Edited by F. Peter Guengerich Exposure to organophosphorus compounds (OPs) may be fatal if untreated, and a clear and present danger posed by nerve agent OPs has become palpable in recent years. OPs inactivate acetylcholinesterase (AChE) by covalently modifying its catalytic serine. Inhibited AChE cannot hydrolyze the neurotransmitter acetylcholine leading to its build-up at the cholinergic synapses and creating an acute cholinergic crisis. Current antidotes, including oxime reactivators that attack the OP-AChE conjugate to free the active enzyme, are inefficient. Better reactivators are sought, but their design is hampered by a conformationally rigid portrait of AChE extracted exclusively from 100K X-ray crystallography and scarcity of structural knowledge on human AChE (hAChE). Here, we present room temperature X-ray structures of native and VX-phosphonylated hAChE with an imidazole-based oxime reactivator, RS-170B. We discovered that inhibition with VX triggers substantial conformational changes in bound RS-170B from a "nonproductive" pose (the reactive aldoxime group points away from the VX-bound serine) in the reactivator-only complex to a "semi-productive" orientation in the VX-modified complex. This observation, supported by concurrent molecular simulations, suggested that the narrow active-site gorge of hAChE may be significantly more dynamic than previously thought, allowing RS-170B to reorient inside the gorge. Furthermore, we found that small molecules can bind in the choline-binding site hindering approach to the phosphorous of VX-bound serine. Our results provide structural and mechanistic perspectives on the reactivation of OP-inhibited hAChE and demonstrate that structural studies at physiologically relevant temperatures can deliver previously overlooked insights applicable for designing next-generation antidotes. Acetylcholinesterase (AChE) 2 (EC 3.1.1.7), an enzyme of the ␣/ hydrolase-fold superfamily, has a critical role in synaptic neurotransmission (1). Nerve agent organophosphorus (OP) compounds, the most poisonous substances made by man, are covalent AChE inhibitors (2). The use of these chemicals is banned internationally. However, recent high-profile incidents of OP intoxication, including mass population sarin poisoning in the Syrian Khan Sheikhoun attack in 2017, poisoning of North Korean dissident Kim Jong Nam with VX, and use of a Novichok agent against Sergei and Yulia Skripal in 2018, demonstrate the existence of a real threat from these substances. Chemically, OPs covalently attach to the side chain hydroxyl of the catalytic serine of AChE to form phosphoserine conjugates resulting in the enzyme's inactivation (3, 4). Catalytic function of the OP-inhibited AChE can be restored through a chemical reaction with nucleophiles, which attack the phosphorus atom of the OP-AChE to regenerate the active enzyme (5, 6). Due to the complexity of the reactivation reaction a universal reactivator equally effective against all OP-AChE conjugates has not been identified. In several aspects reactiv...