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Cholinesterase Inhibitors: Including Insecticides and Chemical Warfare Nerve Agents
Part 4: The Cholinergic Toxidrome
Section 12: Public Health and Medico-Legal Issues

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

  • Describe the importance of notifying public health authorities and other emergency response agencies in poisonings due to cholinesterase inhibitors.


Healthcare workers are often the first to identify a sentinel patient in what turns out to be a full-blown disease outbreak, (Reigart and Roberts 1999) disaster, or terrorist attack.

Several actions are important to take to reduce morbidity and mortality in cholinesterase poisoning cases.

  • Notification of appropriate public health agencies.
  • Determination if the patient's history suggests that others may also have been exposed.
  • If information suggests the possibility of a multi-casualty or terrorist event, prompt notification of other emergency response agencies in the area (e.g., area hospitals, clinics, urgent care centers, private physician offices, emergency management offices, fire departments, police, EMS providers, hazmat teams and poison centers) so they can have advance notice and be prepared to handle a hazardous materials emergency.

Saving of clothing, body fluids, and belongings in a safe, secured area in case needed for evidence (preserve the chain of evidence). This should be done in a way that also protects against secondary exposure.

Key Points

  • Accidents and terrorist attacks involving cholinesterase inhibitors have the potential of affecting multiple victims.
  • An important aspect of patient management is to notify public health agencies, and other emergency response agencies (e.g., fire departments, police, EMS providers, hazmat teams, poison centers, and other hospitals, clinics, urgent care centers, and private physician offices) accomplishing this task rapidly.
  • Isolate and save potential forensic evidence (e.g., clothing, body fluid samples, and belongings).

Progress Check

44. Which of the area emergency response agencies should be promptly notified in the event of a cholinesterase inhibitor exposure with the potential for multiple victims? (Choose ALL correct answers)

A. Area EMS providers.
B. Private physicians' offices.
C. The local/regional poison center.
D. The public health agency.
E. None of the above.


To review relevant content, see Introduction in this section.

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Agency for Toxic Substances and Disease Registry, 4770 Buford Hwy NE, Atlanta, GA 30341
Contact CDC: 800-232-4636 / TTY: 888-232-6348

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