treatmetreatmentntOur goal is : Our goal is :

11))meticulous supportive caremeticulous supportive care..2)Prevent complication.2)Prevent complication.

ICUICU

Infant type : : ICU ICU antitoxin.antitoxin. antibiotics?antibiotics? Food born type: * elimination of toxins from GIT (lavag, * elimination of toxins from GIT (lavag,

induce vomiting, high enema.)induce vomiting, high enema.) * Neutralization of toxins (antitoxins).* Neutralization of toxins (antitoxins). * supportive care( ABC ).* supportive care( ABC ). *inhibition of toxin production *inhibition of toxin production (antibiotic).(antibiotic). Wound type: (surgical ,antitoxins, (surgical ,antitoxins,

antibiotic).antibiotic).

PositionPosition Maintain airway & breathing (face up-on bed 30Maintain airway & breathing (face up-on bed 30o)o)

Small cloth roll is placed under cx vert. to title the Small cloth roll is placed under cx vert. to title the Head back soHead back sodrain the Secretion drain the Secretion

+abd. Viscera pull the Diaphragm down +abd. Viscera pull the Diaphragm down inc resp.movement.inc resp.movement. Bending the middle of the bedBending the middle of the bed maintain head maintain head

& trunk not elevated (if done & trunk not elevated (if done hypotonic thorax hypotonic thorax will slump into the Abdomenwill slump into the Abdomendec.resp.)dec.resp.)

Endotrachial Endotrachial tubetube

50%50% of cases will need of cases will need it.it.

Indication Indication *dec. gag reflex,*dec. gag reflex, *dec. cough *dec. cough reflexreflex * progressive * progressive airwayairway obsructionobsruction Best done prophylactically.Best done prophylactically.

FeedingFeedingnaso gastric or naso jeujenal naso gastric or naso jeujenal

tubetube is better than IV fluid ttt is better than IV fluid ttt (as this may take prolonged time)(as this may take prolonged time)

Bladder careBladder care

When bladder palsy occur When bladder palsy occur gentle suprapubic pressure while the Pt gentle suprapubic pressure while the Pt

is sitting and with the Head supportedis sitting and with the Head supported complete voiding complete voiding so so avoiding UTIavoiding UTI

Emetics:Emetics: Avoid magnesium containing Lavage Avoid magnesium containing Lavage

( ( push toxins downpush toxins down))

Enemas:Enemas: * Not when paralytic ileus. * Not when paralytic ileus. * High enema to eliminate !* High enema to eliminate ! Unabsorbed toxinsUnabsorbed toxins

AAntibioticsntibiotics Not needed in infant or food born Not needed in infant or food born

type……………………………..why?type……………………………..why? As bacterial lysis and death ocuur in the As bacterial lysis and death ocuur in the Intestine where the Toxins releasedIntestine where the Toxins released..**Indication:Indication: 1-wound type.1-wound type. 2-22-2ndnd bacterial infection as pneumonia. bacterial infection as pneumonia.**Contra indication:Contra indication: the Use of aminoglycosids (potentiate the the Use of aminoglycosids (potentiate the

blocking effect of toxin at MIP.blocking effect of toxin at MIP.

DRUGSDRUGS*penicillin G or trimethoprem\*penicillin G or trimethoprem\

sulphamethoxazol.sulphamethoxazol.

*avoid drugs which inhibit resp. center *avoid drugs which inhibit resp. center (eg. sedative , (eg. sedative , metchlopramid)metchlopramid)

*constipation *constipation (fluid + stool softener)(fluid + stool softener)

Specific ttt (anti Specific ttt (anti toxins)toxins)

Human derived antitoxins.Human derived antitoxins.Expensive but Expensive but 1- dec. the time of hospital 1- dec. the time of hospital

addmission addmission (5.5 W(5.5 W 2.5W). 2.5W). 2- dec. hospital cost by 70,000 $.2- dec. hospital cost by 70,000 $.

Should start as early as possible.Should start as early as possible.

anti toxinsanti toxins Most useful in 1st 24 hours.Most useful in 1st 24 hours. Trivalent ABE .Trivalent ABE .

Obtain from CDC: 404-639-3753 (day); 404-639-Obtain from CDC: 404-639-3753 (day); 404-639-2888 (night) .2888 (night) .

Use on clinical diagnosis: Without waiting for lab Use on clinical diagnosis: Without waiting for lab confirmation.confirmation.

Lowers fatality rate & shortens illnessLowers fatality rate & shortens illness (For Type A) .(For Type A) .

Complications (immune): 9% Complications (immune): 9%

ComplicationComplication

Due to:Due to: 1- prolonged hospitalization( w1- prolonged hospitalization( wss- m- mss)) 2- pt is under ventilator.2- pt is under ventilator. 3- nosocomial infections.3- nosocomial infections. 4- iatrogenic. 4- iatrogenic.

ComplicationComplication ARDS.ARDS. Aspiration.Aspiration. OM.OM. Pneumonia.Pneumonia. Tension pneumothorax.Tension pneumothorax. Recurrent atelactsis.Recurrent atelactsis. Trachiitis.Trachiitis. Subglotis stenosis.Subglotis stenosis. UTI , convulsion(<Na) , sepsis , transfution UTI , convulsion(<Na) , sepsis , transfution

reaction.,,,,,,reaction.,,,,,,

SequelsSequels1- chronic fatigue.1- chronic fatigue.

2- > incidence of strabismus.2- > incidence of strabismus.

PrognosisPrognosis Ventilator dependence frequency:Ventilator dependence frequency: Type A > B > E .Type A > B > E . Slow improvement in Slow improvement in strength strength over weeks to over weeks to

months .months . 1 year: Most near normal ± fatigue .1 year: Most near normal ± fatigue . Autonomic functionAutonomic function may improve later than may improve later than

weakness .weakness . Mortality:Mortality: 5% to 10% . 5% to 10% . ~10% of sudden unexpected death ~10% of sudden unexpected death in in

infancyinfancy is caused by botulism is caused by botulism

PreventionPrevention 1)Canning or preserving foods1)Canning or preserving foods with appropriate heat, pressure, & with appropriate heat, pressure, &

low pH.low pH.

by:by:** boiling for 10 minutes boiling for 10 minutes destroy ! Toxins. destroy ! Toxins. * pressure cooker (>115.5 c) * pressure cooker (>115.5 c) destroy ! Spores. destroy ! Spores.

PreventionPrevention2-Avoid exposure of infants to honey2-Avoid exposure of infants to honey ((10%may 10%may

contain Clostridium botulinum sporescontain Clostridium botulinum spores).).

3-Botulinum intoxication3-Botulinum intoxication: : No immunity from No immunity from subsequent episodes.subsequent episodes.

4-Immunization4-Immunization ((Pentavalent toxoid -Used only for Pentavalent toxoid -Used only for high risk personnel: Laboratory workers; Militaryhigh risk personnel: Laboratory workers; Military ). ).

5-in wound type5-in wound type good debridement & antibioticsgood debridement & antibiotics..

Infection ControlInfection Control Isolation PrecautionsIsolation Precautions

In the hospital settingIn the hospital setting:: standard precautions are adequate as standard precautions are adequate as

person to person to personperson transmissions dose not transmissions dose not occuroccur..

In the laboratory settingIn the laboratory setting:: sodium hypochlorite or sodium sodium hypochlorite or sodium

hydroxide inactivate the toxinhydroxide inactivate the toxin

Pt secret Pt secret clostridium clostridium botioliniumbotiolinium in stool for in stool for weeksweeks

soso be carful be carful when handling pt when handling pt

secretion.secretion.

Always remember

Botox injectionsBotox injections:: The bacterium Clostridium botulinum is the The bacterium Clostridium botulinum is the

same bacterium that is used to produce same bacterium that is used to produce Botox .Botox . a pharmaceutical used as injections for clinical a pharmaceutical used as injections for clinical

and cosmetic use. and cosmetic use.

However, what is used in Botox treatments is However, what is used in Botox treatments is the purified and the purified and diluted A neurotoxin.diluted A neurotoxin.

Occasionally there may be some side effects.Occasionally there may be some side effects.

small amounts of purified botulinum toxin small amounts of purified botulinum toxin injected into affected musclesinjected into affected muscles

purified botulinum toxin injected into purified botulinum toxin injected into affected musclesaffected muscles Examples include: Examples include: Spasmodic torticollis Spasmodic torticollis Strabismus Strabismus Blepharospasm Blepharospasm Laryngeal dystonia Laryngeal dystonia Focal dystonias of the hand Focal dystonias of the hand Limb spasticity Limb spasticity Hemifacial spasm Hemifacial spasm Cerebral palsy Cerebral palsy Migraine headache Migraine headache Hyperhydrosis Hyperhydrosis Post-stroke spasticity Post-stroke spasticity

Can botulism be used asCan botulism be used as a a bioterrorismbioterrorism

threat?threat?

Aerosolized botulinum toxin is a Aerosolized botulinum toxin is a possible mechanism for a possible mechanism for a bioterrorism attack bioterrorism attack

Inhalational botulism does not Inhalational botulism does not occur naturallyoccur naturally..

conclusionconclusion Is acute flaccid paralytic illness caused by the Is acute flaccid paralytic illness caused by the

neurotoxins.neurotoxins.

3 form of human botulism:3 form of human botulism: (infant , food borne , wound botulism,.)(infant , food borne , wound botulism,.)

Clinical picture is enough for diagnosis acute Clinical picture is enough for diagnosis acute onset of flaccid paralysis clear sensorium onset of flaccid paralysis clear sensorium

no fever , no par aesthesia.no fever , no par aesthesia.

Ttt is urgent referral to ICU .Ttt is urgent referral to ICU .

جزاكم الله خيراجزاكم الله خيرا