Normal (>60% serum)
Gram stain and culture	URGENT	ROUTINE	-	Exclude bacterial meningitis	No organisms

Special Handling: Standard processing. The KEY finding is a NORMAL CSF, which helps EXCLUDE GBS (where protein is typically elevated) and meningitis (where pleocytosis is present).

Contraindications: Elevated ICP without imaging (CT first), coagulopathy (INR >1.5, platelets <50K), skin infection at LP site. Anticoagulation should be held.

3. TREATMENT¶

3A. Acute/Emergent¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Heptavalent botulinum antitoxin (HBAT) (equine-derived, serotypes A-G) — obtained from CDC	IV	All forms of botulism (foodborne, wound, adult intestinal colonization, inhalational); administer as early as possible — antitoxin neutralizes circulating toxin but does NOT reverse already-bound toxin	1 vial :: IV :: :: 1 vial (containing equine-derived antibodies to types A-G) IV; dilute 1:10 in 0.9% NS; infuse slowly over 15-30 min initially, increase rate per CDC protocol; contact CDC Emergency Operations Center 770-488-7100 (24/7) to obtain antitoxin; administer as soon as clinical suspicion is high — do NOT wait for lab confirmation	History of equine protein hypersensitivity (perform skin test first per CDC protocol); serum sickness risk 5-10% (monitor for 10-21 days post-infusion)	Skin test before infusion if history of atopy or equine exposure; monitor VS q5min during infusion and q15min x 4h post; observe for anaphylaxis (epinephrine at bedside); delayed serum sickness (fever, rash, arthralgias at 10-21 days)	STAT	STAT	-	STAT
BabyBIG (botulism immune globulin intravenous, human)	IV	Infant botulism ONLY (age <1 year); FDA-approved for infant botulism types A and B	50 mg/kg :: IV :: :: 50 mg/kg (1 mL/kg) IV single dose; infuse at 0.5 mL/kg/h initially, increase to 1.0 mL/kg/h if tolerated; obtain from California Infant Botulism Treatment and Prevention Program (IBTPP) at 510-231-7600 (24/7)	IgA deficiency; prior severe reaction to human immunoglobulin	Vital signs q15min during infusion; watch for anaphylaxis; renal function	-	STAT	-	STAT
Intubation and mechanical ventilation	-	Respiratory failure — single most important cause of death in botulism	N/A :: - :: :: Indications: FVC <15-20 mL/kg, NIF weaker than -30 cmH2O, >30% decline in FVC from baseline, rising pCO2, clinical respiratory distress, inability to protect airway due to bulbar weakness. Use non-depolarizing agents (rocuronium preferred). AVOID succinylcholine (risk of exaggerated response in denervated muscle). Anticipate PROLONGED ventilation (weeks to months)	N/A (life-saving)	Ventilator settings per ICU protocol; daily assessment; plan for tracheostomy if ventilation expected >14 days	STAT	STAT	-	STAT
Wound debridement and drainage (wound botulism)	Surgical	Wound botulism — remove source of ongoing toxin production; perform AFTER antitoxin administration to avoid releasing more toxin into circulation	N/A :: Surgical :: :: Thorough surgical debridement of infected wound; drain abscess if present; obtain tissue for anaerobic culture; perform AFTER antitoxin has been given	Hemodynamic instability (stabilize first)	Wound site; CBC; signs of secondary infection	-	STAT	-	STAT
Metronidazole (wound botulism)	IV	Wound botulism — eradicate C. botulinum from wound; adjunct to debridement	500 mg :: IV :: :: 500 mg IV q8h x 10-14 days; alternative to penicillin (avoids aminoglycoside interaction concern)	Severe hepatic impairment; disulfiram-like reaction with alcohol	LFTs; neuropathy (prolonged use); seizures (rare)	-	STAT	-	STAT
Penicillin G (wound botulism — alternative)	IV	Wound botulism — alternative to metronidazole for C. botulinum eradication	3 million units :: IV :: :: 3 million units IV q4h x 10-14 days	Penicillin allergy; AVOID aminoglycosides concurrently (potentiate neuromuscular blockade)	Allergic reaction; renal function	-	STAT	-	STAT
DVT prophylaxis: Enoxaparin	SC	Immobilized patients at high risk of VTE	40 mg :: SC :: :: 40 mg SC daily; start on admission	Active bleeding, platelets <50K, CrCl <30 (use UFH)	Platelets q3 days; anti-Xa if renal impairment	-	ROUTINE	-	ROUTINE
DVT prophylaxis: Heparin SC (alternative)	SC	VTE prophylaxis if enoxaparin contraindicated	5000 units :: SC :: :: 5000 units SC q8-12h	Active bleeding, HIT	Platelets q3 days	-	ROUTINE	-	ROUTINE
Pneumatic compression devices	-	All immobilized patients	N/A :: - :: :: Apply bilaterally on admission; continue until ambulatory	Acute DVT, severe PVD	Skin checks daily	STAT	STAT	-	STAT
IV fluid resuscitation (0.9% NS)	IV	Dehydration from GI prodrome (foodborne botulism — nausea, vomiting, diarrhea)	20 mL/kg :: IV :: :: 20 mL/kg IV bolus, then maintenance; target euvolemia	Fluid overload, CHF	I/O, BMP, volume status	STAT	STAT	-	STAT

3B. Symptomatic Treatments¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Atropine	IV	Bradycardia from autonomic dysfunction; excessive secretions	0.5-1 mg :: IV :: :: 0.5-1 mg IV PRN for symptomatic bradycardia; may repeat q3-5 min; max 3 mg	Tachycardia, angle-closure glaucoma	HR, rhythm; urinary retention	STAT	STAT	-	STAT
Glycopyrrolate	IV/PO	Excessive oral secretions (antisialagogue); preferred over atropine for secretion management	0.2 mg :: IV :: :: 0.2 mg IV q4-6h PRN; or 1-2 mg PO TID	Ileus, urinary retention, angle-closure glaucoma	Secretion volume; HR; bowel function	-	ROUTINE	-	ROUTINE
Acetaminophen	PO/IV	Pain, headache, fever	650-1000 mg :: PO :: :: 650-1000 mg PO/IV q6h; max 4g/day (2g if hepatic impairment)	Severe liver disease	LFTs if prolonged	STAT	ROUTINE	ROUTINE	STAT
Metoclopramide	IV	Gastroparesis, nausea, ileus (autonomic dysfunction common)	10 mg :: IV :: :: 10 mg IV q6h PRN; max 40 mg/day; limit to <12 weeks	Seizure history, Parkinson disease, GI obstruction	Tardive dyskinesia with prolonged use	-	ROUTINE	-	ROUTINE
Ondansetron	IV	Nausea and vomiting (foodborne botulism GI symptoms)	4 mg :: IV :: :: 4 mg IV q6-8h PRN	QT prolongation, severe hepatic impairment	ECG if QT concern	STAT	ROUTINE	-	ROUTINE
Docusate sodium	PO	Constipation (immobility + autonomic dysfunction)	100 mg :: PO :: :: 100 mg PO BID	GI obstruction	Bowel function	-	ROUTINE	ROUTINE	ROUTINE
Senna	PO	Constipation	8.6-17.2 mg :: PO :: :: 8.6-17.2 mg PO qHS	GI obstruction	Bowel function	-	ROUTINE	ROUTINE	-
Polyethylene glycol (MiraLAX)	PO	Constipation (if docusate insufficient)	17 g :: PO :: :: 17 g PO daily in 8 oz water	GI obstruction	Bowel function	-	ROUTINE	ROUTINE	-
Artificial tears (methylcellulose)	Ophthalmic	Dry eyes from impaired blinking (CN VII involvement, reduced lacrimation)	1-2 drops :: Ophthalmic :: :: 1-2 drops each eye q2-4h while awake; lubricating ointment at night	None significant	Corneal integrity; ophthalmology if corneal exposure	-	ROUTINE	ROUTINE	ROUTINE
Melatonin	PO	Insomnia, ICU delirium prevention	3-5 mg :: PO :: :: 3-5 mg PO qHS	None significant	Sleep quality	-	ROUTINE	-	ROUTINE
Lorazepam	IV	Anxiety, agitation in intubated patient	0.5-1 mg :: IV :: :: 0.5-1 mg IV q6-8h PRN; use with caution — may worsen hypotonia	Respiratory depression (extreme caution if not intubated)	RR, sedation scale; avoid in non-intubated patients	-	URGENT	-	URGENT

3C. Second-line/Refractory¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Guanidine hydrochloride	PO	Historical agent to enhance acetylcholine release at NMJ; limited efficacy; NOT standard of care; may provide modest improvement in chronic phase	15-35 mg/kg :: PO :: :: 15-35 mg/kg/day divided TID-QID; start low and titrate; limited evidence for benefit	Bone marrow suppression, renal impairment	CBC, BMP weekly; bone marrow toxicity (aplastic anemia reported)	-	EXT	EXT	EXT
4-Aminopyridine (dalfampridine)	PO	Potassium channel blocker to enhance neuromuscular transmission; off-label, limited evidence; may improve strength in recovery phase	10 mg :: PO :: :: 10 mg PO BID (extended-release); off-label use	Seizure history (lowers threshold), renal impairment (CrCl <50)	Seizures; renal function	-	EXT	EXT	-
Tracheostomy	Surgical	Prolonged mechanical ventilation (>14 days expected — common in botulism)	N/A :: Surgical :: :: Perform when ventilation anticipated >14 days; improves patient comfort, oral hygiene, weaning potential	Coagulopathy (correct first)	Stoma site; decannulation readiness in recovery	-	ROUTINE	-	ROUTINE
Percutaneous gastrostomy (PEG)	Surgical	Prolonged inability to swallow safely; enteral nutrition access	N/A :: Surgical :: :: Place when dysphagia expected to persist >2-3 weeks	Coagulopathy, abdominal pathology	Tube site; feeding tolerance	-	ROUTINE	-	ROUTINE

3D. Recovery/Rehabilitation Therapies¶

Treatment	Route	Indication	Dosing	Contraindications	Monitoring	ED	HOSP	OPD	ICU
Physical therapy (PT) (CPT 97110-97542)	-	All botulism patients; early passive ROM to prevent contractures; progressive strengthening during recovery	N/A :: - :: :: Daily passive ROM while paralyzed; active-assisted exercises as strength returns; progressive strengthening and gait training in recovery	Hemodynamic instability	Functional status; fall risk; fatigue	-	ROUTINE	ROUTINE	ROUTINE
Occupational therapy (OT)	-	Upper extremity function, ADLs, adaptive equipment	N/A :: - :: :: Daily OT for fine motor recovery, ADL training, adaptive equipment	Hemodynamic instability	Functional independence	-	ROUTINE	ROUTINE	ROUTINE
Speech-language pathology (SLP)	-	Dysphagia evaluation and treatment; aspiration prevention; communication strategies if intubated/trached	N/A :: - :: :: Bedside swallow evaluation; instrumental assessment (FEES or MBS) before oral intake; speech/communication strategies	None	Aspiration risk; swallow function	-	URGENT	ROUTINE	URGENT

CRITICAL MEDICATION WARNINGS:

AVOID aminoglycosides (gentamicin, tobramycin, amikacin) — potentiate neuromuscular blockade and worsen paralysis
AVOID magnesium sulfate at high doses — potentiates neuromuscular blockade
AVOID succinylcholine — risk of exaggerated response; use rocuronium if paralytic needed
AVOID fluoroquinolones — potential neuromuscular blockade potentiation
AVOID neuromuscular blocking agents unless absolutely necessary for intubation
DO NOT use antibiotics for foodborne botulism (organism is in gut only; lysis could release more toxin — applies to infant botulism; foodborne is pre-formed toxin)
Infant botulism: AVOID antibiotics that lyse C. botulinum in gut (aminoglycosides especially contraindicated) — use BabyBIG, not HBAT

4. OTHER RECOMMENDATIONS¶

4A. Referrals & Consults¶

Recommendation	ED	HOSP	OPD	ICU
Neurology consultation — all suspected botulism; diagnostic confirmation; EMG/NCS interpretation; differentiation from GBS, MG, stroke	STAT	STAT	-	STAT
Critical care / Pulmonology — respiratory monitoring and ventilator management; all patients with bulbar or respiratory weakness	STAT	STAT	-	STAT
Infectious disease — confirm diagnosis; guide antibiotic therapy for wound botulism; coordinate public health notification	URGENT	URGENT	-	URGENT
Public health / CDC notification — MANDATORY: botulism is a nationally notifiable disease; contact state health department AND CDC Emergency Operations Center (770-488-7100) to obtain antitoxin and for epidemiologic investigation	STAT	STAT	-	STAT
Toxicology / Poison control — if foodborne: identify implicated food; coordinate with public health; differential diagnosis assistance	URGENT	ROUTINE	-	URGENT
Surgery (wound botulism) — wound debridement and drainage for wound botulism; abscess management in IVDU patients	-	STAT	-	STAT
Speech-language pathology (SLP) — dysphagia evaluation; aspiration prevention; communication strategies	-	URGENT	ROUTINE	URGENT
Physical therapy (PT) — early passive ROM; progressive mobilization; gait training in recovery	-	URGENT	ROUTINE	URGENT
Occupational therapy (OT) — upper extremity function; ADLs; adaptive equipment	-	URGENT	ROUTINE	URGENT
Rehabilitation medicine (physiatry) — rehabilitation planning; disposition (inpatient rehab vs SNF vs home)	-	ROUTINE	ROUTINE	-
Respiratory therapy — bedside spirometry (FVC, NIF); pulmonary toilet; ventilator weaning protocols	-	STAT	-	STAT
Ophthalmology — if persistent diplopia, ptosis, or corneal exposure from impaired blinking	-	ROUTINE	ROUTINE	-
Nutrition / Dietitian — enteral/parenteral feeding plan if prolonged dysphagia; caloric needs during recovery	-	ROUTINE	-	ROUTINE
Social work — discharge planning; family support; financial resources for prolonged hospitalization	-	ROUTINE	ROUTINE	-
Psychology / Psychiatry — anxiety, depression, PTSD (common with prolonged ICU stay and ventilator dependence)	-	ROUTINE	ROUTINE	-

4B. Patient Instructions¶

Recommendation	ED	HOSP	OPD
Return to ED / Call 911 if: increasing difficulty breathing, new swallowing difficulty, worsening double vision, progressive weakness, inability to hold up head, chest pain, or lightheadedness	STAT	STAT	ROUTINE
Botulism is a serious but treatable condition; early antitoxin administration improves outcomes	STAT	ROUTINE	ROUTINE
Recovery is typically slow (weeks to months); full recovery is possible but may take up to a year	-	ROUTINE	ROUTINE
Do NOT drive until vision (diplopia), strength, and reflexes have fully recovered and cleared by neurologist	-	ROUTINE	ROUTINE
Comply with physical and occupational therapy exercises as prescribed	-	ROUTINE	ROUTINE
Report any new difficulty breathing, swallowing, or worsening weakness immediately	-	ROUTINE	ROUTINE
Foodborne botulism prevention: do not eat food from bulging or damaged cans; properly refrigerate foods; follow safe home canning practices (pressure canning for low-acid foods; boil home-canned foods for 10 min before eating)	-	ROUTINE	ROUTINE
Wound botulism (IVDU patients): avoid injection drug use; if continuing, use clean needles and do not skin-pop or muscle-pop; seek help for substance use disorder	-	ROUTINE	ROUTINE
Follow-up with neurology in 1-2 weeks after discharge; NCS/EMG may be repeated at 3-6 months to document recovery	-	ROUTINE	ROUTINE
Inform future healthcare providers about botulism history (anesthesia precautions — prolonged paralysis risk with certain agents)	-	ROUTINE	ROUTINE
Fall prevention: use assistive devices as recommended during recovery; remove tripping hazards at home	-	ROUTINE	ROUTINE
Monitor for signs of blood clots: leg swelling, redness, chest pain, shortness of breath	-	ROUTINE	ROUTINE

4C. Lifestyle & Prevention¶

Recommendation	ED	HOSP	OPD
Gradual return to activity as tolerated; avoid overexertion during recovery; fatigue is common for months	-	ROUTINE	ROUTINE
Safe food handling: proper canning techniques (pressure canning at 250F/121C for low-acid foods); refrigerate perishables; discard bulging, leaking, or damaged cans	-	ROUTINE	ROUTINE
Boil home-canned foods for 10 minutes before eating (destroys botulinum toxin)	-	ROUTINE	ROUTINE
Honey should NOT be given to infants <1 year (infant botulism risk from Clostridium spores)	-	ROUTINE	ROUTINE
Wound care: keep wounds clean; seek medical attention for infected wounds especially in IVDU patients	-	ROUTINE	ROUTINE
Substance use disorder treatment referral for IVDU patients with wound botulism	-	ROUTINE	ROUTINE
Balanced nutrition for neuromuscular recovery (adequate protein, B vitamins)	-	ROUTINE	ROUTINE
Mental health support (prolonged ICU stay, ventilator dependence, slow recovery cause significant psychological stress)	-	ROUTINE	ROUTINE
Adequate sleep (promotes neurologic recovery)	-	ROUTINE	ROUTINE
Smoking cessation (impairs tissue healing and neuromuscular recovery)	-	ROUTINE	ROUTINE

═══════════════════════════════════════════════════════════════ SECTION B: REFERENCE (Expand as Needed) ═══════════════════════════════════════════════════════════════

5. DIFFERENTIAL DIAGNOSIS¶

Alternative Diagnosis	Key Distinguishing Features	Tests to Differentiate
Guillain-Barre syndrome (GBS)	ASCENDING paralysis (starts distally, moves proximally — opposite of botulism); sensory symptoms common; areflexia; CSF shows elevated protein with normal WBC (albuminocytologic dissociation); no pupil involvement; no GI prodrome typical of botulism	NCS/EMG (demyelinating or axonal pattern; NO incremental response); LP (elevated protein); anti-ganglioside antibodies
Myasthenia gravis (MG)	Fatigable weakness; fluctuating symptoms; ptosis and diplopia (similar to botulism); intact pupillary reflexes; no GI prodrome; chronic course	AChR/MuSK antibodies; repetitive nerve stimulation shows DECREMENTAL response at LOW-rate (2-3 Hz) stimulation (vs. incremental at high-rate in botulism); edrophonium test positive
Lambert-Eaton myasthenic syndrome (LEMS)	Proximal weakness; hyporeflexia with post-exercise facilitation; autonomic dysfunction (dry mouth); associated with SCLC; chronic onset	NCS shows incremental response at high-rate RNS (SIMILAR to botulism); VGCC antibodies positive; CT chest for malignancy
Brainstem stroke	Acute onset; focal neurologic deficits; cranial nerve findings may overlap; crossed findings (ipsilateral face, contralateral body); no GI prodrome; no descending pattern	MRI brain with DWI (acute infarct); CTA/MRA (vascular occlusion); normal NCS/EMG
Tick paralysis	Ascending paralysis similar to GBS; rapid onset; tick found on exam; rapid reversal after tick removal; no sensory loss; normal CSF	Physical exam (search for tick — scalp, hairline, skin folds); NCS may show reduced CMAPs; CSF normal
Organophosphate/nerve agent poisoning	Cholinergic crisis: SLUDGE symptoms (salivation, lacrimation, urination, defecation, GI distress, emesis); miosis; muscle fasciculations then weakness; bradycardia	Cholinesterase levels (depressed); atropine challenge (improves symptoms); toxicology screen
Diphtheria	Pharyngeal membrane; palatal weakness early; sensorimotor neuropathy develops weeks after infection; myocarditis	Throat culture; diphtheria toxin assay; clinical history; travel/vaccination history
Acute intermittent porphyria	Abdominal pain (prominent); psychiatric symptoms; autonomic dysfunction; motor-predominant neuropathy; dark urine	Urine ALA and PBG (elevated during attack); genetic testing
Poliomyelitis / West Nile virus	Asymmetric flaccid paralysis; fever; anterior horn cell pattern; CSF pleocytosis	CSF (elevated WBC); viral PCR; MRI (anterior horn signal change)
Myasthenic crisis	Similar bulbar and respiratory failure; known MG history typically; rapid deterioration	AChR antibodies; history of MG; decremental response on RNS
Eaton-Lambert crisis	Acute exacerbation of LEMS; proximal weakness; autonomic symptoms	VGCC antibodies; malignancy screening; high-rate RNS
Hypermagnesemia	Iatrogenic (MgSO4 infusion); weakness; hyporeflexia; respiratory depression	Serum magnesium level (markedly elevated)
Conversion disorder (FND)	Non-physiologic weakness pattern; Hoover sign; give-way weakness; may mimic any neurologic presentation	Normal NCS/EMG; normal labs; clinical exam features inconsistent with organic disease

6. MONITORING PARAMETERS¶

Parameter	ED	HOSP	OPD	ICU	Frequency	Target/Threshold	Action if Abnormal
Forced Vital Capacity (FVC)	STAT	STAT	ROUTINE	STAT	q2-4h in ED/ICU; q4-6h on floor; q1h if declining	FVC >15-20 mL/kg (approx >1.0-1.5L for 75 kg adult)	FVC <15-20 mL/kg or declining >30% from baseline -> elective intubation; transfer to ICU
Negative Inspiratory Force (NIF/MIP)	STAT	STAT	ROUTINE	STAT	q2-4h with FVC	NIF more negative than -30 cmH2O (e.g., -40 is better than -20)	NIF weaker than -30 cmH2O -> prepare for intubation
Peak Cough Flow	-	ROUTINE	-	ROUTINE	q4-6h with FVC	>270 L/min (effective cough)	Airway clearance interventions; suction; assisted cough
Oxygen saturation (SpO2)	STAT	STAT	-	STAT	Continuous in ICU; q2-4h on floor	>=94%	LATE finding — do NOT rely on SpO2 alone; FVC and NIF are far more sensitive indicators of impending failure
Arterial blood gas (pCO2)	STAT	ROUTINE	-	STAT	q4-6h; more frequently if declining FVC	pCO2 <45 mmHg	Rising pCO2 indicates hypoventilation and impending respiratory failure — intubate
Blood pressure	STAT	STAT	-	STAT	q4h on floor; continuous in ICU	Stable; watch for hypotension (autonomic)	Hypotension: IV fluids, vasopressors if refractory; AVOID long-acting agents
Heart rate and rhythm (telemetry)	STAT	STAT	-	STAT	Continuous in ICU; telemetry on floor	HR 60-100; sinus rhythm	Bradycardia: atropine; tachycardia: volume, pain control; arrhythmia: per ACLS
Neurologic exam (cranial nerves, strength, reflexes)	STAT	STAT	ROUTINE	STAT	q4-8h; focus on pupillary response, ptosis, bulbar function, proximal then distal strength	Stable or improving; descending pattern is characteristic	Worsening (new cranial nerve palsies, progressing to limbs) -> reassess respiratory status STAT; ensure antitoxin given
Pupillary examination	STAT	STAT	ROUTINE	STAT	q4h	Reactive, symmetric pupils	Fixed, dilated pupils (mydriasis) suggest botulism (distinguishes from GBS/MG); document progression
Swallowing function	URGENT	STAT	ROUTINE	STAT	Daily assessment; formal SLP if bulbar symptoms	Safe oral intake	NPO if unsafe; NG tube or PEG for nutrition
Gag reflex and cough strength	STAT	STAT	ROUTINE	STAT	q4-6h	Present and strong	Absent gag -> NPO; aspiration precautions; suction at bedside
Bowel function	-	ROUTINE	ROUTINE	ROUTINE	Daily	Regular bowel movements	Ileus is common (autonomic dysfunction); bowel program; avoid opioids if possible
Bladder function	-	ROUTINE	ROUTINE	ROUTINE	I/O monitoring; post-void residual if needed	Adequate output; PVR <200 mL	Urinary retention (autonomic dysfunction) -> bladder scan; intermittent catheterization
Renal function (BUN, Cr)	-	ROUTINE	-	ROUTINE	Daily in acute phase; q48h when stable	Stable creatinine	Adjust medications; hydration
Wound inspection (wound botulism)	-	STAT	ROUTINE	STAT	BID wound checks post-debridement	Clean, healing wound; no signs of re-infection	Signs of infection -> repeat debridement; adjust antibiotics

7. DISPOSITION CRITERIA¶

Disposition	Criteria
Discharge home	Extremely rare in acute botulism; only for VERY mild cases (minimal weakness, stable respiratory function, no bulbar symptoms); reliable outpatient follow-up; family/caregiver support; neurology follow-up within 1-2 weeks
Admit to ICU (MOST patients)	All suspected botulism should be admitted to ICU or monitored setting; respiratory monitoring (FVC/NIF) required; any bulbar weakness; any respiratory compromise; antitoxin administration and monitoring; autonomic instability
Admit to floor (monitored bed)	Mild cases after antitoxin with stable respiratory function (FVC >25 mL/kg and stable); no bulbar weakness; able to protect airway; continuous telemetry available; step-down from ICU when improving
Transfer to higher level of care	Need for ICU with neurology and critical care expertise; need for antitoxin (coordinate with CDC for transfer if antitoxin unavailable locally); ECMO capability if refractory respiratory failure
Inpatient rehabilitation	Significant residual motor deficits; able to participate in 3h/day therapy; medically stable; ventilator weaned or stable tracheostomy
Skilled nursing facility	Unable to tolerate intensive rehabilitation; requires ongoing nursing care; ventilator-dependent (long-term acute care facility — LTAC)
Long-term acute care (LTAC)	Prolonged ventilator dependence (common in botulism — weeks to months); requires weaning protocol; medically stable but not ready for rehab

8. EVIDENCE & REFERENCES¶

Recommendation	Evidence Level	Source
Heptavalent botulinum antitoxin (HBAT) — early administration reduces mortality and duration of illness	Class IIa, Level B	Arnon et al. JAMA 2006; Tacket et al. Am J Med 1984
BabyBIG (human botulism immune globulin) for infant botulism — reduces hospitalization by 3+ weeks	Class I, Level A	Arnon et al. N Engl J Med 2006
EMG/NCS with repetitive nerve stimulation — incremental response at high-rate stimulation diagnostic	Class IIa, Level B	Cherington M. J Neurol Neurosurg Psychiatry 1982; Gutierrez et al. Muscle Nerve 2000
Mouse bioassay — gold standard for botulinum toxin detection; serum sensitivity ~33-44%	Class IIa, Level C	CDC. MMWR Recomm Rep 1998
Respiratory monitoring (FVC/NIF) for intubation decisions in neuromuscular respiratory failure	Class I, Level B	Lawn et al. Arch Neurol 2001; Wijdicks & Borel, Neurology 1998
Wound debridement AFTER antitoxin administration for wound botulism	Class IIa, Level C	Werner et al. Clin Infect Dis 2000; CDC guidelines
Avoid aminoglycosides — potentiate neuromuscular blockade in botulism	Class III (Harm), Level C	Santos et al. Ann Intern Med 1981
Contact CDC Emergency Operations Center (770-488-7100) for antitoxin access	Class I, Level C	CDC Botulism Treatment Guidelines
Botulism is a nationally notifiable disease — mandatory reporting	Class I, Level C	CDC nationally notifiable conditions; state public health law
Do not administer antibiotics in infant botulism (risk of toxin release from bacterial lysis)	Class III (Harm), Level C	Arnon et al. N Engl J Med 2006; IBTPP guidelines
Prolonged mechanical ventilation expected (median 58 days type A; 26 days type B)	Class IIa, Level B	Wilcox et al. Chest 1990
DVT prophylaxis for immobilized patients	Class I, Level C	Standard of care for immobilized patients
Early rehabilitation improves functional outcomes	Class I, Level B	Standard of care in neuromuscular disease
Metronidazole preferred over aminoglycosides for wound botulism antibiotic therapy	Class IIa, Level C	Expert consensus; Werner et al. Clin Infect Dis 2000
Succinylcholine avoidance in neuromuscular junction disorders	Class III (Harm), Level C	Risk of hyperkalemia and prolonged blockade
Antitoxin most effective when given within 24h of symptom onset; still beneficial up to 72h	Class IIa, Level B	Tacket et al. Am J Med 1984; retrospective data

APPENDIX A: BOTULISM TYPES AND CLINICAL FEATURES

Type	Source/Mechanism	Typical Onset	Key Features	Antitoxin
Foodborne	Pre-formed toxin ingested in contaminated food (home-canned goods, fermented fish, honey-based products)	12-36h (range 6h-10 days)	GI prodrome (N/V/D) -> cranial nerve palsies -> descending paralysis	HBAT (adults)
Wound	C. botulinum colonizes wound (IVDU — black tar heroin skin-popping); toxin produced in vivo	4-14 days after wound contamination	NO GI prodrome; wound infection signs; fever; descending paralysis	HBAT + antibiotics + debridement
Infant	C. botulinum spores colonize infant gut (honey, soil, dust); toxin produced in vivo	Gradual (days)	Age <1 year; constipation, poor feeding, weak cry, floppy infant, descending weakness	BabyBIG (human-derived)
Iatrogenic	Therapeutic/cosmetic botulinum toxin (onabotulinumtoxinA, etc.) overdose or systemic spread	Hours to days post-injection	Local then systemic weakness; dose-related; history of recent injection	Supportive care; HBAT if systemic
Adult intestinal colonization	Rare; similar to infant botulism but in adults (GI surgery, altered flora, antimicrobial use)	Gradual	Similar to foodborne but without clear food source; prolonged course	HBAT
Inhalational	Aerosolized toxin (bioterrorism concern); not naturally occurring	12-80h post-exposure	No GI prodrome; same descending paralysis pattern	HBAT

APPENDIX B: EMG/NCS FINDINGS IN BOTULISM vs. KEY DIFFERENTIALS

Parameter	Botulism	GBS (AIDP)	Myasthenia Gravis	Lambert-Eaton (LEMS)
CMAP amplitude	Reduced (especially type A)	Normal early; reduced in axonal variants	Normal	Reduced
SNAP amplitude	Normal	Reduced or absent	Normal	Normal
Distal latency	Normal	Prolonged (demyelinating)	Normal	Normal
Conduction velocity	Normal	Slow (demyelinating)	Normal	Normal
F-waves	Normal	Prolonged or absent	Normal	Normal
Low-rate RNS (2-3 Hz)	Decremental (mild)	Normal or decremental	Decremental (>10%)	Decremental
High-rate RNS (20-50 Hz)	INCREMENTAL (>100% facilitation)	No facilitation	No significant change	INCREMENTAL (>100%)
Post-exercise facilitation	Present	Absent	No improvement or worse	Present (marked)
Needle EMG	BSAPs; fibrillations in severe cases	Fibrillations if axonal; normal early	Normal or myopathic in severe	Normal or myopathic

APPENDIX C: CDC ANTITOXIN ACCESS PROTOCOL

Step	Action
1	Clinical suspicion of botulism established (do NOT wait for lab confirmation)
2	Contact state/local health department IMMEDIATELY
3	Contact CDC Emergency Operations Center: 770-488-7100 (24/7)
4	CDC releases HBAT from nearest Strategic National Stockpile (SNS) location
5	Typical delivery time: 1-2 hours within continental US after CDC approval
6	Perform skin test for equine sensitivity BEFORE infusion (per CDC protocol included with antitoxin)
7	Administer antitoxin: dilute 1:10 in NS; slow IV infusion; epinephrine at bedside
8	Collect pre-treatment specimens (serum, stool, wound if applicable) for confirmatory testing
9	Monitor for anaphylaxis (acute) and serum sickness (10-21 days post-infusion)

APPENDIX D: RESPIRATORY MONITORING AND INTUBATION THRESHOLDS

Parameter	Threshold for Intubation	Notes
FVC	<15-20 mL/kg	More aggressive threshold than GBS due to rapid progression
NIF (MIP)	Weaker than -30 cmH2O	Same threshold as GBS
FVC decline	>30% from baseline	Trend is critical — check frequently
pCO2	Rising above 45-50 mmHg	Indicates hypoventilation; late sign
SpO2	<94%	Very late sign — do NOT wait for desaturation
Clinical signs	Dyspnea, use of accessory muscles, paradoxical breathing, tachypnea >30, inability to count to 20, weak cough, inability to swallow secretions	Clinical judgment is essential
Special consideration	Botulism patients may require PROLONGED ventilation (type A median 58 days; type B median 26 days); plan for early tracheostomy	Discuss with patient/family early

CHANGE LOG¶

v1.1 (February 2, 2026) - Validated per checker pipeline (v1.1) - Standardized Section 4A (Referrals & Consults) to 5-column format (Recommendation | ED | HOSP | OPD | ICU); merged Indication content into Recommendation column - Standardized all structured dosing fields to empty third field format (dose :: route :: :: full_instructions) across Sections 3A, 3B, 3C, 3D to match approved plan conventions - Fixed intubation dosing field from erroneous "20 mL/kg" first field to "N/A" (intubation is a procedure, not a medication dose) - Fixed pneumatic compression devices dosing field to use "N/A" first field (non-medication intervention) - Updated OT contraindications from "Same as PT" to explicit "Hemodynamic instability" (removed cross-reference)

v1.0 (February 2, 2026) - Initial template creation - Comprehensive botulism management covering foodborne, wound, iatrogenic, infant, and adult intestinal colonization forms - Structured dosing format for all medications - CDC antitoxin access protocol included - EMG/NCS differential table (botulism vs. GBS vs. MG vs. LEMS) - Respiratory monitoring thresholds with botulism-specific considerations - Complete differential diagnosis section with 13 alternative diagnoses - Critical medication warnings (aminoglycosides, succinylcholine, antibiotics in infant botulism)