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Botulism is caused by a neurotoxin produced by Clostridium botulinum, which ultimately leads to a flaccid paralysis. There are four forms of botulism based on site of toxin production: food‐borne, wound, intestinal, and inhalational [45].

In food‐borne botulism, early symptoms are non‐specific and gastrointestinal, including nausea, vomiting, and diarrhea. This may progress to blurred vision, double vision, dry mouth, and difficulty in swallowing, breathing, and speaking. Descending muscle paralysis occurs, starting with shoulders, and progressing to upper arms, lower arms, thighs, and then calves. Respiratory muscle paralysis ultimately leads to death. Food‐borne botulism is caused by the ingestion of C. botulinum toxin present in contaminated food, or by deliberate contamination as a biologic weapon. The case‐fatality rate in the US is 5‐10%.

Intestinal botulism is rare and occurs mainly in infants. It causes a striking loss of head control, diminished suckling and crying ability, constipation, and respiratory failure. Intestinal botulism occurs with ingestion of botulism spores, rather than ingestion of toxin. Spores, which may come from honey, food, and dust, germinate in the colon [45]. The case‐fatality rate of hospitalized cases is less than 1%.

Wound botulism causes the same symptoms as food‐borne botulism. This is rare and is caused by spores entering an open wound from soil or gravel.

Inhalational botulism is the most common form in the case of use of botulinum toxin as a biologic weapon. Symptoms are the same as food‐borne botulism, but the incubation period may be longer.

Botulism is not transmitted person to person. Therefore, EMS personnel should use standard precautions when caring for patients with suspected or known botulism. No special equipment is required. In the case of suspected aerosol exposure to the toxin, clothing should be removed and placed in plastic bags, and the exposed person should shower thoroughly.

Treatment in the prehospital setting consists of supportive care and transport to the hospital. Botulinum antitoxin administered as soon as possible will arrest progression of symptoms but will not reverse paralysis. Recovery follows the regeneration of new neuromuscular connections. Treatment for wound botulism may also include antibiotic therapy and wound debridement to remove the source of toxin‐producing bacteria.