Question 22

College Answer

Ensure appropriate isolation prior to transfer:

• negative pressure room with appropriate venting activated checked, and operational
• ante-room with facilities for donning and doffing of PPE
• separate toilet and hygiene facilities
• adequate PPE supplies ideally staffed by an “opt-in” model
• rehearse donning and doffing procedures with observed and guided doffing

Ensure appropriate staff safety:

• intervention and observations to a minimum
• blood tests are contraindicated unless sent to a designated laboratory with appropriate containment facilities

Specific Patient Management:

• focussed clinical examination to determine both physiologic disturbance and to look for other diagnoses (malaria, typhoid)
• empiric antibiotics for typhoid etc. and antimalarials
• strategy to maintain adequate fluid intake (oral, or iv with appropriate precautions)
• active symptom management of nausea & vomiting, diarrhoea (often profuse), pain
• no blood tests unless logistics allow

Other:

• staff welfare and de-brief
• family support

Additional Examiners’ Comments:
Most  answers  were  very  superficial ,  lacking  consideration  of  the  detail  needed  to  describe  adequate isolation practices and were not at specialist level

Discussion

If anyone wants to know what a "specialist level" answer is supposed to look like, they can read this recent 2014 article on severe Ebola by West et al, as it contains - in greater detail - the sort of issues that were brought up  briefly in the college answer.

Thus, the management of the Ebola patient can be divided into four major domains:

• Protect the public (isolate the patient)
• Protect your staff
• Supportive management
• Specific therapies

Protect the public: epidemic control measures ( see the NSW Health Ebola document)

• Specific plans regarding transfer of confirmed cases to a dedicated facility.
• Dedication of a specific "VHF designated" facility, where specialist staff are concentrated.
• Dedicated isolation rooms, with specific features:
• Single room with door closed
• Ideally, a negative pressure room
• Own bathroom; not connected to central sewer (special disposal arrangements)
• Strict limits on visitors (none!)
• Special arrangements for disposal of patient's wastes and disposable equipment

Protect your staff: personal protective equipment

• Staff training for VHF personal protective equipment (PPE).
• Specific instructions to transport and retrieval staff trained in VHF PPE.
• Surgical scrubs (not your comfy home clothes)
• Disposable long sleeve gown
• Face shield
• Surgical hood
• P2/N95 mask or disposable powered air purifying respirator (PAPR) hood
• Fluid repellent below-knee boot covers
• Double gloves with long cuffs

Supportive management

1. Intubation may be required in case of significant respiratory failure.
   Specific problems may arise:
   1. Greatest risk of aerosol transmission will be to the airway operator, who would need to be appropriately protected
   2. Coagulopathy could create a post-intubation haemoptysis problem due to relatively trivial airway trauma
   3. Frequent suctioning could cause enough airway trauma to produce lower airway haemorrhage
2. Respiratory support
   1. Copious volumes of fluid resuscitation may produce pulmonary oedema
   2. NIV may be sufficient initially, but has a greater potential to aerosolize secretions.
   3. Invasive ventilation is the preferred method.
   4. The invasively ventilated patient should be ventilated with lung-protective ventilation.
   5. Expired gas from the patient should pass through a HEPA or equivalent filter.
   6. Extracorporeal life support is not advised (expecting haemorrhagic complications)
3. Circulatory support
   1. Aggressive volume repletion with isotonic fluids
   2. Ebola can be complicated by adrenal necrosis; "stress dose" steroids should be considered early
   3. Standard noradrenaline is probably going to play a role.
4. Neurological dysfunction
   1. These patients may be obtunded for a variety of reasons.
   2. Of the reasons one needs to exclude, the most important are:
      1. Intracranial haemorrhage in the coagulopathic patient
      2. Seizures (including non-convulsive status)
      3. If not obtunded, they may be in pain, feeling isolated, and frightened beyond belief.
      4. Experts recommend videoconferencing facilities be made available to permit contact with loved ones
5. Electrolyte abnormalities
   1. Massive fluid and electrolyte loss is to be expected
   2. Apart from anticipating and correcting it, no specific recommendations can be made
6. Fluid balance and renal failure
   1. Vast volumes of crystalloid may be used; so you better use a balanced solution.
   2. ATN is present on post-mortem of Ebola victims, and is thought to originate from the shock state- correcting the haemodynamic derangement is therefore a priority.
   3. Standard indications for renal replacement therapy apply.
   4. All effluent must be disposed of in some sort of formalised fashion (like the rest of the Ebola patient material, one cannot simply put it in the routine medical waste bins)
7. Nutrition
   1. If this is a person originating from the characteristic part of Africa where Ebola is endemic, premorbid malnutrition needs to be considered.
   2. Thus, refeeding syndrome needs to be watched for
   3. No specific recommendations can be made other than to watch for haemorrhagic complications of NGT insertion
8. Correction of coagulopathy
   1. If substantial bleeding has occurred, the DIC must be supported with blood products. Tranexamic acid may play a role.

Specific therapies

• Many of these therapies have been approved by the American FDA only because of the ongoing emergency situation. Some are barely in Phase I trials.
• Several experimental therapies exist:
  • Brincidofivir (in vitro activity)
  • ZMapp monoclonal antibody cocktail
  • TKM-Ebola an interfering RNA molecule used to block expression of two viral replication genes
  • Convalescent whole blood
  • To date, none are exactly evidence-based.