Thread by @Gas_Craic

Organophosphate poisoning, toxicology, dengue, snake bites and malaria.... sure what could go wrong? #SOA21 @ICS_updates Drs. Chacko, Yacoub, Bhaumik and Dondorp tell us more.... 🧵👇😘

Let's go to India - Tamil Nadu.

I'd advise anyone not overly family with Organophosphates to start here: ncbi.nlm.nih.gov/books/NBK49986… #SOA21

Breaking down self harm.... 36% DSH = organophosphates. Every 30 minutes = 1 suicide with organophosphates. #SOA21

They use a 3 pronged approach. Today, we look at altering toxicity and managing patients better. #SOA21

Class 1 Compounds = high mortality. Worst outcomes. Particularly monocrotophos and parathion. #SOA21

FFP and Albumin can mop up the organophosphates actually.... some treatment targets. #SOA21

Mainstay = atropine due to its actions around M2-3 receptors. Brady and secretions mitigated. USE INFUSIONS rather than boluses - associated with lower death. #SOA21 Zoomed in - some unique presentations of organophosphate poisonings.

22% = extrapyramidal symptoms - peak Day 4-5. Some patients had residual symptoms (all in) for > a month! Highly costly. Scopolamine likely has better CNS penetration for these patients. Some cases are also atropine refractive... but adding in a smidge of adrenaline helped!#SOA21

Oximes... reduced I&V and death. Both arms received oximes (infusion/bolus). Sri-Lankan study found harm. Meta-analysis = no benefit. (Think pralidoxime: link.springer.com/article/10.100…) But is there a benefit if they're used earlier? #SOA21

Bioscavengers - like FFP/Albumin? Nah. Not been found to improve outcome... (yet). #SOA21

DOPE - "delayed-onset encephalopathy and coma in acute organophosphate poisoning". GCS good... then good.... then drops for 8-10 days! Brain dead or Organophosphate Coma? The clue is miosed pupils if OP. Can also just be an encephalopathy instead. #SOA21 Wait for resolution.

Dr Chacko's department outcomes have improved dramatically over the years. 50% to <5% over 30 years. They only use atropine - otherwise SUPPORTIVE CARE has the major role here. #SOA21

Some great take home points. Good resus and supportive care. Focus on atropine (infusion). Lots of research still to do. Oximes still uncertain. Narrow the type of OP early. Unusual presentations like DOPE - don't get caught out. #SOA21

Early signs of OP would include cholingeric toxidromes - drooling, incr secretions, bradycardias... #SOA21

In this talk, atropinisation is done rapidly - aims are: HR>80, dry lungs, BP>90sys. Give 2-3mg of atropine, repeat every 3-5mins until these parameters are met, then start infusion - 1mg/ml - infusion rate to meet the targets. #SOA21 Titrate.

Zooming over now to Vietnam! Let's look at Dengue Fever... #SOA21

Just to recap... for all of us who don't see it every day 😂😅 #SOA21

Vietnam is a hugely INDEMIC area. Number one reason for admission to their local hospital, and indeed ICU there. #SOA21 Top 10 threat to GLOBAL health. Poorly effective vaccine (relatively). Continues to spread around the world. No therapeutics for it.

With climate change, and thus translocation of the MOSQUITO - Dengue will continue to spread.... so PAY ATTENTION! #SOA21 Into Southern China, into Australia, Southern American states...

Distinct DISEASE PHASES in Dengue. Present with high fever, peaking viraemia. Culprit for critical period is (likely) an over-zealous inflammatory response. #SOA21 Some similarities to COVID-19! Hyperinflammatory syndrome in late disease when viraemia is in sharp decline.

Severe = 5% of patients. Most common = shock via incr. capillary permeability. #SOA21

Bleeding manifestations: #SOA21

In one Ho Chi Minh City - cases = 15,000/yr --> 500 of them to ICU. Every single paeds bed in ICU during rainy season = full of Dengue. #SOA21

Main research themes on Dengue. #SOA21 including novel diagnostics and wearable devices!

Predicting severe disease. 4 serotypes of dengue. 2nd time you get it can be WORSE due to antibody dependent enhancement (ADE) --> leads to higher viral loads. #SOA21

Higher viral loads = worse clinical outcomes #SOA21 Also hyperinflammation = worse. High CRP associated with worse outcomes. Other markers like IL-1 pathways interesting (new trial with Anakinra (an IL-1 antag = coming soon!)

So no current therapeutics... older studies looked at the drugs below... sadly no yield. As Sophie has said, upcoming trial on IL-1 inhib anakinra is upcoming. #SOA21

The hunt for a therapeutic agent continues... #SOA21

@DrSoumyadeepB takes us through Snakebites! #SOA21

India has >HALF the snakebite deaths globally. #SOA21

Significant disability sequelae due to SBites. #SOA21 CHRONIC mental health issues too. PTSD, Depression etc.

The burden is UNDERESTIMATED. #SOA21

Snakebites are relatively rare in cities - much more common in rural areas. Usually farmers - politically voiceless. #SOA21

These people have to sell and give up quite a lot. VICIOUS cycle of poverty... can effect the entire community + intergenerational effects. #SOA21

This is a common emergency dependent on the area. Even non-venomous snake bites need to attend for evaluation. We need better ways of diagnosis. #SOA21 This is very challenging - a region specific problem.

WHO strategy has dedicated money to this.... #SOA21

We have a big problem in terms of how well the evidence informed the guidelines. Primary stakeholders in this neglected? #SOA21

The evidence base..... poor SR's relevant to ICU. #SOA21

FIRST AID PHASE - many many things ineffective. #SOA21 but based on small studies and small sample sizes.

FabAV antivenom? or Broader? #SOA21

Prophylactic premedication? Adrenaline. #SOA21 Surgical aspects also being looked at. Poor levels of RCTs let alone SRs/MAs.

So what to do? #SOA21