Ebola, Emergency Medicine, and Global Bioethics...• Fowler, et al. (2014). Caring for critically...
Transcript of Ebola, Emergency Medicine, and Global Bioethics...• Fowler, et al. (2014). Caring for critically...
Ebola, Emergency Medicine, and Global Bioethics
Sarah M Winston Bush, MD Assistant Professor
University of Cincinnati Department of Emergency Medicine
A look at the medicine…
What does Ebola look like clinically?
• High fevers • Vomiting • Diarrhea • Fatigue • Loss of Appetite • Abdominal Pain • Headaches
• Myalgias • Cough • Maculopapular Rash • Hiccups
Hemorrhage? • Occurs ~50% of time • GI in origin • Mucosal bleeding • Hematomas • Oozing IV sites • Conjunctival Hemorrhage
http://gudhealth.com/ebola-hemorrhagic-fever.html
http://www.peakprosperity.com/forum/86357/ebola-outbreak-2014
• 80 bed center in Kailahun • Tents of patients – suspected, probable, confirmed • PCR testing can take up to 24 hours • Strict PPE guidelines
– Buddy system – Restricted to 40 minutes at a time in PPE and in the
tents • Treatment – Supportive only • Discharge criteria – neg blood test and 3 days
symptom free
• Common: – Renal Failure – Hypokalemia – Lactic acidosis – Elevated Liver Function Tests
• Uncommon: – Hemorrhage (typically GI)
• Barriers to treatment in West Africa: – Late presentation – Lack of equipment
• PPE • Oxygen • Electrolyte testing • Hemodynamic monitoring • IV supplies and IVFs
– Community mistrust – Communication barriers
Diagnostics • Rule out other common causes
– Malaria – Other endemic infectious diseases
• Ebola test: – Africa – some sites have onsite PCR
testing that can take up to 24 hours – US: Send out test to CDC
Treatment • Supportive care
– IVF resuscitation early • Correct hypovolemic shock and electrolyte
disturbances – Nutrition – Treat concomitant malaria – Prevention of secondary infection
Treatment • Isolation
– Prevent the spread • Role of antibiotics • Experimental drugs?
– ZMapp – Brincidofovir
• Blood transfusion
• 1995 outbreak in DRC • 5 donor pts – IgG and IgM antibodies to Ebola • 8 recipient patients ages 12-54
– Prior to transfusion: • 7/8 treated for Malaria • 3/8 had hemorrhagic symptoms • 8/8 tested positive for Ebola antigens
• 7/8 survived – Pt 8 – never developed IgM antibodies to Ebola despite
transfusion
Here in Cincinnati… • 911 dispatchers have begun screening • EMS has been educated on appropriate
screening & precautions – Immediate application of PPE – Immediate decontamination of ambulances
with bleach to prevent further spread
UCMC Emergency Plans for Ebola
• Goals: – Provide quality care to all patients – Prevent further exposures
UCMC Emergency Plans for Ebola
• Triage: – Flu like illness – Appropriate travel history
• West Africa: – Guinea, Liberia, Nigeria, Senegal, Sierra Leone
• Democratic Republic of the Congo
– Exposure history • Redundancy within the EMR
Immediate Isolation
UCMC Emergency Plans for Ebola
• PPE carts • Assessment and Treatment
– Malaria and other infectious causes • Notification
https://www.greenedu.com/personal-protective-equipment-procedures-online-anytime-courses
Thank you!
References • Baize, et al. (2014). Emergence of Zaire Ebola virus in Guinea. N Engl J Med. 1-8. • Briand, et al. (2014) The International Ebola Emergency. N Engl J Med. 371:13 . 1180-1183. • Decker, et al. (2014). Preparing for Critical Care Services to Patients with Ebola. Annals of Internal Medicine.
www.annals.org. downloaded 10-11-14. • Fowler, et al. (2014). Caring for critically ill patients with Ebola virus disease. Am J Respir Crit Care Med.
190:7 733-737. • Frieden, et al. (2014). Ebola 2014 – New challenges, new global response and responsibility. N Engl J Med.
371:13 1177-1180. • Gatherer, D. (2014). The 2014 ebola virus disease outbreak in West Africa. Journal of general virology. 95,
1619-1624. • Gostin, Lucey, & Phelan. (2014). The Ebola Epidemic: A global health emergency. JAMA. 312:11. 1095-
1096. • Mupapa, et al. (1999). Treatment of Ebola hemorrhagic fever with blood transfusion from convalescent
patients. Journal of infectious disease.179: S18-23. • Wolz, A. (2014). Face to face with Ebola – An emergency care center in Sierra Leone. N Engl J Med.
371:12. 1081-1083. • WHO ebola response team. (2014). Ebola virus in West Africa – the first 9 months of the epidemic and
forward projections. N Engl J Med. 1-15. • WHO. WHO recommended guidelines for epidemic preparedness and response: Ebola Hemorrhagic Fever.
www.WHO.int. downloaded 10-8-14.
• Outcomes:
• From Dec 30, 2013- Sept 14, 2014 – 4507 confirmed/probable cases – Median age 32 years – 318 infected health care workers (151
deaths)
Virological analysis: no link between Ebola outbreaks in west Africa and Democratic Republic of Congo Situation assessment - 2 September 2014 (*)
• Both Zaire species of Ebola – DRC: close to 1995 outbreak in Kitwit, DRC
strain • No connection between the two
outbreaks • Index case in DRC: Pregnant woman
eating bushmeat http://www.who.int/mediacentre/news/ebola/2-september-2014/en/
• Clinical presentation – Africa – US
• Mainstays of diagnosis and treatment – Resuscitation – Supportive care – Isolation
• Plans at UCMC ED – EMS/911
Mode of Transmission • Contact with any bodily fluids
– Airborne transmission never been confirmed
• Percutaneous (ie – the dreaded needle stick)
• Contact with dead bodies
https://www.greenedu.com/personal-protective-equipment-procedures-online-anytime-courses