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Cholinesterase Inhibitors: Including Insecticides and Chemical Warfare Nerve Agents
Table of Contents

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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Cover Page Key Concepts About This and Other Case Studies in Environmental Medicine How to Apply for and Receive Continuing Education Credit Acknowledgements Disclaimer and Disclosure	Part 4: The Cholinergic Toxidrome Section 11: Management of the Cholinergic Toxidrome Three Management Strategies
How to Use This Course Introduction Available Versions Instructions Instructional Format Learning Objectives	Part 4: The Cholinergic Toxidrome Section 11: Management of the Cholinergic Toxidrome Management Strategy 1: Prevention of Secondary Exposure Learning Objectives How Secondary Exposure Occurs Example of Secondary Exposure (Optional Reading) Misconception: Reality Five Tactics for Preventing Secondary Contamination Controversy Key Points Progress Check
Initial Check Instructions Case Study Initial Check Questions Initial Check Answers	Part 4: The Cholinergic Toxidrome Section 11: Management of the Cholinergic Toxidrome Management Strategy 2: Supportive Care Learning Objectives Introduction Importance of Respiratory Support Key Points Progress Check
Part 1: Community Preparedness for Mass Casualty Events Involving Cholinesterase Inhibitors Learning Objectives Introduction Misconception Reality Need for Community Level Planning, Training, and Drills Coordination of Community Personnel The Importance of Evidence-Based Planning Misconception Reality Patient Self-Transport Planning Implications of Self-Transport Key Points Progress Check	Part 4: The Cholinergic Toxidrome Section 11: Management of the Cholinergic Toxidrome Management Strategy 3: Medications Three First-Line Medications
Part 2: What are cholinesterase inhibitors? Learning Objectives The Primary Toxic Effect of Cholinesterase Inhibitors Breakdown of Acetylcholine by Cholinesterase (Optional Reading) Breakdown of Acetylcholine (Optional Reading) How Acetylcholine is Blocked (Optional Reading) Attraction of Cholinesterase Inhibitor to Acetylcholinesterase (Optional Reading) Molecular Bond Changes (Optional Reading) Cholinesterase Inhibitor Attached to Cholinesterase (Optional Reading) Effects of Blocked Acetylcholine Breakdown Other Effects of Cholinesterase Inhibitors (Optional Reading) Review of Definitions Two Classes of Cholinesterase Inhibitors Key Points Progress Check	Part 4 - Section 11 Management Strategy 3: Medications Atropine Learning Objectives Atropine: Mechanism of Action Diagnostic Use: The “Atropine Challenge” Atropine: Available Forms (Optional Reading) Atropine: Stability of Solution (Optional Reading) Atropine: Route of Administration Misconception Reality Reasons Why Signs of Atropinism Are Not the Appropriate End Point to Guide Atropine Treatment Atropine Dose Misconception Reality Total Doses of Atropine in Poisoning with Organophosphorus Compounds (Optional Reading) Extremely High Total Doses of Atropine May be Needed in Suicidal Ingestions of Organophosphorus Compounds (Optional Reading) Nerve Agents Require Lower Total Doses of Atropine (Optional Reading) Carbamates Require Lower Doses (Optional Reading) Atropine: Low Incidence of Adverse Effects Alternatives to Atropine (Optional Reading) Key Points Progress Check
Part 3: What types of pathology do cholinesterase inhibitors cause? Learning Objectives Categories of Pathological Effects Key Points Progress Check	Part 4 - Section 11 Management Strategy 3: Medications 2-PAM (2-Pyridine Aldoxime Methylchloride) (Pralidoxime) Learning Objectives Introduction How 2-PAM Works Aging How Long Does It Take for Aging to Occur? Reasons for Delayed Onset of Toxicity and Aging, and Need for Extended Treatment with 2-PAM 2-PAM: Mechanism of Action (Optional Reading) How Acetylcholinesterase Normally Works (Optional Reading) How Cholinesterase Inhibitors Work (Optional Reading) How Cholinesterase Inhibitors Work: Aging (Optional Reading - continued) How 2-PAM Works at the Molecular Level (Optional Reading) 2-PAM in Carbamate Toxicity Misconception Reality 2-PAM in Carbamate Toxicity 2-PAM: Availability (Optional Reading) 2-PAM: Obtain Blood Prior to Treatment 2-PAM: Dosing Controversy Regarding 2-PAM Dose (Optional Reading) Need for Maintenance I.V. Infusion 2-PAM: Duration of Treatment Reasons for Apparent Failure to Respond to 2-PAM 2-PAM: Synergism with Atropine 2-PAM: Adverse Effects Controversy Regarding What Receptor Sites are Affected by 2-PAM (Optional Reading Does 2-PAM Cross the Blood-Brain Barrier? (Optional Reading) Controversy Regarding 2-PAM Efficacy Factors Needing Control in Studies on 2-PAM (Optional Reading) Published Attempts at Controlled Human Studies with 2-PAM (Optional Reading) Key Points Progress Check
Part 4: The Cholinergic Toxidrome Section 1: What is the Cholinergic Toxidrome? Learning Objectives Introduction Types of Cholinergic Receptors Mixed Nicotinic and Muscarinic Effects Summary Diagram of Signs and Symptoms Nicotinic vs. Muscarinic Effects Key Points Progress Check	Part 4 - Section 11 Management Strategy 3: Medications Diazepam Learning Objectives Misconception Reality Introduction: Diazepam for Seizures Indications Dose (Sidell 1997; Leikin, Thomas et al. 2002) Key Points Progress Check
Part 4: The Cholinergic Toxidrome Section 2: Nicotinic Acetylcholine Receptors Learning Objectives Key Function of Nicotinic Receptors Molecular Physiology of Nicotinic Receptors (Chemical-Gated Na⁺ Channels) (Optional Reading) Molecular Structure and Physiology of the Nicotinic Receptor (Optional Reading) Locations of Nicotinic Receptors Clinical Findings Due to Nicotinic Stimulation from Cholinesterase Inhibitors Nicotinic Mnemonic Key Points Progress Check	Part 4: The Cholinergic Toxidrome Section 11: Management of the Cholinergic Toxidrome Antidote Stocking (Optional Reading) Learning Objectives (Optional Reading) Misconception Reality Inadequacies in Antidote Stocking (Optional Reading) Atropine from Bulk Powder (Optional Reading) Mixing Protocol (Optional Reading) Support Available from the CDC Strategic National Stockpile (Optional Reading) Key Points
Part 4: The Cholinergic Toxidrome Section 3: Muscarinic Acetylcholine Receptors Learning Objectives Muscarinic, G-Protein Mediated Receptors Molecular Physiology of Muscarinic Receptors (Optional Reading) Molecular Structure and Physiology of Muscarinic Receptors (Optional Reading) Where Muscarinic Receptors Are Located Clinical Effects on the Peripheral Nervous System Due to Excessive Stimulation of Muscarinic Receptors Peripheral Muscarinic Effects Muscarinic Mnemonics Key Points Progress Check	Part 4: The Cholinergic Toxidrome Section 11: Management of the Cholinergic Toxidrome Syrup of Ipecac, Gastric Lavage, Cathartics, and Activated Charcoal Learning Objectives Treatments No Longer Recommended as Routine Treatments for Poisoning Key Points Progress Check
Section 4: Clinical Findings in Cholinesterase Inhibitor Toxicity Are Due to a Mixture of Nicotinic and Muscarinic Effects Learning Objectives Sympathetic vs. Parasympathetic Effects Central Nervous System (CNS) Effects Cause of Death Frequency of Signs and Symptoms Frequency of Signs and Symptoms in Cholinesterase Inhibitor Toxicity (Optional Reading) Misconception Reality Key Points Progress Check	Part 4: The Cholinergic Toxidrome Section 12: Public Health and Medico-Legal Issues Learning Objectives Introduction Key Points Progress Check
Part 4: The Cholinergic Toxidrome Section 5: Signs and Symptoms by Route of Exposure and Chemical Structure of the Involved Cholinesterase Inhibitor (Optional Reading) Learning Objectives (Optional Reading) Signs and Symptoms by Route of Exposure (Optional Reading) Chemical Structure versus Toxicity (Optional Reading) Vapor Exposure (Namba, Nolte et al. 1971; Tareg, B et al. 2001) (Conjunctival and Respiratory) (Optional Reading) Dermal Exposure (Sidell 1997; Tareg, B et al. 2001) (Optional Reading) Oral Exposure (Optional Reading) Reasons for Delayed Onset of Clinical Findings (Optional Reading) Key Points (Optional Reading)	Part 5: The Intermediate Syndrome Learning Objectives Intermediate Syndrome is a Delayed Onset of Muscle Weakness and Paralysis Incidence Signs and Symptoms Typically Seen (Karalliedde and Senanayake 1989; Clark 2002; Erdman 2004) Complications Treatment Disposition Prognosis Key Points Progress Check
Part 4: The Cholinergic Toxidrome Section 6: Effects on Routine Laboratory Tests Learning Objectives Introduction Key Points Progress Check	Part 6: Organophosphate-Induced Delayed Neuropathy (OPIDN) Learning Objectives Introduction Etiology Pathology Signs and Symptoms Treatment Prognosis Key Points Progress Check
Part 4: The Cholinergic Toxidrome Section 7: Differential Diagnosis of the Cholinergic Toxidrome Learning Objectives Conditions that Can be Mimicked by Cholinesterase Inhibitor Toxicity Differential Diagnosis Key Points	Part 7: Organophosphorus Ester-Induced Chronic Neurotoxicity (OPICN) Learning Objectives Introduction Signs and Symptoms Controversy Treatment Key Points Progress Check
Part 4: The Cholinergic Toxidrome Section 8: Signs and Symptoms: Differences in Pediatric Cases Learning Objectives Differences in Pediatric Cases Pediatric Signs and Symptoms Key Points Progress Check	Part 8: Other Issues Related to Cholinesterase Inhibitor Exposure Learning Objectives Cancer Risks Fetal Effects Gulf War I Illness Immune System Effects Key Points Progress Check
Part 4: The Cholinergic Toxidrome Section 9: Importance of the Exposure History Learning Objectives Introduction Where Cholinesterase Inhibitors are Found Home Exposures Occupational Exposures Consumer Exposures Exposure History Questions Key Points Progress Check	Assessment and Posttest Instructions Introduction Online Instructions Posttest Relevant Content
Part 4: The Cholinergic Toxidrome Section 10: Laboratory Assessment of the Cholinergic Toxidrome Red Blood Cell (RBC) and Serum Cholinesterase Learning Objectives Misconception Reality Introduction The Two Types of Cholinesterase Levels Sources of Error in the Measurement of Cholinesterase Levels (Optional Reading) Case Example (Optional Reading) Variations among Laboratories (Optional Reading) Levels Correlated with Toxicity (Optional Reading) The Role of Baseline Cholinesterase Levels (Optional Reading) Other Causes of Cholinesterase Level Abnormalities Key Points Progress Check	Literature Cited References
Part 4: The Cholinergic Toxidrome Section 10: Laboratory Assessment of the Cholinergic Toxidrome Direct Measurement of Cholinesterase Inhibitors and Their Metabolic Byproducts Learning Objectives Introduction Cholinesterase Inhibitors That Can Be Measured Metabolic Byproducts That Can Be Measured Key Points Progress Check

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Page last reviewed: October 16, 2007
Page last updated: October 16, 2007
Content source: Agency for Toxic Substances and Disease Registry

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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