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 of Emergency Medicine

A look at the medicine…

What does Ebola look like clinically? • High fevers • Myalgias • Vomiting • Cough • Diarrhea • Maculopapular Rash • Fatigue • Hiccups • Loss of Appetite • Abdominal Pain • Headaches

Hemorrhage? • Occurs ~50% of time • GI in origin • Mucosal bleeding http://www.peakprosperity.com/forum/86357/ebola-outbreak-2014 • Hematomas • Oozing IV sites • Conjunctival Hemorrhage http://gudhealth.com/ebola-hemorrhagic-fever.html

• 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 Immediate – Appropriate travel history Isolation • West Africa: – Guinea, Liberia, Nigeria, Senegal, Sierra Leone • Democratic Republic of the Congo – Exposure history • Redundancy within the EMR

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