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EMS Ebola Guidelines Ron Brown, MD, FACEP. BACKGROUND.

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Presentation on theme: "EMS Ebola Guidelines Ron Brown, MD, FACEP. BACKGROUND."— Presentation transcript:

1 EMS Ebola Guidelines Ron Brown, MD, FACEP

2 BACKGROUND

3 Small RNA-type virus. Not very hardy—soap and water kills. Can live on fomite surfaces when moist for hours to days. Spread: mild-moderately contagious – For reference, one Ebola patient is expected to infect two people in an uncontrolled outbreak; influenza, 13-15 people – Is NOT aerosolized in patient exhalation. That means it won’t float around in the air like influenza or TB. – Spread by large droplets or frank fluid, found in feces, saliva, blood, etc. Might become aerosolized by nebulizer treatments Can be spread by a cough or sneeze directly onto another person Main route is mucus membranes, eyes, microabrasions of skin – Microabrasions are not visible to the naked eye Parenteral exposure results in more serious infection

4 EV initially attacks immune sentinel cells: macrophages and dendritic cells – Then spreads via lymph system to lymphocytes – Will infect and replicate in all types of cells Earlier and more severe onset associated with higher fatality rate Survivors mount a quick immune response and improve in around 6 days

5 Presentation Mimics viral illness like influenza Sudden onset of mayalgias, fever, headache, fatigue/malaise and abdominal pain – Vomiting, copious diarrhea are later findings, days into the illness Sore throat without other respiratory complaint, and hiccups (for unknown reasons) may also occur relatively early – Bleeding problems visible clinically occur in a minority (18%) – Bruising-like rash can occur late – Severe cases progress to multiple organ system failure Altered mental status in febrile or encephalopathic patients can increase risk to health care professional – Dehydration exacerbates the illness: both from capillary leakage early and copious diarrhea late

6 CDC GUIDELINES

7 CDC Interim EMS Guidelines Ebola is a virus of the Hemorrhagic Fever category Ebola is spread by DIRECT contact – It is not spread via aerosol, like influenza or tuberculosis Precautions are CONTACT and DROPLET. Initial symptoms are vague viral illness-type, therefore an exposure history is crucial – 911 callers will be screened by Dispatch – Clinic transfers will be screened by clinic staff

8 CDC recommended Dispatch Call Screening Screen initially for fever >38.0, and severe headache, myalgias, vomiting, diarrhea, abdominal pain, bleeding If positive, history of one of the following within the last three weeks – Direct contact (with fluids) with suspected or known Ebola patient – Travel to/from or resident of Ebola OUTBREAK area – Handling of bats or other animals from endemic areas Alert EMS

9 CDC: EMS Assessment Scene safety – Put on PPE – Keep patient separated from others (family, bystanders) – USE CAUTION ON INITIAL APPROACH Ebola Virus Disease (EVD) can cause delerium, ataxia

10 EMS Assessment Screen patient – Fever >100.4 (38.0), measured by patient OR EMS measurement – Plus additional symptoms Abdominal pain Vomiting or diarrhea Severe headache Myalgias (muscle pain) – Plus indicative exposure history Contact with bodily fluid of suspected or known Ebola patient Travel or resident, Ebola outbreak area (ONLY Africa at this time) Handling of animals in Ebola area (Africa), esp fruit bats

11 EMS Care If negative for risk factors (exposure plus one of the above), proceed with regular care

12 EMS Care If positive: – Limit activities that increase risk Intubation Use of needles/IV/IO Nebulizers CPR

13 Cleaning equipment (CDC) Wear PPE Patient-care surfaces must be decontaminated – Basic chlorine bleach is effective. Not a hardy virus. Will use standard decontamination equipment. Body fluid spill – Bulk decontamination then disinfection Reusable patient care equipment (cables, etc) – In a biohazard bag after removal from patient – Clean then disinfect per usual procedure Consider discarding linens

14 SCEMS EBOLA PROCEDURES

15 Checklists Two checklists: – First Response agency Lower level PPE Limited to no interaction with patient Main thrust is safety and identification – Transport agency: “Dispatch to Decontamination” For positive screens (= suspect Ebola Virus Disease patient) Includes dedicated transport rigs, Hazmat Team supervision, higher level PPE, decontamination

16 FIRST RESPONDERS Checklist

17 First Response PPE What is appropriate First Response PPE? – Gloves Get in the habit of considering your gloves a barrier, but also contaminated, and don’t cross-contaminate needlessly. Strip every time turning away from patient-care to handle not-immediately- needed equipment (eg computer) Note anything handled while caring for the patient is considered a patient-care surface and is contaminated – Gown: fluid impermeable – Eye protection: goggles or face shield – N95 face mask

18 1. Perform “Doorway Triage” Don gowns, gloves, eye protection, N-95 mask Screen Suspected Patient Using Criteria: = Travel + Any one symptom below: – Travel or direct contact with an individual who has traveled to an affected region in the past 21 days? – And at least one of the following:  fever > 100.5  fatigue  muscle cramps  nausea/vomiting/diarrhea  abdominal pain  severe headache  unexplained hemorrhage/bleeding/bruising

19 2. Positive Screen - Initial Actions Do not enter structure or make unnecessary physical contact with patient Contact Providence Medical Control to verify screening and current affected regions Request MSO (Infection Control Officer) Instruct Patient to don simple facemask If Necessary and Available: Use Fluid Barrier Suit, PAPR, Fluid Resistant Apron, to enter structure prior to Decon 12 arrival – Stress necessary and available, and TRAINED in donning-doffing

20 3. High Suspect Patient – Full Plan Activation Request to the scene: – Decon 12 – Medic 12A or Medic 5A (Pre-Sealed Units Designated Ebola ) BC or Agency Duty Chief

21 High Suspect Patient – Full Plan Activation Decon 12 technicians will provide guidance and outfit/seal initial on scene crew in PPE – Full splash/droplet protection and PAPR (Powered Air Purifying Respirator) and Fluid Resistant Apron – No skin/clothing exposed—Slow Down—Take Time to seal properly In areas not prepared to use PAPRs personnel will be provided to assist in transport – District 1, 7 and Everett Fire will provide trained personnel for transport throughout Snohomish County

22 4. Treatment and Transport Providence is the hospital for Ebola patients in Snohomish County Avoid CPAP, intubation, nebulizers, suction, I.V. etc. Do not resuscitate patients who have arrested Consider two providers to transport using the buddy system – One person provides care – One person observes and assists care provider with adherence to infection control protocol

23 DISPATCH TO DEMOBILIZATION Checklist

24 Above checklist, plus:

25 Hospital Arrival Crew will unload patient in coordination with hospital staff Patient will enter the hospital through the decon room Decon 12 will supervise handoff and decontamination of EMS

26 Disinfecting/Sanitizing Isolate transport unit and prepare to decontaminate the crew Sanitize all equipment and interior with an EPA registered hospital disinfectant approved for Noro-Rota-Adeno and or polio virus in full PPE Remove and discard all PPE used in a sealed biohazard bag put into a biohazards waste bin Again, Hazmat (Decon 12) will direct decontamination – Personnel decontamination based on level of contamination and exposure

27 Demobilization Crew and Response units will follow instructions from Public Health before leaving the hospital At this time this is a “case-by-case” disposition of transport crew


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