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Cholinesterase Inhibitors: Including Insecticides and Chemical Warfare Nerve Agents
Part 4: The Cholinergic Toxidrome
Section 11: Management of the Cholinergic Toxidrome
Management Strategy 2: Supportive Care

Course: WB 1098
CE Original Date: October 16, 2007
CE Renewal Date: October 16, 2010
CE Expiration Date: October 16, 2012
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Learning Objectives

Upon completion of this section, you should be able to

  • Identify the most important organ system requiring supportive care in patients suffering from the cholinergic toxidrome.


Monitoring and intensive supportive care are critical components of patient management in severe poisoning cases. Monitoring of exposed patients may need to be prolonged because of the possibility of delayed onset of effects from cholinesterase inhibitors.

Importance of Respiratory Support

Death from cholinesterase inhibitor poisoning is usually due to respiratory failure from a combination of: (Zwiener and Ginsburg 1988; Sofer, Tal et al. 1989; Reigart and Roberts 1999)

  • Bronchoconstriction.
  • Bronchorrhea.
  • Central respiratory depression.
  • Weakness or paralysis of respiratory muscles.

Therefore, early, aggressive respiratory support is a mainstay of treatment, including endotracheal intubation and mechanical ventilation when indicated.

Key Points

  • Supportive care plays a critical role in the medical management of the cholinergic toxidrome.
  • Aggressive respiratory support is particularly important, since respiratory failure is the usual cause of fatality.

Progress Check

33. The most important aspect of supportive care for cholinesterase inhibitor toxicity is aimed at: (Choose the ONE BEST answer)

A. The cardiovascular system.
B. The respiratory system.
C. The liver and kidneys.
D. The digestive tract.
E. None of the above.


To review relevant content, see Importance of Respiratory Support in this section.

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