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Key Concepts
  • Cholinesterase inhibitors are a class of compounds that includes chemical warfare nerve agents and certain insecticides.
  • Fatalities occur mainly due to effects on respiration due depression of respiratory drive, paralysis of muscles of respiration, bronchoconstriction, and airway obstruction from profuse respiratory tract secretions.
  • Treatment includes the use of atropine, 2-PAM, diazepam, and aggressive supportive care.
About This and Other Case Studies in Environmental Medicine

This educational case study document is one in a series of self-instructional courses designed to increase the primary care provider’s knowledge of hazardous substances in the environment and to promote the adoption of medical practices that aid in the evaluation and care of potentially exposed patients. The complete series of Case Studies in Environmental Medicine is located on the ATSDR Web site at In addition, the downloadable PDF [PDF – 1.88 MB] version of this educational series and other environmental medicine materials provides content in an electronic, printable format, especially for those who may lack adequate Internet service.


We gratefully acknowledge the work that the medical writers, editors, and reviewers have provided to produce this educational resource. Listed below are those who have contributed to development of this version of the Case Study in Environmental Medicine.

Please Note: Each content expert for this case study has indicated that there is no conflict of interest to disclose that would bias the case study content.

ATSDR Authors: Erik Auf Der Heide, MD

ATSDR Planners: Valerie J. Curry, MS; John Doyle, MPA; Bruce J. Fowler, Ph.D.; Kimberly Gehle, MD; Sharon L. Hall, Ph.D.; Michael Hatcher, DrPH; Kimberly Jenkins, BA; Ronald T. Jolly; Delene Roberts, MSA; Brian Tencza, MS.

ATSDR Commenters: Susan Gorman, PharmD, SB; Paul Joe, M.D.; Nickolette Roney, BA

Peer Reviewers: Alan H. Hall, M.D., Toxicology Consulting and Medical Translating Services, Inc. (TCMTS, Inc.), P.O. Box 184, Mile 5.0 Pass Creek Road, Elk Mountain, WY 82324; Sheldon L. Wagner, MD, Professor of Clinical Toxicology, Oregon State University, Emeritus, Corvallis, Oregon 97331-2106

Disclaimer and Disclosure


The state of knowledge regarding the treatment of patients potentially exposed to hazardous substances in the environment is constantly evolving and is often uncertain. In developing its educational products ATSDR has made a diligent effort to ensure the accuracy and the currency of the presented information. ATSDR, however, makes no claim that the environmental medicine and health education resources discussed in these products comprehensively address all possible situations related to various substances. The products are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients potentially exposed to hazardous substances. The products are not a substitute for a health-care provider’s professional judgment. Please interpret the environmental medicine and the health education resources in light of specific information regarding the patient and in conjunction with other medical authorities. Use of trade names in ATSDR products is for identification purposes only and does not imply endorsement by the Agency for Toxic Substances and Disease Registry or the U.S. Department of Health and Human Services.

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U.S. Department of Health and Human Services
Agency for Toxic Substances and Disease Registry
Division of Toxicology and Human Health Sciences
Environmental Medicine Branch