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 12: Public Health and Medico-Legal Issues

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.

Introduction

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