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Cholinesterase Inhibitors: Including Insecticides and Chemical Warfare Nerve Agents
Assessment and Posttest Instructions

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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Introduction

ATSDR seeks feedback on this course so we can assess its usefulness and effectiveness. We ask you to complete the assessment questionnaire online for this purpose.

In addition, if you complete the assessment and posttest online, you can receive continuing education credits as follows:

Accrediting Organization
Credits Offered

Accreditation Council for Continuing Medical Education (ACCME)

CME: The Centers for Disease Control and Prevention is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The Centers for Disease Control and Prevention designates this educational activity for a maximum of 3.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

American Nurses Credentialing Center (ANCC), Commission on Accreditation

CNE: The Centers for Disease Control and Prevention is accredited as a provider of Continuing Nursing Education by the American Nurses Credentialing Center's Commission on Accreditation. This activity provides 3.5 contact hours.

National Commission for Health Education Credentialing, Inc. (NCHEC)

CHES: The Centers for Disease Control and Prevention is a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is a designated event for the Certified Health Education Specialist (CHES) to receive 3.5 Category I contact hours in health education, CDC provider number GA0082.

International Association for Continuing Education and Training (IACET)

CEU: The CDC has been approved as an Authorized Provider by the International Association for Continuing Education and Training (IACET), 1760 Old Meadow Road, Suite 500, McLean, VA 22102. The CDC is authorized by IACET to offer 0.3 IACET CEU's for this program.

Online Instructions

To complete the assessment and posttest, go to Training and Continuing Education Online and follow the instructions on that page.

You can immediately print your continuing education certificate from your personal transcript online. No fees are charged.

Posttest

  1. Which of the following community emergency response agencies should be involved in planning for disasters such as those involving mass exposures to cholinesterase inhibitors? (Choose ALL correct answers)
    1. Emergency management/disaster offices
    2. All area hospitals
    3. The poison center
    4. Fire departments
    5. EMS providers
    6. The Local Emergency Planning Committee (LEPC)
    7. None of the above
  2. Which of the following should be assumed to happen with incidents involving patients acutely exposed to cholinesterase inhibitors (Choose ALL correct answers)
    1. Patients will be transported to the hospital without having been decontaminated
    2. Chemically exposed patients will be sent to a single hospital in the community designated for chemical casualties
    3. Contaminated patients will arrive unannounced
    4. None of the above
  3. Cholinesterase inhibitor toxicity leads to (Choose ALL correct answers)
    1. Excessive cholinesterase activity
    2. Depression of cholinesterase activity
    3. Excessive amounts of acetylcholine
    4. Occupation of cholinesterase binding sites by the cholinesterase inhibitor
    5. None of the above
  4. Which of the following are among the 4 major types of pathology caused by cholinesterase inhibitors? (Choose ALL correct answers)
    1. The cholinergic toxidrome
    2. The acute polyneuropathic syndrome
    3. The intermediate syndrome
    4. Organophosphate-induced delayed neuropathy
    5. None of the above
  5. The key function of nicotinic receptors is to (Choose ALL correct answers)
    1. Trigger excretion of exocrine glands
    2. Trigger rapid neural and neuromuscular transmission
    3. Suppress rapid neural and neuromuscular transmission
    4. Modulate intrinsic rhythmic electrical and mechanical activity
    5. None of the above
  6. Which of the following effects of acute cholinesterase toxicity involve nicotinic receptors? (Choose ALL correct answers)
    1. Sweating
    2. Miosis (pupillary constriction)
    3. Hyperglycemia
    4. Fasciculations
    5. None of the above
  7. In which of the following anatomical locations are nicotinic receptors found? (Choose ALL correct answers)
    1. Neuromuscular junctions
    2. Sympathetic nervous system
    3. Autonomic ganglia
    4. Central nervous system
    5. None of the above
  8. Muscarinic receptors (Choose ALL correct answers)
    1. Are faster to respond than nicotinic receptors
    2. Are not found in the central nervous system
    3. Trigger bronchodilation
    4. Trigger mostly sympathetic nervous system effects
    5. None of the above
  9. Which of the following are true about the cholinergic toxidrome? (Choose ALL correct answers)
    1. CNS effects are mediated by both nicotinic and muscarinic receptors
    2. CNS effects can mimic mental illness
    3. Uncontrolled seizures can lead to long-term CNS effects
    4. Seizures are more common in adults than children
    5. None of the above
  10. Acute cholinesterase inhibitor toxicity has been known to result in the following laboratory abnormalities (Choose ALL correct answers)
    1. Leukocytosis
    2. Peaked T-waves on EKG
    3. Elevated serum glucose
    4. Hyperkalemia or hypokalemia
    5. None of the above
  11. Which of the following medical conditions can be mimicked by cholinesterase inhibitor toxicity? (Choose ALL correct answers)
    1. Mental illness
    2. Food poisoning
    3. Opiate overdose
    4. Influenza
    5. None of the above
  12. Pediatric cholinesterase inhibitor poisoning differs from that in adults in the following ways (Choose ALL correct answers)
    1. Seizures are less likely
    2. Nicotinic effects are more likely
    3. Fasciculations are more common
    4. Bradycardia is less common
    5. None of the above
  13. Potential sources of exposure to cholinesterase inhibitors include which of the following (Choose ALL correct answers)
    1. Insecticides
    2. Antiparkinson drugs
    3. Snake venom
    4. Malaysian Bean sprouts
    5. None of the above
  14. Which of the following questions should be included in history for suspected cholinesterase inhibitor exposure? (Choose ALL correct answers)
    1. Typical work activities
    2. Medications
    3. Hobbies
    4. Use of traditional or ethnic remedies
    5. None of the above
  15. Which of the following are true about laboratory tests for cholinesterase inhibitor toxicity? (Choose ALL correct answers)
    1. The rapid availability of RBC cholinesterase levels, compared to serum cholinesterase levels makes them a useful tool for the emergency management of acutely toxic patients
    2. Reduction in RBC cholinesterase levels to normal is a good end point for titration for initial doses of 2-PAM
    3. Normal ranges of serum cholinesterase vary widely among individuals, but RBC cholinesterase level normals vary little among individuals
    4. Since the imposition of federal laboratory standards, the normal ranges for serum and RBC cholinesterase levels are the same for each laboratory
    5. None of the above
  16. Supportive care is an important aspect of treatment for the cholinergic toxidrome and should be focused primarily on maintaining and improving (Choose the ONE BEST answer)
    1. Renal function
    2. Hepatic function
    3. Respiratory function
    4. CNS function
    5. None of the above
  17. Atropine counteracts cholinesterase inhibitor toxicity by (Choose the ONE BEST answer)
    1. Competitively occupying muscarinic receptor sites
    2. Competitively occupying nicotinic receptor sites
    3. Competitively occupying nicotinic and muscarinic receptor sites
    4. Neutralizing acetylcholine
    5. None of the above
  18. Which of the following is/are the best end-points against which to titrate the dose of atropine in acute cholinesterase poisoning? (Choose the ONE BEST answer)
    1. Pupillary dilation
    2. Pupillary constriction
    3. Clinically significant reduction of bronchorrhea and bronchoconstriction, (as reflected by level of oxygenation and ease of ventilation)
    4. Development of heart rate of between 100-150/min
    5. Return of consciousness
    6. Return of muscle strength
    7. all of the above
    8. None of the above
  19. In order of preference, the best routes of atropine administration are: (Choose the ONE BEST answer)
    1. Intramuscular is better than Intravenous which is better than Autoinjector
    2. Intravenous is better than Autoinjector which is better than Intramuscular
    3. Autoinjector is better than Intravenous which is better than Intramuscular
    4. Intravenous is better than Intramuscular which is better than Autoinjector
    5. Intravenous is best; Intramuscular and Autoinjector are equally good
    6. None of the above
  20. Which type of cholinesterase toxicity can require the highest doses of atropine? (Choose the ONE BEST answer)
    1. Inhalation of nerve agent
    2. Dermal exposure to organophosphorus agents
    3. Suicidal ingestion of organophosphorus agents
    4. Ingestion of carbamates
  21. Which of the following are true about 2-PAM? (Choose ALL correct answers)
    1. It should never be used in carbamate poisoning
    2. It works by attaching to the cholinesterase inhibitor bound to cholinesterase, attaching to and removing the inhibitor
    3. It reduces the effectiveness of atropine
    4. It is ineffective after aging occurs
    5. None of the above
  22. Which of the following are reasons for treatment failure with 2-PAM? (Choose ALL correct answers)
    1. Inadequate dose
    2. Co-administration of atropine
    3. Redistribution of cholinesterase inhibitor from fat tissue
    4. Aging has already occurred
    5. None of the above
  23. Which of the following lead to delayed aging, and therefore prolongation of the time course when 2-PAM is still effective? (Choose ALL correct answers)
    1. Co-administration of atropine
    2. Poisoning from fat-soluble organophosphorus compounds
    3. Dermal exposure
    4. Poisoning with chemicals that must be metabolically converted before they possess cholinesterase inhibiting properties
    5. None of the above
  24. Which of the following is true about seizures resulting from cholinesterase inhibitors? (Choose ALL correct answers)
    1. They are more common in adults than in children
    2. Although diazepam is effective in controlling seizures, it has not been shown to improve clinical outcome
    3. Diazepam should not be used unless seizures occur
    4. CNS damage from cholinesterase inhibitors is due to a direct toxic effect, not seizure activity
    5. None of the above
  25. Which of the following are currently recommended in the routine treatment of poisoning?
    1. Syrup of ipecac
    2. Gastric lavage
    3. Cathartics
    4. Activated charcoal
    5. None of the above
  26. Which of the following is true regarding the intermediate syndrome? (Choose ALL correct answers)
    1. It most commonly occurs after nerve agent poisoning
    2. If good supportive care has been given and there is no hypoxic damage, the condition usually resolves spontaneously
    3. Atropine is indicated if muscarinic signs are present
    4. Delayed, but sudden-onset of respiratory weakness or paralysis may occur, leading to respiratory failure
    5. None of the above
  27. Which of the following are true about Organophosphate-induced delayed neuropathy (OPIDN)? (Choose ALL correct answers)
    1. It is caused by a molecular alteration of nicotinic receptors at the neuromuscular junction of distal skeletal muscle groups
    2. Pain is not a characteristic symptom
    3. If there has not been any hypoxic damage, and good supportive care has been given, full recovery is the rule
    4. Early and adequate doses of 2-PAM and atropine have been shown to prevent this condition
    5. None of the above
  28. Which of the following are true about Organophosphorus ester-induced neurotoxity (OPICN) (Choose ALL correct answers)
    1. It is a set of long-term, persistent neuropsychiatric signs and symptoms
    2. No specific treatment has been identified
    3. Studies carried out to assess whether the condition can occur after asymptomatic exposures to cholinesterase inhibitors have suffered from methodological problems
    4. It occurs when cholinesterase inhibitors trigger a permanent defect in neurotarget esterase
    5. None of the above
  29. Which of the following are true about cholinesterase inhibitors? (Choose ALL correct answers)
    1. Chronic, asymptomatic exposure to cholinesterase inhibitors is associated with an increased risk of chronic lymphocytic leukemia
    2. Neural tube defects have been associated with symptomatic exposures during the first trimester of pregnancy
    3. The available evidence does not explain the myriad of symptoms of Gulf War Illness on the basis of exposure to cholinesterase inhibitors
    4. The Wenger-Herzold study demonstrated clinically significant long-term decrements in immunity in those with long-term exposure to organophosphorus compounds, but not carbamates
    5. None of the above
  30. The most characteristic early finding in intermediate syndrome is: (Choose the ONE BESTanswer)
    1. Loss of sensation in distal extremities
    2. Inability of the patient to lift his/her head off the pillow
    3. Muscle fasciculations
    4. Profound salivation (liters per day)
    5. None of the above
  31. Muscarinic receptors are found in: (Choose ALL correct answers)
    1. Skeletal muscle
    2. Smooth muscle
    3. Exocrine glands
    4. Sweat glands
    5. None of the above
  32. Which of the following are true about the central nervous system effects of cholinesterase inhibitors (Choose the ONE BEST answer)
    1. The pathology can be explained on the basis of increased muscarinic, as opposed to nicotinic, receptor activity
    2. The pathology can be explained on the basis of increased nicotinic, as opposed to muscarinic, receptor activity
    3. The pathology is poorly understood but involves both nicotinic and muscarinic receptors
    4. None of the above
  33. Which of the following central nervous system signs and symptoms have been reported in cases of cholinesterase inhibitor poisoning? (Choose ALL correct answers)
    1. Anxiety
    2. Emotional lability
    3. Convulsions
    4. Excess dreaming
    5. None of the above
  34. Which of the following questions on an exposure history are appropriate for the physician to ask in a patient suffering from signs and symptoms suggestive of cholinesterase inhibitor poisoning? Choose ALL correct answers
    1. What are your hobbies?
    2. Do you cook with wild mushrooms?
    3. Does anyone at home have similar signs or symptoms?
    4. Do you handle venomous snakes?
    5. None of the above
  35. Cholinesterase inhibitors block the ability of acetylcholinesterase to break down acetylcholine by? (choose the ONE best answer)
    1. Occupying the binding site on cholinesterase to which the acetylcholine would attach
    2. Preventing the release of acetylcholine from its attachment on cholinesterase
    3. Attaching to acetylcholine which prevents its attachment to cholinesterase
    4. None of the above
  36. What causes the cholinergic toxidrome? (Choose the ONE best answer)
    1. An excess of acetylcholine
    2. A deficiency of acetylcholine
    3. An excess of acetylcholinesterase
    4. None of the above
  37. Where are cholinergic receptors are found? (Choose ALL correct answers)
    1. At the neuromuscular junction
    2. In the central nervous system
    3. In the sympathetic, peripheral nervous system
    4. In the parasympathetic, peripheral nervous system
    5. None of the above
  38. Nicotinic and muscarinic receptors differ in which the following ways (Choose ALL correct answers)
    1. They have different functions
    2. They have different mechanism by which they trigger signal transmission
    3. They may exist at different anatomical locations
    4. None of the above
  39. Why do excessive levels of acetylcholine (“The cholinergic toxidrome”) cause different signs and symptoms, depending on whether the nicotinic or muscarinic receptors are involved? (Choose ALL correct answers)
    1. Because some nicotinic and muscarinic receptors are located in and affect different anatomic structures
    2. Because nicotinic and muscarinic receptors are triggered by different neurotransmitters
    3. Because nicotinic and muscarinic receptors have different mechanisms of action
    4. None of the above
  40. Factors that account for variation in the clinical presentation of cholinesterase toxicity include: (Choose ALL correct answers)
    1. Route of exposure
    2. The balance of nicotinic and muscarinic effects on the sympathetic and parasympathetic nervous system
    3. Age of the patient
    4. The specific cholinesterase-inhibiting chemical
    5. None of the above
  41. Which of the following are major factors leading to respiratory failure in cases of cholinesterase inhibitor poisoning? (Choose ALL correct answers)
    1. Bronchodilation
    2. Central respiratory depression
    3. Weakness or paralysis of the respiratory muscles
    4. Excessive respiratory tract secretions
    5. None of the above
  42. Which of the following statements are true regarding serum or red blood cell cholinesterase levels? (Choose ALL correct answers)
    1. The use of these tests helps to avoid serious errors in emergency treatment
    2. With current technology, interindividual variation in results, is no longer a significant problem
    3. While percentage of inhibition in the same person may be different in different laboratories, the absolute cholinesterase values are usually the same
    4. None of the above
  43. Which of the following statements are true about the laboratory measurement of cholinesterase inhibitors themselves or their metabolites? (Choose ALL correct answers)
    1. Each test can measure only one chemical, so it is only useful if you know the specific chemical to which the patient was exposed
    2. The results are not usually available in time to guide emergency treatment
    3. The test results are usually very accurate
    4. None of the above
  44. Which of the following statements is true about the patient with exposure to cholinesterase inhibitors? (Choose ALL correct answers)
    1. If the patient has only been exposed to cholinesterase inhibitor vapor, there is no risk of secondary exposure
    2. If the patient has ingested a cholinesterase inhibitor, others can be exposed if the patient vomits
    3. More important than which decontamination fluid is used is how rapidly decontamination is initiated
    4. Water and soapy water are very effective decontamination fluids
    5. None of the above
  45. If a hospital receives a patient with cholinesterase inhibitor toxicity and there is the potential that others were also exposed at the scene, which of the following should be notified (Choose ALL correct answers)
    1. All other area hospitals
    2. The local fire department
    3. The poison center
    4. Area EMS providers
    5. None of the above

Relevant Content

To review content relevant to the posttest questions, see:

Question
Location of Relevant Content
1 Community preparedness
2 Community preparedness
3 What type of pathology do cholinesterase inhibitors cause?
4 What type of pathology do cholinesterase inhibitors cause?
5 Nicotine acetylcholine receptors
6 Nicotine acetylcholine receptors
7 Nicotine acetylcholine receptors
8 Muscarinic acetylcholine receptors
9 What is the cholinergic toxidrome?
10 Effects on routine laboratory tests
11 Differential diagnosis
12 Signs and symptoms: differences in pediatric cases
13 Who is at risk for exposure? The exposure history
14 Who is at risk for exposure? The exposure history
15 Effects on routine laboratory tests
16 Management strategy 2: Supportive care
17 Management strategy 3: Medications - Atropine
18 Management strategy 3: Medications
19 Management strategy 3: Medications
20 Management strategy 3: Medications
21 Management strategy 3: Medications – 2-PAM
22 Management strategy 3: Medications
23 Management strategy 3: Medications
24 Management strategy 3: Medications - Diazepam
25 Syrup of ipecac, gastric lavage, cathartics, and activated charcoal
26 The intermediate syndrome
27 Organophosphate-induced delayed neuropathy (OPIDN)
28 Organophosphorus ester-induced chronic neurotoxicity (OPICN)
29 Other issues related to cholinesterase inhibitor toxicity
30 The intermediate syndrome
31 Muscarinic acetylcholine receptors
32 Clinical findings are due to a mixture of nicotinic and muscarinic effects
33 Clinical findings are due to a mixture of nicotinic and muscarinic effects
34 Who is at risk for exposure? The exposure history
35 What are cholinesterase inhibitors?
36 The cholinergic toxidrome: What is the cholinergic toxidrome?
37 The cholinergic toxidrome: What is the cholinergic toxidrome?
38 The cholinergic toxidrome: What is the cholinergic toxidrome?
39 The cholinergic toxidrome: What is the cholinergic toxidrome?
40 The cholinergic toxidrome: Clinical findings in cholinesterase inhibitor toxicity are due to a mixture of nicotinic and muscarinic effects.

The cholinergic toxidrome: Signs and Symptoms: differences in pediatric cases
41 Management strategy 2: supportive care
42 Laboratory Assessment of the Cholinergic Toxidrome: Red Blood Cell (RBC) and Serum Cholinesterase Levels
43 Laboratory Assessment of the Cholinergic Toxidrome: Direct Measurement of Cholinesterase Inhibitors and Their Metabolic Byproduct
44 Management of the Cholinergic Toxidrome: Management Strategy 1: Prevention of Secondary Exposure
45 Public Health and Medico-Legal Issues
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