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Dec 7, 2021 โ€ข 43 tweets โ€ข 24 min read โ€ข Read on X
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.... ๐Ÿงต๐Ÿ‘‡๐Ÿ˜˜
Let's go to India - Tamil Nadu.
I'd advise anyone not overly family with Organophosphates to start here: ncbi.nlm.nih.gov/books/NBK49986โ€ฆ #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/10.100โ€ฆ) 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 ๐Ÿ˜‚๐Ÿ˜… #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

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More from @Gas_Craic

Dec 8, 2021
What were the most impactful non-COVID papers over the past 2 years? Let's delve in and take a look. #SOA21
Finally an opportunity to not talk about COVID! #SOA21
TOMAHAWK - immediate vs delayed/selective angio. 3 years to conduct the trial in 31 ICUs. 554 patients. 'Worse' survival in immediate angiograph? Not SS, but close... #SOA21
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Dec 8, 2021
We've looked at bats for a long time.... #SOA21 They have strong interferon responses, but not strong inflammation....
So what happens instead? #SOA21 They will tolerate high levels of viraemia with little symptoms. Bats are old... 65million years ago - they appeared at the end of the dinosaurs! They are far longer lived that other mammals. Senescence is late - more towards end of life.
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Dec 7, 2021
Biomarker guided abx treatments in sepsis. We catch up with Drs/Profs: Paul Dark, Stacy Todd, Enitan Carrol, Jonathan Sandoe and Matthew Stevenson on this large area of research @ICS_updates #SOA21
So, do biomarkers have any utility in guiding abx use in sepsis? We can measure, usually, these ones fairly easily: #SOA21
In around 2014, commissioned review in PCT. Seemed to suggest a shorter duration in abx use when PCT used.... tenuous data though. #SOA21 Low quality. Little evidence from UK... how does this fit into NHS practice in the realms of stewardship?
Read 13 tweets
Dec 7, 2021
@iceman_ex, myself and @dr_mattmorgan talk about how to keep yourself intellectually safe on Social Media at #SOA21 (full talk at soa.ics.ac.uk)

A thread ๐Ÿงต๐Ÿ‘‡
There's been a lot that's gone on over the past few years that's exposed the well known 'darker' side of social media. Traditional paradigms of knowledge dissemination have changed (if not disappeared). Much higher tech-savy population. #SOA21
This has democratised the discussion space to an extent. It allows for *anybody* (lit. anybody) to get involved. #SOA21
Read 17 tweets
Dec 6, 2021
Is COVID-19 hyperinflammation, or a cytokine storm in a teacup? @DrPujaMehta1 's fab talk from #SOA21 today! Image
Main Q = "Hyperinflation contributing to worse outcomes for some patients with COVID-19" - clinical similarities to sHLH seen. Viruses are the most common trigger of sHLH. Early reports from China suggested cytokine profile was similar to sHLH in terms of COVID severity. #SOA21 Image
We now know some things work and some things don't.... in certain populations. #SOA21 Image
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Dec 6, 2021
What have we learned during COVID? Prof Tony Gordon takes us through a whirlwind tour of COVID-19 research.... #SOA21 Image
Scientists AND politicians in the spotlight during COVID. Very different approaches between the two groups.#SOA21 Image
First reports and articles with hundreds of patients.... moving on to thousands of patients. #SOA21 ImageImage
Read 21 tweets

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