When do patients with descending paralysis and suspected botulism require inpatient EMG?

If a health care provider suspects botulism in a patient presenting with descending paralysis (beginning from the cranial/bulbar region) and certain clues such as autonomic nerve involvement with dilated poorly reactive pupils, constipation, etc. can help, then treatment must be administered immediately, including antitoxin and supportive care (ICU admission, intubation if necessary) before the diagnosis is confirmed, exactly because the disease can lead to death within hours. In such urgent scenarios, the goal of diagnostic evaluation should be to confirm the diagnosis as soon as possible. If EMG is available, it must be done; high-frequency repetitive nerve stimulation in sedated patients, or low-frequency rep stim in awake patients with ...