Ebola, Emergency Medicine, and Global Bioethics Sarah M Winston - - PowerPoint PPT Presentation

Ebola, Emergency Medicine, and Global Bioethics

Sarah M Winston Bush, MD Assistant Professor University of Cincinnati Department

• f 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
• utbreaks
• 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