Agency for Toxic Substances and Disease Registry
Case Studies in Environmental Medicine (CSEM) 

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

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.

Introduction

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