Ebola Clinical Care Guidelines 2 Sep 2014 PDF

Crganlzed by Lhe ubllc PealLh Agency of Canada
Canadlan CrlLlcal Care SocleLy

Canadlan Assoc. of Lmergency hyslclans
Assoc. of Medlcal Mlcroblology & lnfecLlous ulseases Canada
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A gulde for cllnlclans ln Canada

Inter|m keport
August 29, 2014

Lbola Cllnlcal Care Culdellnes 2

CCCS - CAL - AMMl
2014 2014

Lbola vlrus hoLo
CourLesy of CuC/ lrederlck A. Murphy


CCCS - CAL - AMMl
2014 2014
lorward
ln response Lo Lhe WPC declaraLlon of Lhe Lbola ouLbreak ln WesL Afrlca as a ubllc PealLh Lmergency of
lnLernaLlonal Concern (PLlC), Lhe ubllc PealLh Agency of Canada (PAC) lnvlLed Lhe Canadlan CrlLlcal Care
SocleLy (CCCS) and Lhe AssoclaLlon of Medlcal Mlcroblology and lnfecLlous ulsease Canada (AMMl) Lo
conslder embarklng upon a collaboraLlon Lo develop cllnlcal care guldellnes Lo supporL cllnlclans ln Canada
who may be requlred Lo LreaL a paLlenL sufferlng from Lhe Lbola vlrus ulsease (Lvu or Lbola"). 8oLh Lhe CCCS
and AMMl were fully supporLlve of collaboraLlng on Lhls lmporLanL lnlLlaLlve. ln order Lo ensure LhaL Lhe
guldance developed was appllcable Lo cllnlclans ln all of Lhe areas of hosplLals mosL llkely Lo be requlred Lo
provlde care, Lhe CCCS and AMMl requesLed LhaL Lhe Canadlan AssoclaLlon of Lmergency hyslclans (CAL)
also be lnvlLed by PAC Lo parLlclpaLe ln Lhe developmenL of Lhe guldellnes. As a resulL Lhe currenL guldellnes
have been produced vla a collaboraLlon of efforLs from all Lhree of Lhe socleLles.
1he currenL lLeraLlon of Lhese guldellnes ls lnLended Lo focus on Lhe managemenL of lsolaLed cases of Lbola ln
persons arrlvlng ln or reLurnlng Lo Canada havlng been exposed Lo Lhe vlrus durlng Lravel ouLslde of Canada,
luLure updaLes of Lhese guldellnes wlll be developed as lnformaLlon evolves or lf Lhere ls a need for cllnlcal
guldance regardlng Lhe managemenL of larger volumes of cases of Lbola ln Canadlan hosplLals. 1he focus of
Lhls documenL ls on Lhe cllnlcal care and paLlenL managemenL (e.g. processes & paLlenL flow, bedslde care,
eLc). WlLh Lhe excepLlon of lnLer-faclllLy LransporL, Lhls documenL wlll noL dlscuss Lhe speclflcs of lnfecLlon
prevenLlon and conLrol (lAC) and Lvu dlagnosLlc LesLlng as Lhese are covered ln separaLe guldellnes from
PAC. AlLhough Lhe speclflc guldance regardlng lAC wlll noL be provlded by Lhls group, Lhe cllnlcal socleLles
whlch represenL Lhose worklng on Lhe fronL llnes of paLlenL managemenL are unlquely poslLloned Lo provlde
lnslghL on Lhe human facLors assoclaLed wlLh applylng lAC guldellnes ln Lhe dellvery of paLlenL care.
lL musL be recognlzed LhaL much of Lhe guldance wlLhln Lhls documenL derlves from experL oplnlon. 1here ls
scanL hlgh-grade evldence regardlng Lhe elLher Lhe paLhophyslology or opLlmal speclflc cllnlcal managemenL of
Lvu. 1he alm of Lhls collaboraLlve was Lo develop a slmple, easy-Lo-use gulde for Lhe cllnlclans who face
LreaLlng Lhelr flrsL case of Lvu. Pavlng Lhe luxury of Llme for conLemplaLlon and debaLe over some of Lhe
lssues aL presenL, raLher Lhan ln Lhe heaL of Lhe momenL, we hope LhaL by arLlculaLlng our raLlonale and
dlscusslng Lhe pros and cons of varlous opLlons cllnlclans wlll flnd our 'experL oplnlon' beneflclal.


CCCS - CAL - AMMl
2014 2014
1ab|e of Contents
Iorward ......................................................................................................................................................... 3
Contr|but|ons ................................................................................................................................................. 7
Core Worklng Croup Membershlp ........................................................................................................................................ 7
ccc5 ................................................................................................................................................................................... 7
cAl .................................................................................................................................................................................. 7
AMMl ................................................................................................................................................................................. 7
CLher ConLrlbuLors ................................................................................................................................................................ 7
Cverv|ew of Lbo|a V|rus D|sease .................................................................................................................... 8
Lpldemlology ......................................................................................................................................................................... 8
1ransmlsslon .......................................................................................................................................................................... 8
Cllnlcal .................................................................................................................................................................................... 8
ulagnosls ................................................................................................................................................................................ 9
1reaLmenL .............................................................................................................................................................................. 9
C||n|ca| Leadersh|p ....................................................................................................................................... 10
o|nt of I|rst Contact - Lmergency Department ........................................................................................... 12
reparedness ....................................................................................................................................................................... 12
Case ldenLlflcaLlon ............................................................................................................................................................... 12
lnfecLlon ConLrol .................................................................................................................................................................. 13
1esLlng guldellnes ................................................................................................................................................................ 14
Where 1o rov|de Care Ior An In-at|ent W|th Lbo|a ................................................................................... 16
C||n|ca| Care of Lbo|a Infected at|ents ........................................................................................................ 18
Cllnlcal LxamlnaLlon & AssessmenL ..................................................................................................................................... 18
MonlLorlng (lnvaslve/non-lnvaslve) .................................................................................................................................... 20
Noo-lovoslve cotJlotespltototy mooltotloq ..................................................................................................................... 20
utloe Ootpot .................................................................................................................................................................... 20
lovoslve ottetlol blooJ ptessote mooltotloq .................................................................................................................... 21
ceottol lloe occess ooJ ceottol veooos ptessote (cvl) mooltotloq ................................................................................. 21
oJ-tlJol cotboo JloxlJe (1cO
2
) mooltotloq .................................................................................................................. 21
Otbet lovoslve mooltotloq ............................................................................................................................................... 22
8ody lluld ConLrol ............................................................................................................................................................... 22
Alrway ManagemenL & venLllaLlon ..................................................................................................................................... 22
Noo-lovoslve veotllotloo .................................................................................................................................................. 22
oJottocbeol lotobotloo .................................................................................................................................................. 2J


CCCS - CAL - AMMl
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Mecboolcol veotllotloo .................................................................................................................................................... 24
lluld 8esusclLaLlon & LlecLrolyLes ....................................................................................................................................... 24
Otol flolJ ooJ electtolyte teplocemeot ............................................................................................................................ 25
lottoveooos occess .......................................................................................................................................................... 25
lottoveooos flolJ teplocemeot ooJ tesoscltotloo ............................................................................................................ 25
lecttolyte teplocemeot ................................................................................................................................................... 26
vasopressors ........................................................................................................................................................................ 27
AnLlbloLlcs & AnLlvlrals ........................................................................................................................................................ 27
Crgan SupporL (lPu, C881, LCMC) ...................................................................................................................................... 28
Cardlopulmonary 8esusclLaLlon ........................................................................................................................................... 29
SympLom ManagemenL ....................................................................................................................................................... 30
rophylaxls and revenLaLlve Measures for Lhe CrlLlcally lll ............................................................................................... 30
nuLrlLlon .............................................................................................................................................................................. 31
LxperlmenLal AnLlvlral MedlcaLlons ..................................................................................................................................... 31
alllaLlve Care ...................................................................................................................................................................... 31
key Messoqes. ................................................................................................................................................................. J1
5ectetloos ........................................................................................................................................................................ J2
uyspoeo (ftom polmoooty bemottboqe ot otbet compllcotloo) ...................................................................................... J2
5oJJeo 1etmlool veots (Mosslve bemoptysls, ospbyxlotloo) ......................................................................................... JJ
regnancy & CbsLeLrlcs ....................................................................................................................................................... 33
aedlaLrlc ConslderaLlons .................................................................................................................................................... 34
lmpacL on PealLh Care Worker's Carlng for Lvu aLlenLs ................................................................................................... 34
sychologlcal SupporL (aLlenLs, lamllles & rovlders) ....................................................................................................... 34
Inter-fac|||ty 1ransport of at|ents w|th LVD ................................................................................................ 36
Ceneral ConslderaLlons for Aeromedlcal LvacuaLlon .......................................................................................................... 36
Altctoft 5electloo ............................................................................................................................................................. J6
loqlstlcol lte-fllqbt lloooloq ooJ lost-fllqbt ltoceJotes ................................................................................................ J7
metqeocy ptoceJotes .................................................................................................................................................... J7
woste Jlsposol ................................................................................................................................................................ J8
cleooloq ooJ Jlslofectloo ................................................................................................................................................ J8
8eglonal Aeromedlcal LvacuaLlon ....................................................................................................................................... 38
lotleot lsolotloo & ll .................................................................................................................................................... J8
naLlonal & lnLernaLlonal Aeromedlcal LvacuaLlon .............................................................................................................. 39
lotleot lsolotloo & ll .................................................................................................................................................... 40
kesearch ...................................................................................................................................................... 43
Append|x 1 - LD Screen|ng for & kesponse to oss|b|e LVD Cases ............................................................... 48


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2014 2014
ALNDIk 2 - 8eds|de Nurs|ng Care ............................................................................................................. 49


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2014 2014
ConLrlbuLlons
Lach of Lhe socleLles conLrlbuLed parLlclpanLs for Lhe worklng group who could provlde parLlcular knowledge,
skllls, and/or experlence relevanL Lo Lhe managemenL of paLlenLs wlLh Lbola. Among Lhe worklng group
members Lhere ls represenLaLlon from a varleLy of cllnlcal backgrounds lncludlng boLh adulL and paedlaLrlc
provlders as well as members of Lhe group who have experlence ln LreaLlng paLlenLs wlLh Lbola ln Afrlca
durlng Lhe currenL ouLbreak as well as prlor ouLbreaks. ln addlLlon Lo Lhe core worklng group members, many
oLher members of Lhe socleLles and oLher cllnlcal experLs conLrlbuLed conLenL and commenLs durlng Lhe
developmenL process. 1hls LrllaLeral collaboraLlon was faclllLaLed by PAC (ur. 1homas Wong, uomlnlque
8aker, Margle Lauzon, AlLhea Pouse, Lva Wong and Shamlr nlzar Mukhl)
Core Worklng Croup Membershlp
CCCS
! ur Mlke ChrlsLlan - lead
! ur 8ob lowler
! ur nlran[an 1ex" klssoon
! ur Anand kumar
! ur lrancols LamonLange
! ur Srlnlvas MurLhy
! ur 8andy Wax
CAL
! ur Laurle Mazurlk - lead
! ur !lll McLwen

AMMl
! ur Mlchael Llbman - lead
! 8lccarda CalloLo
! ur. Cary Carber
! ur !ay keysLone
! ur Alllson McCeer
! ur CLLo vanderkool
CLher ConLrlbuLors
! ur !ames uowner
! ur SLephen Laplnsky
! ur 8ussell Macuonald
lease send correspondence or commenLs Lo:
Lvu[cbrnecc.ca


CCCS - CAL - AMMl
2014 2014
Cvervlew of Lbola vlrus ulsease
Lpldemlology
Lbola vlrus ls member of Lhe fllovlrldae, enveloped non-segmenLed, negaLlve sLranded 8nA vlruses. 1here are
flve ldenLlfled subLypes of Lbola vlrus of whlch four have caused human dlsease ln Afrlca,: Lbola Zalre, Lbola
Sudan, Lbola lvory CoasL, and Lbola 8undlbugyo. 1he flfLh vlrus, Lbola 8esLon has caused dlsease ln nonhuman
prlmaLes buL noL ln humans. 1he reservolr of Lbola vlrus ls mosL llkely Lo be frulL baLs ln CenLral Afrlca buL no
human cases have been conLracLed dlrecLly from baLs. ln Lhe wlld, Lbola vlrus llkely spreads from frulL baLs Lo
oLher anlmals such as rodenLs, monkeys and chlmpanzees, followlng whlch humans acqulre Lhe lnfecLlon from
eaLlng poorly cooked anlmals or handllng raw anlmal meaL (8ushmeaL).
1he flrsL case of Lbola vlrus dlsease (Lvu) was deLecLed ln 1976 ln a large ouLbreak ln souLhern Sudan and
norLhern uemocraLlc 8epubllc of Congo (u8C). 1wenLy subsequenL ouLbreaks have been recorded ln Afrlca
wlLh a LoLal of fewer Lhan 1000 deaLhs unLll Lhe currenL 2014 ouLbreak. 1he morLallLy raLe from Lvu varles
from 30 Lo 90 dependlng on Lhe subLype of Lhe vlrus, Lhe hlghesL morLallLy ls seen from Lbola Zalre (whlch ls
Lhe cause of Lhe 2014 WesL Afrlcan ouLbreak) and Lhe lowesL from Lbola 8undlbugyo lnfecLlons. 1he 2014
ouLbreak began ln !anuary 2014 and ls Lhe largesL on record wlLh more Lhan 2,000 cases and 1,000 deaLhs
(~60 morLallLy) as of AugusL, 2014, and cases reporLed ln Culnea, Slerra Leone and Llberla, wlLh llmlLed
spread ln nlgerla.

1ransmlsslon
MosL human lnfecLlons occur by dlrecL conLacL wlLh secreLlons and excreLlons of lnfecLed paLlenLs or cadavers
and noL by aerosol spread. 1he vlrus enLers Lhe hosL Lhrough mucosal surfaces, breaks and abraslons ln Lhe
skln or by Lhe parenLeral rouLe. PealLh care workers are frequenLly lnfecLed from needle sLlcks or breaks ln
personal proLecLlon Lechnlques. AsympLomaLlc lndlvlduals ln Lhe lncubaLlon perlod have noL been
documenLed Lo LransmlL Lhe lnfecLlon.

Cllnlcal
1he cllnlcal plcLure of Lbola vlrus dlsease (Lvu) beglns wlLh an abrupL onseL of fever followlng an lncubaLlon
perlod of 2 Lo 21 (mean 4-10 days) and ls characLerlzed lnlLlally by a nonspeclflc flullke lllness wlLh fever,


CCCS - CAL - AMMl
2014 2014
headache, malalse, myalgla , sore LhroaL and gasLrolnLesLlnal sympLoms such as nausea vomlLlng, dlarrhoea
and abdomlnal paln. AlLhough cough can occur, lL ls noL a prlmary feaLure of Lhls lllness. A maculopapular rash
and con[ucLlval ln[ecLlon may occur. osLural hypoLenslon, confuslon and coma precede deaLh. Paemorrhaglc
manlfesLaLlons, occurrlng ln fewer Lhan 30 of cllnlcal cases, arlse Loward Lhe end of Lhe flrsL week of lllness
and lnclude peLechlae, blood loss from venlpuncLure slLes, brulslng and gasLrolnLesLlnal bleedlng.

ulagnosls
LaboraLory abnormallLles assoclaLed wlLh Lvu lnclude early leukopenla, lymphopenla and aLyplcal
lymphocyLosls. AS1 and AL are ofLen elevaLed. roLhrombln and parLlal LhromboplasLln Llmes are lncreased,
and flbrln spllL producLs are deLecLable lndlcaLlng dlssemlnaLed lnLravascular coagulaLlon. aLlenLs who dle
ofLen do so beLween Lhe slxLh and 16Lh day ln hypovolemlc shock and mulLl-organ fallure. 1he deflnlLlve
dlagnosls of Lvu ls made by 81-C8 or anLlgen deLecLlon.

1reaLmenL
1he malnsLay of LreaLmenL ls supporLlve care, whlch lncludes careful aLLenLlon Lo lnLravascular volume sLaLus
and oral or lnLravenous fluld Lherapy, correcLlon of elecLrolyLe and meLabollc abnormallLles, correcLlon of
coagulaLlon abnormallLles, nuLrlLlonal supporL, and anLlbloLlcs for secondary bacLerlal lnfecLlons. LxperlmenLal
Lheraples, lncludlng monoclonal anLlbody admlnlsLraLlon, small lnhlblLory 8nA molecules, Lbola vlrus-speclflc
convalescenL plasma Lherapy and hyper-lmmune globulln, pre- and posL-exposure lmmunlzaLlon, are sLlll
experlmenLal wlLhouL proven beneflL ln humans. AlLhough some of Lhese LreaLmenLs have recenLly been used
ln a small number of lndlvlduals, Lhe avallable daLa remalns lnsufflclenL Lo deLermlne Lhelr cllnlcal efflcacy and
safeLy ln humans. LfforLs Lo launch cllnlcal Lrlals are underway and Lhe World PealLh CrganlzaLlon has lssued
eLhlcal guldance on use of such agenLs
1
.

1
bttp.//www.wbo.lot/cst/tesootces/pobllcotloos/ebolo/etblcol-cooslJetotloos/eo/
2
http://www.phac-aspc.gc.ca/id-mi/vhf-fvh/ebola-ipc-pci-eng.php


CCCS - CAL - AMMl
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Cllnlcal Leadershlp
PealLh faclllLles leadershlp should provlde dlrecLlon, be engaged and ensure LhaL Lhe lnsLlLuLlon has Lhe
ablllLy Lo deLecL and provlde lnlLlal approprlaLe levels of care for all communlcable dlseases, lncludlng Lhose
LhaL are:
1. 8are or occur only by lmporLaLlon
2. Pave hlgh raLes of lnfecLlvlLy
3. Pave hlgh morLallLy

nea|thcare Inst|tut|ons shou|d be a|ert for the poss|b|||ty of rare and severe d|seases, and the screen|ng of
pat|ents for such |||ness shou|d be rout|ne.
1he consequences of Lhese dlseases are as follows:
1. lor paLlenLs - care of an unfamlllar dlsease may be subopLlmal, and fear, even when Lhe dlagnosls has
noL been conflrmed, may conLrlbuLe Lo paLlenLs recelvlng lower quallLy of care.
2. lor sLaff regardlng Lhelr own healLh and healLh of Lhelr famllles - Lhey need Lo have confldence ln Lhe
medlcal sysLem LhaL Lhey and Lhelr famllles wlll be proLecLed from nosocomlal Lransmlsslon durlng
healLh care.
3. lor Lhe enLlre healLh sysLem - whlle Lhe Lmergency ueparLmenL may be Lhe porLal of enLry Lo Lhe
lnsLlLuLlon for many paLlenLs wlLh lnfecLlous dlseases, such paLlenLs ofLen also recelve care from many
oLher servlces lncludlng: medlcal wards, lCus, operaLlng rooms, dlagnosLlc lmaglng, laboraLory and
paLhology servlces, and pharmacy.
4. Messaglng Lo Lhe medla Lo lnform clLlzens - lL ls llkely LhaL Lhere wlll be members of Lhe general publlc
who presenL for assessmenL (worrled-well") afLer hearlng of cerLaln novel communlcable dlseases and
Lhls has Lhe poLenLlal Lo place addlLlonal sLress on Lhe capaclLy of Lhe Lu and hosplLal generally, and
hence we need Lo lnform whlle belng prepared for Lhe consequences of lncreased publlc concern and
aLLenLlon.

Adm|n|strat|on Leaders w|th|n the |nst|tut|on shou|d ensure that they are prepared for these d|seases as
part of rout|ne care.
1hus admlnlsLraLlon and senlor leaders should ensure LhaL resources are avallable such as personal
proLecLlve equlpmenL (L) and experLs ln paLlenL managemenL, lnfecLlon prevenLlon and conLrol Lo help
gulde processes of care dellvery, general sLafflng, equlpmenL, medlcal supplles, eLc..


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C||n|ca| Leaders shou|d ensure that a team |s |n p|ace to coord|nate the overa|| response.
1he Leam may vary from lnsLlLuLlon Lo lnsLlLuLlon buL should lnclude a senlor nurse, senlor physlclan,
lnfecLlon conLrol offlcer, and employee safeLy offlcer as well as a communlcaLlons offlcer. Should Lhere be
Lhe posslblllLy of a Lvu case dlscovered ln Lu, or oLher area of Lhe hosplLal, Lhe sLaff of LhaL cllnlcal area
should prompLly noLlfy approprlaLe personnel Lhrough Lhelr usual reporLlng channels who wlll Lhen acLlvaLe
Lhe hosplLal speclflc Leam Lhrough whlch wlll Lhen use predeflned proLocols and prepared messaglng LhaL
wlll need Lo be deployed on shorL noLlce.


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olnL of llrsL ConLacL - Lmergency ueparLmenL
reparedness
lL ls key for Lmergency ueparLmenLs (Lu) Lo prepare for respondlng Lo a poLenLlal paLlenL wlLh Lvu before
Lhelr flrsL posslble case presenLs Lo Lhelr deparLmenL. 1hls lnvolves developlng plans Lo screen paLlenLs and
Lhe response should a paLlenL screen poslLlve. ldeally, Lu wlll have a slngle process whlch allows Lhem Lo
screen for and approprlaLely respond Lo any paLlenL presenLlng wlLh a hlghly lnfecLlous dlsease be lL Lvu,
ML8S Cov, P7n9, or any oLher novel emerglng paLhogen. Powever, Lhls documenL wlll focus solely on lssues
relaLed Lo Lvu. Appendlx 1 provldes examples of Lhe Lype of approach recommended wlLhln Lhe Lu Lo screen
for and respond Lo a poLenLlal paLlenL wlLh Lvu. 8elow a brlef descrlpLlon of Lhe key aspecLs of case
ldenLlflcaLlon, lnfecLlon conLrol and LesLlng ln Lhe Lu ls provlded however PCWs should refer Lo Lhe mosL up-
Lo-daLe guldance for Lhese areas provlded on-llne by Lhe naLlonal and rovlnclal publlc healLh agencles
2
.

Case ldenLlflcaLlon
Larly ldenLlflcaLlon of poLenLlal Lbola cases ls essenLlal for lmplemenLlng Lransmlsslon prevenLlon measures,
lncludlng paLlenL lsolaLlon and personal proLecLlve equlpmenL for healLh care workers. Larly ldenLlflcaLlon ls
based on: A) cllnlcal presenLaLlon, Anu 8) epldemlologlc rlsk. lease refer Lo Lhe PAC webslLe for Lhe mosL
up-Lo-daLe case deflnlLlon
3
. Case deflnlLlons can evolve over Llme based upon Lhe changlng epldemlology of
an ouLbreak ln addlLlon Lo advancemenLs ln our sclenLlflc undersLandlng.
Case ldenLlflcaLlon requlres a hlgh lndex of susplclon, rouLlne screenlng of all paLlenLs, knowledge of cllnlcal
feaLures of Lvu, and frequenLly updaLed knowledge of relevanL exposure rlsks for Lvu.
Lvu ls almosL always assoclaLed wlLh hlgh fever - usually aL leasL 38.6 degrees Celslus. AlLhough a slngle
LemperaLure Laken aL Lrlage may be normal, a hlsLory of fever or feverlshness wlll be presenL. rosLraLlon and
headache may be useful very early lndlcaLors. 8ash, con[uncLlval ln[ecLlon, nausea and vomlLlng usually sLarL
several days lnLo lllness. 8ecause Lhese sympLoms are non-speclflc, knowledge of and screenlng for Lravel
hlsLory and oLher exposures ls crlLlcal.
Lvu should be suspecLed ln a febrlle paLlenL whose onseL of sympLoms ls wlLhln 2 Lo 21 days of:

2
J
http://www.phac-aspc.gc.ca/id-mi/vhf-fvh/national-case-definition-nationale-cas-eng.php


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resldence ln or Lravel Lo an area where Lvu Lransmlsslon ls acLlve
4

dlrecLly or lndlrecLly carlng for a probable or conflrmed case of Lvu (e.g. dlrecL paLlenL care or conLacL
wlLh envlronmenL or fomlLes of a case)
spendlng Llme ln a healLhcare faclllLy where Lvu paLlenLs are belng LreaLed
household exposure Lo a conflrmed or probable Lvu paLlenL
processlng laboraLory speclmens from a conflrmed or probably Lvu paLlenL, or ln a hosplLal ln an area
where Lvu Lransmlsslon ls acLlve
ulrecL exposure Lo human remalns (e.g. Lhrough parLlclpaLlon ln funeral rlLes) ln an area where Lvu
Lransmlsslon ls acLlve
ConLacL wlLh baLs or prlmaLes from Lvu-affecLed counLry

ln serlously lll afebrlle paLlenL wlLh a slgnlflcanL exposure hlsLory (as above), conslderaLlon should be glven Lo
wheLher Lvu ls a posslble dlagnosls, consulLaLlon wlLh an lnfecLlous dlsease or Lroplcal dlsease speclallsL may
be approprlaLe.
ln a febrlle paLlenL wlLh a slgnlflcanL exposure hlsLory on screenlng, a deLalled hlsLory and cllnlcal assessmenL
ls requlred Lo deLermlne wheLher a rlsk for Lvu exlsLs and LesLlng for Lvu ls lndlcaLed. ConsulLaLlon wlLh
publlc healLh, publlc healLh laboraLorles and lnfecLlous dlseases should be underLaken lmmedlaLely Lo ensure
LhaL paLlenL managemenL ls opLlmal, and lnfecLlon conLrol precauLlons are lmplemenLed prompLly lf needed.

lnfecLlon ConLrol
ApproprlaLe lnfecLlon conLrol precauLlons should be lnlLlaLed
3
. SLaff should be Lralned and experlenced wlLh
Lhe use of Lhe approprlaLe L. ldeally a 'buddy sysLem' should be ln place Lo ensure 'cross-checks' of L
use. lnfecLlon conLrol conslderaLlons commonly lnclude Lhe followlng lLems llsLed however, PCWs should
consulL Lhelr local lAC pollcles and naLlonal/rovlnclal ubllc PealLh guldellnes:
! rlvaLe room and LolleL (negaLlve pressure lf avallable parLlcularly lf an aerosol generaLlng procedure ls
conducLed)

4
As of August 17, 2014, EVD transmission is active in Guinea, Liberia, Sierra Leone, and Nigeria. Refer to the World Health Organizationss Ebola Virus
Disease (EVD) website for updated information on affected areas: http://www.who.int/csr/disease/ebola/en/
5


CCCS - CAL - AMMl
2014 2014
! roLecLlon from blood and body flulds uslng sLandard and conLacL precauLlons. AL a mlnlmum, Lhls
lncludes gloves, fluld reslsLanL or lmpermeable gown, eye proLecLlon (goggles or shleld), mouLh and nose
proLecLlon (mask and face shleld). AddlLlonal equlpmenL may be needed lf coplous exposure ls anLlclpaLed,
such as double gloves, lmpervlous apron, leg coverlngs, shoe coverlng.
! Aerosol generaLlng procedures requlre addlLlonal resplraLory proLecLlon, such as n93 resplraLors or A8,
and musL be performed ln a negaLlve pressure room.
! Lx18LML CAu1lCn Lo avold sharps (percuLaneous) ln[urles.
o LlmlL Lhe use of needles and oLher sharps as much as posslble
o hleboLomy, procedures, and laboraLory LesLlng should be performed accordlng Lo whaL ls
essenLlal for adequaLe dlagnosLlc evaluaLlon and medlcal care and should be performed by
mosL quallfled person avallable
o All needles and sharps should be handled wlLh exLreme care and dlsposed ln puncLure-proof,
sealable conLalners

! uedlcaLed, dlsposable medlcal equlpmenL should be used where posslble and approprlaLe. CLher
equlpmenL Lo be cleaned and dlslnfecLed as per lAC proLocols.
! Pand hyglene before and afLer conLacL accordlng Lo Lhe 4 MomenLs of Pand Pyglene (8Ll/llnk lAC or
oLher).
! ulllgenL envlronmenLal cleanlng and dlslnfecLlon and safe handllng of poLenLlally conLamlnaLed maLerlals ls
paramounL, as blood, vomlL, feces and oLher body secreLlons represenL poLenLlally lnfecLlous maLerlals. A
dlslnfecLanL wlLh a broad specLrum vlruclde clalm wlLh a uln should be used accordlng Lo Lhe
manufacLurer's lnsLrucLlon.
6

1esLlng guldellnes
ln Canada, Lhe llkellhood of a dlagnosls of Lbola ln a febrlle reLurned Lraveller ls generally much lower Lhan Lhe
llkellhood of Lhe common lmporLed febrlle lllnesses. ln parLlcular, MALA8lA ls endemlc ln all reglons where
Lbola has been ldenLlfled. uelay ln Lhe dlagnosls and LreaLmenL of malarla can lead Lo severe or leLhal dlsease
ln a shorL perlod of Llme.
! u8CLn1 malarla LesLlng should be performed ln all paLlenLs. Malarla remalns Lhe slngle mosL llkely
dlagnosls ln febrlle paLlenLs from reglons llkely Lo be affecLed by Lvu ouLbreaks.

6


CCCS - CAL - AMMl
2014 2014
! ArrangemenLs musL be made wlLh labs for Lbola vlrus dlsease LesLlng (Lyplcally by real Llme polymerase
chaln reacLlon or anLlgen or anLlbody deLecLlon sysLems).lease refer Lo your provlnclal/LerrlLorlal publlc
healLh auLhorlLy for lnformaLlon on access Lo Lbola vlrus LesLlng.
! CLher LesLlng ls gulded by Lhe paLlenL's sympLoms and slgns, buL wlll Lyplcally lnclude aL leasL baslc
hemaLology and chemlsLry analyses, culLures of blood, and posslbly a chesL radlograph.
! 1he laboraLorles musL be lnformed abouL any speclmens LhaL may conLaln Lbola vlrus so LhaL approprlaLe
LransporL and handllng can be arranged. Speclmens should be carrled by hand ln approprlaLe conLalners.
1hey should nC1 be senL by pneumaLlc Lube or slmllar sysLems.


CCCS - CAL - AMMl
2014 2014
Where 1o rovlde Care lor An ln-aLlenL WlLh Lbola
SelecLlon of Lhe approprlaLe cllnlcal area Lo manage a paLlenL wlLh Lbola once he or she has enLered a healLh
care faclllLy wlll be dependenL upon a number of facLors. Lvery lnsLlLuLlon wlll have Lo make an lndlvldual
declslon abouL whaL ls besL for Lhelr parLlcular clrcumsLance. Powever, lL cannoL be sLressed enough LhaL,
slmllar Lo Lhe baslc prlnclples LhaL apply ln emergency preparedness[1], hosplLals should underLake an
lnvenLory of Lhelr faclllLles and ldenLlfy poLenLlal areas for managlng hlghly lnfecLlous paLlenLs such as Lhose
wlLh Lbola we|| before Lhey are faced wlLh Lhelr flrsL poLenLlal case.

When assesslng poLenLlal areas Lo care for an Lbola paLlenL conslderaLlon should be glven Lo Lhe followlng
facLors:
! Slngle aLlenL 8oom wlLh a prlvaLe baLhroom, door and anLeroom (or space Lo creaLe one)
o negaLlve pressure lsolaLlon ls only essenLlal lf aerosol generaLlng procedures are Lo be
conducLed
! AblllLy Lo dlspose of body flulds safely wlLhln Lhe paLlenL's room
! lnfrasLrucLure for paLlenLs Lo communlcaLe Lo sLaff/vlslLors ouLslde of Lhe room
! AblllLy Lo resLrlcL access Lo Lhe area as well as Lo Lhe paLlenL's room
! AblllLy Lo provlde dedlcaLed paLlenL care equlpmenL (preferably dlsposable)
! AblllLy Lo provlde crlLlcal care wlLhouL havlng Lo move Lhe paLlenL should he/she deLerloraLe
o SucLlon
o MonlLors
o Slnk (wlLh dlalysls connecLlons lf needed)
o LlecLrlcal ouLleLs (lncludlng emergency power supply)
o Medlcal Cas (Cxygen & Medlcal Alr) connecLlons
o Space for llfe supporL equlpmenL
! lf faclllLy resources permlL, overhead holsLs Lo faclllLaLe paLlenL movemenL wlLh mlnlmal sLaff lnvolved
! SufflclenL space for provlders Lo don and doff L, ldeally wlLh a separaLe 'clean' enLrance and 'dlrLy' exlL
! SLorage for medlcal supplles and L ouLslde of Lhe room


CCCS - CAL - AMMl
2014 2014
! ApproprlaLe faclllLles ouLslde of Lhe room Lo clean or dlspose of conLamlnaLed medlcal equlpmenL and
supplles.
! oLenLlal for access Lo or placemenL of polnL-of-care LesLlng equlpmenL
! Work area ouLslde of Lhe room for sLaff
! necessary l1 & communlcaLlons connecLlons for boLh sLaff and paLlenL use
! AblllLy Lo brlng porLable x-ray machlnes lnLo room Lo mlnlmlze paLlenL LransporL
! hyslcally separaLed from oLher non-Lvu paLlenLs
! Close access Lo elevaLors or dlagnosLlc sulLes Lo mlnlmlze LransporLaLlon Llmes

When a Canadlan hosplLal ls faced wlLh Lhe need Lo care for a slngle paLlenL wlLh Lbola, for many hosplLals Lhe
mosL pracLlcal place Lo provlde Lhls care may be ln an lnLenslve Care unlL (lCu). lCus ln many hosplLals are Lhe
mosL llkely locaLlons Lo possess Lhe facLors ldeal for carlng for an Lbola paLlenL. ln addlLlon Lo Lhe physlcal and
loglsLlc lssues, lCu provldes 1:1 (or hlgher) nurse Lo paLlenL raLlos whlch wlll ln parL mlLlgaLe Lhe negaLlve
lmpacL on paLlenL care due Lo Lhe burden assoclaLed wlLh Lhe L requlremenLs[2]. lurLher, paLlenLs sufferlng
from Lvu requlre close aLLenLlon Lo fluld managemenL and volume resusclLaLlon, skllls LhaL crlLlcal care
cllnlclans possess as a prlmary experLlse. llnally, lCu sLaff Lyplcally represenL a conLalned audlence Lo LargeL
for educaLlon and Lralnlng relaLed Lo Lhe provlslon of care Lo paLlenLs wlLh L8v. 1hey should already be well
pracLlced ln Lhe use of approprlaLe L, and ln performlng aerosol-generaLlng procedures lf necessary, for
Lhese slLuaLlons.


CCCS - CAL - AMMl
2014 2014
Cllnlcal Care of Lbola lnfecLed aLlenLs
Cllnlcal LxamlnaLlon & AssessmenL
1he dlscusslon of Lhls secLlon wlll be brlef and focus prlmarlly on Lhe ldenLlflcaLlon of common compllcaLlons
assoclaLed wlLh Lvu and Lo provlde a gulde Lo Lhe expecLed naLural hlsLory of Lhe lllness. Cllnlcal examlnaLlon
of Lhe paLlenL should occur aL leasL Lwlce dally (once per nurslng shlfL) ln paLlenLs who are noL severely lll.
aLlenLs who are severely lll requlre more lnLense monlLorlng, slmllar Lo oLher crlLlcally lll paLlenLs. MonlLorlng
should follow Lhe usual approach Lo paLlenL assessmenL wlLh an addlLlonal focus on vlLal slgns and Lhelr
varlablllLy (dlscussed furLher below under 'MonlLorlng').

1he naLural hlsLory of Lbola ls Lyplcally dlvlded lnLo Lhree phases: early, laLe, and Lermlnal or recovery[3-3].
undersLandlng Lhe common flndlngs durlng each of Lhese phases wlll allow Lhe cllnlclan Lo ldenLlfy boLh
expecLed and unexpecLed compllcaLlons should Lhey occur.
1he followlng feaLures may be seen ln Lhe early phase of Lbola lnfecLlon:
! laLlgue & malalse
! Cenerallzed weakness
! lever (sudden onseL)
! Peadache
! Myalgla & arLhralgla
! haryngeal eryLhema
! LymphadenopaLhy
! nausea & anorexla
! vomlLlng
! ularrhoea (non-bloody)

1he followlng feaLures Lend Lo develop durlng Lhe laLer phase of dlsease. lL should be noLed LhaL ofLen Lhe
feaLures overlap and Lhere ls noL a clear dlsLlncLlon beLween Lhe phases. AddlLlonally, desplLe Lhe
classlflcaLlon of Lbola as a haemorrhaglc fever" and Lhe dlscusslon of haemorrhaglc sympLoms below,
bleedlng ls a predomlnanL sympLom ln a mlnorlLy of paLlenLs wlLh Lbola.


CCCS - CAL - AMMl
2014 2014
! Abdomlnal paln (8uC Lenderness on palpaLlon +/- hepaLomegaly)
! rofuse dlarrhoea
! Severe vomlLlng
! Plccups
! Con[uncLlvlLls
! Confuslon, dellrlum, prosLraLlon, selzures, coma
! Maculopapular rash wlLh eryLhema and desquamaLlon
! Shock
! ChesL aln
! lcLerus or [aundlce
! 8esplraLory dlsLress (rarely prlmary, more commonly ln response Lo meLabollc acldosls, volume overload,
eLc.)
! Mlscarrlage ln pregnanL women
! Paemorrhaglc manlfesLaLlons
o Lcchymosls & peLechlae
o Cozlng from lnLravenous and venepuncLure slLes
o Melena or hemaLochezla
o Con[uncLlval haemorrhage
o LplsLaxls
o PaemaLemesls
o PaemopLysls
o vaglnal bleedlng
o PaemaLurla

aLlenLs who enLer Lhe Lermlnal phase of Lhe lllness are ofLen obLunded and hypoLenslve prlor Lo
cardloresplraLory fallure.


CCCS - CAL - AMMl
2014 2014
Should Lhe paLlenL enLer Lhe recovery phase, lL can occur over days, weeks or monLhs [3]. Many sympLoms
may perslsL durlng Lhls phase lncludlng weakness, welghL loss, headache, mlgraLory arLhralglas, desquamaLlon,
halr loss, and anaemla. AddlLlonally, laLe occurrences of acuLe orchlLls and uvelLls have been reporLed[3].

MonlLorlng (lnvaslve/non-lnvaslve)
As prevlously menLloned, Lhe care of paLlenLs wlLh Lvu ls prlmarlly supporLlve.[4] aLlenLs wlLh probable or
conflrmed Lvu should be monlLored ln a seLLlng LhaL ls capable of lnLenslve and frequenL monlLorlng of vlLal
slgns, fluld balance, and neurologlc sLaLus. ldeally all paLlenL monlLors should be vlslble from ouLslde of Lhe
paLlenL's room elLher vla a wlndow or saLelllLe monlLorlng sLaLlon and alarms musL be audlble from ouLslde of
Lhe paLlenL's room wlLh Lhe doors closed. vldeo monlLorlng of Lhe room can also enhance Lhe effecLlveness of
paLlenL monlLorlng. llnally, Lhe paLlenL should have a mechanlsm Lo slgnal for asslsLance and communlcaLe
wlLh sLaff ouLslde of Lhe room. ln addlLlon Lo monlLorlng, nurslng sLaff carlng for Lhe paLlenL should have well
prescrlbed parameLers for alerLlng Lhe paLlenL's aLLendlng physlclan lf Lhere ls deLerloraLlon ln Lhe paLlenL's
sLaLus.

non-lnvaslve cardloresplraLory monlLorlng
non-lnvaslve cardloresplraLory monlLorlng lncludlng hearL raLe (LkC), resplraLory raLe, oxygen saLuraLlon
(pulse oxlmeLry) and non-lnvaslve blood pressure (nl8) should be avallable for all paLlenLs wlLh Lbola,
alLhough Lhe frequency of monlLorlng should be deLermlned by Lhe paLlenL's cllnlcal condlLlon. 1he use and
frequency, ln parLlcular, of nl8 monlLorlng of paLlenLs wlll have Lo be assessed on an lndlvldual basls,
dependlng upon Lhe paLlenL's severlLy of lllness, Lype of nl8 monlLor and degree of caplllary leak (ecchymosls
& peLechlae) as slgnlflcanL brulslng may resulL parLlcularly from older generaLlon nl8 monlLors LhaL use
repeaL hlgh cuff pressures. newer generaLlon of monlLors and manual 8 monlLorlng may be less LraumaLlc.

urlne CuLpuL
PydraLlon and volume sLaLus are parLlcularly lmporLanL facLors ln paLlenLs wlLh Lbola glven boLh Lhelr
gasLrolnLesLlnal losses and Lhe poLenLlal for caplllary leak or haemorrhage. 1herefore, close monlLorlng of
urlne ouLpuL ls an essenLlal Lool for deLecLlng volume depleLlon, parLlcularly slnce accuraLe documenLaLlon of
fluld balance (ln's and ouL's") ls ofLen dlfflculL ln Lhe seLLlng of vomlLlng and dlarrhoea. ln less severely lll
paLlenLs Lhe measuremenL of volded urlne ls approprlaLe. Powever, lf Lhe paLlenL ls havlng slgnlflcanL


CCCS - CAL - AMMl
2014 2014
dlarrhoea or ls serlously/crlLlcally lll Lhe preferred meLhod of monlLorlng urlne ouLpuL wlll be wlLh a loley
caLheLer and uromeLer. 1hls should be recorded on an hourly basls.
SequenLlal welghL assessmenL may also be a useful lndex for fluld managemenL parLlcularly lf Lhe paLlenL ls
exhlblLlng subsLanLlal unmeasured fluld losses due Lo dlarrhea or lnsenslble losses.

lnvaslve arLerlal blood pressure monlLorlng
lnvaslve arLerlal blood pressure monlLorlng should be consldered ln selecL cases wlLh hemodynamlc lnsLablllLy
requlrlng vasoacLlve agenLs and frequenL blood-work monlLorlng. 1he poLenLlal beneflLs musL be balanced
agalnsL Lhe rlsk of blood exposure and Lhe poLenLlal for arLerlal spray of blood ln Lhe evenL of a clrculL
dlsconnecL or leak. ln mosL clrcumsLances radlal arLerlal access would be preferable over femoral access
parLlcularly glven Lhe frequency of sollage of Lhe groln area, and for Lhe posslblllLy of coagulopaLhy among
some paLlenLs. lf Lhe paLlenL has cenLral venous access ln place and nl8 monlLorlng ls effecLlve, Lhe addlLlon
beneflL of arLerlal monlLorlng ls mlnlmal and may be ouLwelghed by Lhe assoclaLed rlsks Lo Lhe paLlenL, or of
blood exposure Lo sLaff.

CenLral llne access and cenLral venous pressure (Cv) monlLorlng
1he currenL llLeraLure on Lhe uLlllLy of Cv monlLorlng ls mlxed. Clven Lhe lack of sLrong evldence Lo supporL
Lhe uLlllLy of Cv monlLorlng we would noL recommend Lhe esLabllshmenL of cenLral venous access for Lhe
purpose of Cv monlLorlng alone. ln such clrcumsLances assessmenL of volume sLaLus based upon cllnlcal
examlnaLlon of Lhe [ugular venous pressure (!v) or oLher cllnlcal lndlcaLors ls mosL approprlaLe. Powever, lf
cenLral venous access has been esLabllshed for an alLernaLlve lnducLlon (dlfflculL perlpheral access,
requlremenL for vasopressors, or elecLrolyLe replacemenL) Lhe use of Cv monlLorlng can be consldered.
Slmllarly, Lhe use of cenLral venous oxygen saLuraLlon as a measure of adequacy of forward flow may be useful
lf lnLravascular volume or cardlac funcLlon ls uncerLaln and cllnlcal examlnaLlon ls noL adequaLely reveallng.

Lnd-Lldal carbon dloxlde (L1CC
2
) monlLorlng
L1CC
2
should be consldered ln paLlenLs who are recelvlng mechanlcal venLllaLlon. 1he comblnaLlon of L1CC
2

monlLorlng and pulse oxlmeLry may decrease Lhe need for arLerlal blood gas analysls, poLenLlally ellmlnaLlng
Lhe need for an arLerlal caLheLer or for repeaLed arLerlal puncLures and Lhus Lhe rlsk of needle sLlck ln[urles Lo
sLaff.


CCCS - CAL - AMMl
2014 2014
CLher lnvaslve monlLorlng
ln general lL ls besL Lo mlnlmlze any forms of lnvaslve monlLorlng due Lo rlsks assoclaLed wlLh coagulopaLhy,
sharps exposure durlng lnserLlon and body fluld exposure. lL ls unllkely LhaL any forms of lnvaslve monlLorlng
aslde from Lhose llsLed above would be necessary for Lhe managemenL of a paLlenL wlLh Lvu.

8ody lluld ConLrol
Clven LhaL Lbola ls prlmarlly LransmlLLed Lhrough body flulds (blood, urlne, dlarrhoea, emesls, sallva, and
oLher flulds) conLrol of Lhese subsLances ls vlLal ln prevenLlng Lransmlsslon and proLecLlng healLh care workers.
lf Lhe paLlenL ls conLlnenL of faeces and urlne, access Lo a prlvaLe washroom should be ensured. Powever, lf
Lhe paLlenL ls lnconLlnenL of urlne or faeces Lhe use of a loley caLheLer and/or faecal collecLlon sysLem should
be consldered, especlally ln chlldren. nasogasLrlc Lubes wlLh gasLrlc sucLlonlng or dralnage may be useful ln
prevenLlng or mlnlmlzlng vomlLlng. lf body flulds are spllled ln Lhe paLlenL care envlronmenL Lhe approprlaLe
conLalnmenL and envlronmenLal cleanlng guldellnes should be followed
7
. Conslder Lhe use of dlsposable
producLs LhaL absorb urlne, vomlL, sLool and make Lhem non-llquld - welghlng can be used Lo assess quanLlLy
lf necessary.

Alrway ManagemenL & venLllaLlon
ulmonary lnvolvemenL of Lbola ls noL a common feaLure of Lhe dlsease, however resplraLory fallure may
occur ln Lhese paLlenLs requlrlng mechanlcal venLllaLlon. Secondary causes of resplraLory fallure may lnclude
(buL are noL llmlLed Lo) shock, faLlgue from prolonged compensaLlon of meLabollc acldosls and laLrogenlc
compllcaLlons (e.g. Lransfuslon-relaLed lung ln[ury). Alrway managemenL may be requlred lndependenL of
resplraLory fallure for alrway proLecLlon purposes, wlLh slLuaLlonal examples lncludlng decreased level of
consclousness or masslve upper Cl bleedlng.

non-lnvaslve venLllaLlon
non-lnvaslve venLllaLlon (nlv) may be consldered for supporL of paLlenLs wlLh Lvu havlng rapldly reverslble
causes of resplraLory fallure, however, Lhere are slgnlflcanL concerns LhaL warranL cauLlon and llkely ouLwelgh
any poLenLlal beneflLs of nlv ln Lhls paLlenL populaLlon. llrsL, many paLlenLs wlLh Lvu have frequenL vomlLlng

7


CCCS - CAL - AMMl
2014 2014
whlch wlll lncrease Lhe rlsk of asplraLlon. Second, nlv wlll cause prolonged rlsk of aerosollzaLlon, and Lherefore
musL be performed ln a negaLlve pressure lsolaLlon room. All sLaff managlng a paLlenL on nlv musL wear Lhe
L requlred durlng aerosol generaLlng procedures whlle ln Lhe paLlenL room. 1hlrd, should Lhe paLlenL fall
nlv and requlre lmmedlaLe lnLubaLlon, Lhere ls hlgher rlsk Lo sLaff by rushlng Lo don L leadlng Lo a breach of
lnfecLlon conLrol and posslble Lransmlsslon. 1herefore, should a Lrlal of nlv be performed, close and frequenL
monlLorlng musL be performed Lo ldenLlfy need for lnLubaLlon as early as posslble Lo allow sufflclenL Llme for
sLaff Lo carefully prepare equlpmenL and lnsLlLuLe approprlaLe lnfecLlon conLrol pracLlces. lourLh, Lhe rlsk of
oropharyngeal bleedlng and hemaLemesls wlLh an nlv mask ln place may creaLe slgnlflcanL rlsk Lo Lhe paLlenL
for asplraLlon, wlLh a slgnlflcanL delay ln sLaff response Lo asslsL due Lo need Lo don L when enLerlng Lhe
paLlenL room. ln general, lL ls safer Lo manage a paLlenL wlLh Lvu and resplraLory fallure uslng a sLraLegy
lncludlng elecLlve lnLubaLlon, LradlLlonal mechanlcal venLllaLlon lncludlng fllLraLlon of exhaled gases, and
frequenL monlLorlng of lmprovemenL ln cllnlcal sLaLus leadlng Lo a conLrolled aLLempL aL exLubaLlon as Lhe
paLlenL responds Lo Lherapy.

LndoLracheal lnLubaLlon
1he need for endoLracheal lnLubaLlon should ldeally be recognlzed early enough Lo allow a non-emergenL
procedure, Lhus avoldlng a poLenLlal rush leadlng Lo mlsLakes ln use of personal proLecLlve equlpmenL (L)
and oLher lnfecLlon conLrol precauLlons. ln addlLlon Lo Lhe usual cllnlcal lndlcaLors suggesLlng Lhe poLenLlal for
a dlfflculL lnLubaLlon, paLlenLs wlLh Lvu may have nasopharyngeal or oropharyngeal bleedlng lmpalrlng
vlsuallzaLlon of Lhe vocal cords durlng lnLubaLlon. An exhalaLlon fllLer should be aLLached Lo Lhe bag
venLllaLlon devlce.
ApproprlaLe L musL be worn when preparlng for hlgh-rlsk aerosol generaLlng medlcal procedures, such as
alrway managemenL. As per lnfecLlon revenLlon and ConLrol guldellnes
8
, Lhls musL lnclude proLecLlve fluld
proof cloLhlng LhaL provldes faclal/eye proLecLlon lncludlng goggles or face shleld, and a resplraLor mask wlLh
proLecLlon aL leasL equlvalenL Lo meeL n93 sLandards wlLh approprlaLe flL LesLlng for Lhe speclflc
resplraLor. lor Lhose properly Lralned ln Lhelr use wlLh meLlculous aLLenLlon pald Lo avold self-conLamlnaLlon,
cllnlclans may also conslder uslng full hood powered alr purlfylng resplraLors (A8) as a more comforLable
opLlon LhaL provldes beLLer proLecLlon agalnsL sprayed body flulds whlle aL Lhe head of Lhe bed, along wlLh
waLer lmpermeable cloLhlng prevenLlng any skln exposure such as a full body sulL. CurrenL lnfecLlon conLrol
recommendaLlons lnclude havlng paLlenLs ln negaLlve pressure lsolaLlon rooms durlng performance of any

8


CCCS - CAL - AMMl
2014 2014
aerosol generaLlng medlcal procedures. AlLhough Lhe alrborne spread of Lbola ls noL a usually recognlzed
mechanlsm of Lransmlsslon ln humans, Lhe poLenLlal for aerosol generaLlon of oLher prlmarlly dropleL
LransmlLLed vlruses has been demonsLraLed durlng some procedures such as lnLubaLlon[6, 7], and Lhe
presence of an anLeroom ln Lyplcal negaLlve pressure paLlenL lsolaLlon rooms allows safer donnlng and dofflng
of L.
1he paLlenL should be lnLubaLed by a cllnlclan hlghly experlenced ln alrway managemenL. Some ad[uncLlve
sLraLegles beyond Lhe use of dlrecL laryngoscopy may be helpful. vldeo/opLlcal laryngoscopy should be
consldered Lo allow beLLer vlsuallzaLlon of Lhe vocal cords ln anLlclpaLed or unanLlclpaLed dlfflculL alrway, and
wlll lncrease Lhe dlsLance beLween Lhe paLlenL and Lhe cllnlclan durlng Lhe lnLubaLlon, whlch may reduce Lhe
llkellhood of aerosollzaLlon exposure or lnadverLenL dlslodgmenL of L.
8apld sequence lnLubaLlon, lncludlng Lhe use of rapld-acLlng neuromuscular blockade, should be
consldered. Clven Lhe poLenLlal for hemodynamlc lnsLablllLy ln paLlenLs wlLh Lvu, Lhe medlcaLlon reglmen for
sedaLlon should conslder use of agenLs LhaL are less llkely Lo drop Lhe blood pressure, such as keLamlne, or use
of agenLs Lo mlLlgaLe or prevenL hypoLenslon Lo due dlrecL slde-effecLs or sedaLlves, or loss of lnLrlnslc
sympaLheLlc acLlvaLlon. Cood lnLravenous access musL be presenL Lo allow rapld fluld resusclLaLlon ln case Lhe
blood pressure drops durlng Lhe lnLubaLlon process, and vasopressors (e.g. phenylephrlne or ephedrlne)
should be lmmedlaLely avallable Lo admlnlsLer as a bolus lf requlred.

Mechanlcal venLllaLlon
usual pracLlces regardlng lnvaslve mechanlcal venLllaLlon should be followed, lncludlng avoldance of excesslve
Lldal volumes (keeplng vL < 6 ml/kg lf posslble), avoldance of excesslve plaLeau pressures (keeplng less Lhan 30
cm P20), approprlaLe poslLlve end explraLory pressure (LL) Lo avold recurrenL aLelecLrauma. venLllaLors
musL have capablllLy for PLA fllLraLlon of exhaled gases. Clven Lhe poLenLlal rlsk for unexpecLed aerosol
generaLlng medlcal procedures (l.e., accldenLal exLubaLlon requlrlng lmmedlaLe re-lnLubaLlon), Lhe paLlenL
should be malnLalned ln a negaLlve pressure lsolaLlon room. ldeally, an lnLerface beLween Lhe mechanlcal
venLllaLor and Lhe paLlenL monlLorlng sysLem wlll allow easler monlLorlng of venLllaLlon parameLers wlLhouL
frequenL reenLry lnLo Lhe paLlenL room.

lluld 8esusclLaLlon & LlecLrolyLes
WlLh crlLlcally lll Lvu paLlenLs, hypovolemla ls Lhe mosL common and predlcLable anomaly. Accordlngly,
admlnlsLraLlon of flulds and elecLrolyLes consLlLuLes Lhe flrsL sLep ln a serles of supporLlve care lnLervenLlons.


CCCS - CAL - AMMl
2014 2014
erslsLenL fluld loss, poLenLlally compounded by oLher causes for shock, ofLen requlre ongolng fluld
replacemenL. 1here are no sLudles speclflc Lo Lhe LreaLmenL of paLlenLs wlLh Lvu Lo gulde fluld managemenL
sLraLegles ln Lhese paLlenLs. 1he suggesLlons below are largely exLrapolaLed from oLher llLeraLure such as Lhe
managemenL of uengue Paemorrhaglc lever or sepLlc shock.
Cral fluld and elecLrolyLe replacemenL
Cral fluld and elecLrolyLe replacemenL ls preferred ln paLlenLs who are noL crlLlcally lll, who are able Lo drlnk
and noL sufferlng from slgnlflcanL nausea and vomlLlng. urpose deslgned oral rehydraLlon soluLlons wlll
provlde Lhe mosL effecLlve volume replacemenL and elecLrolyLe replacemenL ln Lhose wlLh slgnlflcanL
dlarrhoea. AnecdoLal observaLlons made durlng Lhe WesL Afrlcan ouLbreak suggesL, however, LhaL severe
cases may be assoclaLed wlLh an lnablllLy Lo eaL and drlnk adequaLely. Larly nC Lube lnserLlon for fluld and
elecLrolyLe repleLlon should be consldered, especlally for chlldren.
lnLravenous access
lnLravenous (lv) access wlll be requlred for Lhose paLlenLs who are unable Lo LoleraLe oral flulds or
hemodynamlcally unsLable. ln Lhe early sLages of Lvu and for Lhose wlLh mllder manlfesLaLlons of Lhe lllness
perlpheral lv access ls sulLable for fluld managemenL. Large bore lvs (14-18 gauge, for adulLs, and age-
approprlaLe for chlldren) are preferred Lo allow large volume fluld resusclLaLlon ln Lhe evenL Lhe paLlenL
deLerloraLes. CenLral or perlpherally lnserLed cenLral venous access should be consldered for paLlenLs who
requlre lnLravenous elecLrolyLe replacemenL (parLlcularly poLasslum), vasopressors, or where vascular collapse
llmlLs perlpheral lv access and lncreases Lhe mulLlple aLLempLs aL lv lnserLlon wlLh Lhe assoclaLed needle sLlck
ln[urles and poLenLlal bleedlng compllcaLlons for Lhe paLlenL and blood exposure Lo sLaff. ln Lhe evenL LhaL
cenLral venous access musL be obLalned, Lhe rlsk of ln[ury Lo elLher Lhe paLlenL or sLaff can be mlnlmlzed by
havlng an experlenced physlclan conducL Lhe procedure under dlrecL ulLrasound vlsuallzaLlon wlLh Lhe paLlenL
calm or sedaLed. AL all Llmes, careglvers should adhere Lo recommended barrler precauLlons and personal
proLecLlve equlpmenL. ConslderaLlon should be glven Lo uslng non-suLure securlng devlces Lo mlnlmlze skln
puncLures as well as Lhe rlsk of needle sLlck ln[urles. lor boLh perlpheral and cenLral lv llnes needle-less
sysLems should be used Lo avold sharps ln[urles.
lnLravenous fluld replacemenL and resusclLaLlon
1he amounL of lnLravenous fluld admlnlsLraLlon requlred wlll depend upon Lhe speclflc paLlenL's sympLoms
and should be gulded by Lhe degree of overL volume loss (dlarrhoea, vomlLlng, and urlnaLlon) as well as facLors
suggesLlng volume conLracLlon: decreased skln Lurgor, dry mucous membranes, Lachycardla, decreased urlne
ouLpuL, and hypoLenslon. We suggesL LhaL 8lnger's lacLaLe (L8) should be Lhe fluld of cholce for volume
replacemenL. 1hls ls based upon evldence exLrapolaLed from Lhe managemenL of paLlenLs wlLh uengue
Paemorrhaglc lever[8] and Lhe managemenL of sepLlc shock[9-11]. 1here ls evldence Lo suggesL LhaL


CCCS - CAL - AMMl
2014 2014
compared wlLh normal Sallne, 8lnger's LacLaLe may be assoclaLed wlLh lower raLes of morLallLy[11], renal
fallure[10], acldosls[12-14], and haemorrhage[13-17]. lor paLlenLs LhaL are hypoLenslve lnlLlal boluses of
8lnger's LacLaLe ln Lhe order of 20ml/kg should be consldered and repeaLed as requlred unLll Lhe hearL raLe,
blood pressure and parameLers of end-organ perfuslon are wlLhln Lhe deslred range. ln Lhe evenL where large
volumes of crysLallold soluLlons are belng admlnlsLered, conslderaLlon may be glven Lo Lhe use of albumln[18].
ArLlflclal collolds (e.g. penLasLarch or hydroxyeLhyl sLarch) should be avolded glven Lhelr assoclaLed rlsks of
renal ln[ury[19], bleedlng[20] and morLallLy[21]. ln Lhe evenL Lhe paLlenL ls haemorrhaglng and/or
coagulopaLhlc conslderaLlon should be glven Lo Lhe admlnlsLraLlon of packed red blood cells, plaLeleLs,
flbrlnogen and plasma as requlred based upon Lhelr hemaLologlc laboraLory values and cllnlcal flndlngs. A
LargeL haemoglobln of greaLer Lhan 70 g/L ls recommended. 1here ls no evldence Lo supporL Lhe Lransfuslon of
plaLeleLs and coagulaLlon facLors ln paLlenLs wlLh ulC who are noL bleedlng or who are noL aL hlgh rlsk of
bleedlng. Powever, LreaLmenL ls [usLlfled ln paLlenLs who have serlous bleedlng, or are aL hlgh rlsk for
bleedlng, or requlre lnvaslve procedures. laLeleLs should be admlnlsLered Lo paLlenLs wlLh a plaLeleL counL of
less Lhan 20 x 10
9
/L of lf less Lhan 30 x 10
9
/L and ls assoclaLed wlLh serlous bleedlng. lf serlous bleedlng ls
occurrlng and Lhe ln8 ls greaLer Lhen 2, fresh frozen plasma (ll) should be admlnlsLered. Slmllarly lf Lhe
flbrlnogen ls low ln Lhe face of slgnlflcanL haemorrhage cryopreclplLaLe should be Lransfused. When managlng
a paLlenL wlLh Lvu who ls experlenclng ulC and haemorrhage cllnlclans should consulL a haemaLologlsL and/or
Lhelr blood bank physlclan. ln cerLaln cases Lhe poLenLlal efflcacy of mulLlple Lransfuslons musL be welghed
agalnsL Lhe avallablllLy of resources.
LlecLrolyLe replacemenL
Cllnlclans should expecL and monlLor for slgnlflcanL elecLrolyLe deflclencles (parLlcularly hypokalemla and
meLabollc acldosls secondary Lo blcarbonaLe loss from vomlLlng and dlarrhoea respecLlvely) Lo occur ln Lhose
paLlenLs sufferlng vomlLlng and/or hlgh volume dlarrhoea. As sLaLed earller, lf LoleraLed, oral replacemenL of
elecLrolyLes ls Lhe preferred meLhod. ConslderaLlon should be glven Lo addlng poLasslum and blcarbonaLe Lo
approprlaLe malnLenance lv flulds early for paLlenLs wlLh dlarrhoea Lo prevenL severe hypokalaemla (assumlng
Lhere ls no evldence of renal fallure) and meLabollc acldosls. ln Lhe evenL LhaL concenLraLed lnLravenous
elecLrolyLe replacemenLs are necessary, cenLral venous access wlll mosL llkely be requlred ln addlLlon Lo
ensurlng approprlaLe cardlac monlLorlng ls ln place. LlecLrolyLe replacemenL proLocols LhaL adhere Lo Lhe
lSM
9
or WPC
10
besL pracLlces for concenLraLed elecLrolyLe replacemenLs should be used. Clven Lhe
lmporLance of elecLrolyLe managemenL ln Lhls paLlenL populaLlon, cenLral laboraLory or polnL-of-care LesLlng

9
bttps.//www.lsmp.otq/tools/lostltotlooolblqbAlett.osp
10
bttp.//www.wbo.lot/potleotsofety/solotloos/potleotsofety/l5-5olotloo5.pJf


CCCS - CAL - AMMl
2014 2014
should lnclude Lhe ablllLy Lo measure serum sodlum, poLasslum, sodlum, blcarbonaLe, creaLlnlne, glucose,
lacLaLe, calclum, magneslum and phosphaLe.

vasopressors
PypoLenslve paLlenLs falllng Lo respond Lo volume resusclLaLlon, or whlle volume resusclLaLlon ls ln progress,
should be supporLed wlLh vasopressor Lherapy ln accordance wlLh Lhe guldellnes for Lhe managemenL of
sepLlc shock[9]. rescrlblng and monlLorlng of vasopressor agenLs should adhere Lo Lhe recommendaLlons for
safe pracLlce from Lhe lSM
11
. 1he guldellnes for vasopressor use ln sepLlc shock are:
! A mean arLerlal blood pressure (MA) LargeL of 63-70 mmPg (or medlan for age ln chlldren) ls a reasonable
lnlLlal LargeL ln adulLs [22] buL should be re-assessed based upon lndlvldual paLlenL facLors such as a
hlsLory of hyperLenslon and lndlcaLors or wheLher or noL saLlsfacLory end-organ perfuslon ls belng
achleved.
! noreplnephrlne lnfuslon (0-1.0 g/kg/mln) ls Lhe preferred flrsL-llne agenL for managlng hypoLenslon.
o ln Lhe evenL noreplnephrlne ls admlnlsLered vla a perlpheral lv Lhe maxlmum concenLraLlon
used should be no more Lhan 4mg/230 ml ('slngle sLrengLh'), a large bore lv should be used
preferably ln Lhe anLecublLal or oLher large veln wlLh good flow and lL should be closely
monlLored for slgns of exLravasaLlon.
o CenLrally admlnlsLered noreplnephrlne can be mlxed ln concenLraLlons of 8mg/230ml ('double
sLrengLh') or 16mg/230ml ('quad sLrengLh').
! vasopressln 0.03g/mln or 0.04g/mln may be used Lo mlnlmlze Lhe dose of noreplnephrlne requlred
! Lplnephrlne can be added as a second llne Lherapy
! LxcepL ln Lhe lnsLance of bradycardla and poLenLlally paedlaLrlc paLlenLs, dopamlne should generally be
avolded glven lLs assoclaLlon wlLh lncreased raLes of cardlac arrhyLhmlas and morLallLy[9, 23].
! uobuLamlne (0-20 g/kg/mln) can be consldered lf Lhere ls evldence of myocardlal dysfuncLlon or ongolng
hypoperfuslon followlng adequaLe volume resusclLaLlon.

AnLlbloLlcs & AnLlvlrals
1he cllnlcal manlfesLaLlons of severe Lvu may overlap sympLoms and slgns observed ln sepLlc shock of
bacLerlal orlgln. 1he publlshed llLeraLure ls generally sllenL on Lhe lncldence of bacLerlal superlnfecLlon ln Lhe

11
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CCCS - CAL - AMMl
2014 2014
conLexL of Lvu. AlmosL all publlshed daLa from prevlous case serles were derlved from seLLlngs where
bacLerlal culLures of any Lype were unavallable. osL morLem paLhology has been descrlbed ln a llmlLed
number of cases. LxLenslve necrosls of a varleLy of organs, especlally llver, spleen, kldneys, and gonads ls
assoclaLed wlLh dlrecL vlral cellular lnvaslon, alLhough Lhe guL appears Lo be relaLlvely spared. Alveolar damage
wlLh lnLersLlLlal edema ls common on paLhology of deceased paLlenLs buL noL a common cllnlcal syndrome. A
dysregulaLed hlghly pro-lnflammaLory and procoagulanL sLaLe ls Lyplcal.
lL would appear LhaL bacLerlal lnfecLlon or sepsls ls an uncommon manlfesLaLlon of Lvu. neverLheless, early
admlnlsLraLlon (w|th|n the f|rst hour[24]) of broad-specLrum anLlbloLlcs Lo Lhose wlLh manlfesLaLlons of
posslble sepsls-assoclaLed hypoLenslon/shock ls senslble. ConslderaLlon should be glven Lo dlsconLlnulng
anLlbloLlcs ln Lhose where culLures and oLher lnvesLlgaLlons do noL reveal bacLerlal superlnfecLlon. 1here ls no
evldence-based guldance on Lhe cholce of speclflc anLlbloLlcs, however, paLlenLs frequenLly wlll be Lhe mldsL
of severe gasLro-lnLesLlnal sympLoms and anLlbloLlcs choosen Lo LreaL poLenLlal enLerlc paLhogens, among
oLhers, may be reasonable.
ApproprlaLe anLlmlcroblal Lherapy for poLenLlal sepsls wlll be dependenL upon where Lhe paLlenL ls on Lhe
lllness Lra[ecLory. aLlenLs presenLlng acuLely wlll llkely have sLandard communlLy paLhogens lf non-Lbola
sepsls ls a conslderaLlon. urugs such as cefoLaxlme/cefLrlaxone and clprofloxacln/levofloxacln are approprlaLe
ln Lhese cases absenL a speclflc concern for 5. ooteos. aLlenLs who are healLh care workers or develop
poLenLlal bacLerlal sepsls afLer >48 hours ln hosplLal are aL greaLer rlsk for nosocomlal paLhogens lncludlng
reslsLanL gram-negaLlves and 5. ooteos (lncludlng M8SA). 8-lacLam/-lacLamase lnhlblLors or carbapenems,
poLenLlally wlLh vancomycln, may be approprlaLe ln Lhose cases.

Crgan SupporL (lPu, C881, LCMC)
A small subseL of paLlenLs wlLh severe Lvu wlll progress Lo organ fallure requlrlng exLracorporeal supporLs
durlng Lhe course of Lhelr lllness. Any declslon Lo use exLracorporeal supporL musL lncorporaLe any basellne
coagulopaLhy presenL.
8enal fallure ls common ln severe cases, alLhough reporLs of Lhe use of dlalysls are absenL. ln approprlaLe
seLLlngs, dlalysls should be consldered ln Lhe paLlenL wlLh Lvu and renal fallure. 1he mode of dlalysls, wheLher
lnLermlLLenL hemodlalysls or conLlnuous renal replacemenL Lherapy, should be lndlvlduallzed based upon Lhe
paLlenLs sLaLus and Lhe LreaLlng cllnlclan.
Llver dysfuncLlon progresslng Lo llver fallure ls a ma[or conslderaLlon for severe Lvu, wlLh hepaLocellular
necrosls found ln Lhe few auLopsles performed ln severe Lvu.[23] LxLracorporeal llver supporL ls noL


CCCS - CAL - AMMl
2014 2014
recommended ln severe Lvu, glven Lhe scanL evldence base, and Lherapy for llver fallure should be
supporLlve, lncludlng correcLlng meLabollc abnormallLles, monlLorlng (cllnlcal or non-lnvaslve) for cerebral
edema, and correcLlng coagulopaLhles.
LxLracorporeal membrane oxygenaLlon (LCMC) for cardloresplraLory fallure has noL been reporLed ln severe
Lvu. 1he lnlLlal presenLaLlon of severe Lvu very uncommonly lncludes severe resplraLory or myocardlal
fallure, wlLh Lhe naLure of Lhe shock Lyplcally belng hypovolemlc or dlsLrlbuLlve ln naLure.[3] 1he llmlLed
poLenLlal beneflL of LCMC ln Lhls seLLlng musL be welghed agalnsL Lhe poLenLlal for slgnlflcanL blood exposure
Lo sLaff durlng cannulaLlon and bleedlng compllcaLlons from Lhe slLes of cannulaLlon due Lo Lhe coagulopaLhy
LhaL can accompany Lvu, parLlcularly ln severe and refracLory cases. lurLher, Lhe close monlLorlng and care
demands assoclaLed wlLh paLlenLs on LCMC would resulL ln slgnlflcanL exposure Llme for sLaff. 1herefore we
do noL recommend LCMC ln paLlenLs wlLh Lvu.

Cardlopulmonary 8esusclLaLlon
Data, and clinical experience, with cardiopulmonary resuscitation (CPR) in patients suffering from EVD is
completely lacking. However, the likelihood of survival with a good outcome from cardiac arrest with CPR in
intensive care units is poor, approximately 3%[26, 27], and is not expected to be better than any adult
12

patients with multi-organ failure which is even lower. Patients with late stage EVD who experience an un-
witnessed cardiac arrest have minimal expectation of survival, and therefore not initiating resuscitation efforts
is appropriate to avoid unnecessary risk to healthcare staff. Patients with multiorgan failure being supported
with artificial life support in a critical care environment who deteriorate to cardiac arrest despite full support are
also highly unlikely to survive. Chest compressions in a patient with end-stage EVD, in addition to being
essentially futile, presents a potentially significant blood and body fluid exposure risk to the health care
workers. In such patients an advance order to withhold CPR for cardiac arrest is appropriate. A very select
group of patients with EVD who are experiencing clinical conditions that are potentially associated with better
outcome from cardiac arrest, such as hypovolemia or electrolyte abnormalities, an acute coronary syndrome
associated with ventricular arrhythmias, may warrant aggressive therapy including defibrillation and
antidysrhythmic drugs for witnessed cardiac arrest.

Despite the instinctive urge to rush into a patient isolation room to help, staff must not take shortcuts in
donning appropriate PPE, which should meet the standards required for management of aerosol generating
medical procedures.

A child who suffers cardiac arrest due to severe EVD and multi-organ disease also has a very small likelihood
of survival, and similar to adults, not initiating CPR is appropriate in this circumstance. If a clear reversible
cause is present, however, this should be promptly treated.

12
cotJloc ottest lo cbllJteo ls JlscosseJ sepototely ot tbe eoJ of tbls sectloo.


CCCS - CAL - AMMl
2014 2014

Medical management of cardiac arrest in a patient with Ebola, if attempted, should follow current BCLS and
PALS/ACLS guidelines.
SympLom ManagemenL
Clven LhaL Lhe overall managemenL of Lvu ls supporLlve, effecLlve sympLom managemenL composes a
slgnlflcanL componenL of Lhe Lheraples cllnlclans may offer Lhelr paLlenLs.
Symptom Aet|o|ogy & Imp||cat|ons Management
Se|zure or Coma
AeLlology unclear, poLenLlally relaLed Lo llver fallure.
1yplcally a omlnous slgn, seen Lyplcally shorLly before deaLh.
Alrway managemenL as requlred
8enzodlazeplnes +/- dllanLln Lo conLrol selzures
LaboraLory lnvesLlgaLlons (e.g. na+, glucose)
C1 head lf laLerallzlng feaLures
nypotens|on
& Shock

lrequenLly an early manlfesLaLlon of severe cases. Also a common
manlfesLaLlon of lllness severlLy and plauslble leLhal paLhway.
lnlLlally, hypovolemla from profound Cl losses. A componenL of
early dlsLrlbuLlve shock remalns a posslblllLy buL has noL been
conflrmed. Secondary sepsls remalns a posslblllLy buL has noL
been conflrmed.
Close monlLorlng of fluld balance
Aggresslve repleLlon of fluld and elecLrolyLe losses (poLasslum,
blcarbonaLe)
Conslder vasopressor Lherapy lf hypoLenslon conLlnues desplLe
adequaLe fluld resusclLaLlon.
Dyspnea or
kesp|ratory fa||ure
8esplraLory lnvolvemenL noL a cardlnal feaLure. olypnea seen aL
all sLages of lllness ln Lhe conLexL of shock and profound
meLabollc acldosls.
Cxygen Lherapy +/- mechanlcal venLllaLlon
Severe d|arrhoea
and vom|tt|ng
lrequenL early presenLaLlon, Lhe aeLlology of whlch remalns
unclear.
nC Lube lnserLlon & sucLlon
Paloperldol 1mg C/lv/SC q8h sLandlng. (0.23-0.3 mg ln chlldren)
MeLoclopramlde 10mg C/lv/SC q6h sLandlng (0.1 mg/kg/dose ln
chlldren)
Into|erant to ora|
|ntake
Common ln severe cases.
AssoclaLed wlLh chesL palns so esophaglLls ls a plauslble
mechanlsm buL unproven.
Conslder enLeral nuLrlLlon lf LoleraLed
lf enLeral nuLrlLlon are poorly LoleraLed, conslder 1n afLer 8 days of
unsuccessful enLeral nuLrlLlon
kU pa|n and
hepatomega|y
Common ln severe cases
unproven buL hepaLlLls plauslble

MonlLorlng of llver blochemlsLry, conslderaLlon of vlLamln k for
early slgns of ln8 elevaLlon, waLch for hypoglycemla
nemorrhage (GI &
puncture s|tes)
Cmlnous slgn, seen Lyplcally shorLly before deaLh
AeLlology mosL llkely ulC
CompleLe hemaLology and llver laboraLory workup
Conslder plaLeleL Lransfuslons ls low, ll lf ln8 elevaLed,
cryopreclplLaLe lf flbrlnogen low
Iever, ch|||s,
headache and
mya|g|as
Common
AeLlology assoclaLed Lo vlremla
AceLamlnophen 630mg C q4h 8n (maxlmum 4g ln 24h)
(edlaLrlcs 10-13 mg/kg/dose C4P Lo ln chlldren, max of 3 doses per
73 mg/kg/day). Lower doses may need Lo be used ln paLlenLs
experlenclng hepaLlc dysfuncLlon.
non-sLeroldal anLl-lnflammaLory medlcaLlons should be sLrlcLly
avolded due Lo Lhelr plaLeleL-lnhlblLlng effecLs, whlch could
exacerbaLe hemorrhage
a|n
Common, ofLen lnvolvlng abdomen, chesL wall, headache and
[olnL paln LhaL are noL adequaLely managed wlLh aceLamlnophen
alone.
narcoLlcs, morphlne, fenLanyl, hydromorphone lf renal lmpalrmenL
rophylaxls and revenLaLlve Measures for Lhe CrlLlcally lll
aLlenLs wlLh severe Lvu have mulLl-organ dlsease and avoldance of secondary lnfecLlons and compllcaLlons ls
vlLal, glven Lhe assoclaLed lmmune dysregulaLlon wlLh acuLe Lvu.[28] SLandard proLocols for Lhe avoldance of
nosocomlal lnfecLlons should lnclude malnLalnlng Lhe head-of-bed aL 30
o
for venLllaLed paLlenLs and llmlLlng
lndwelllng urlnary caLheLer and cenLral venous llne days, where appllcable. Speclflcally, sLraLegles Lo avold


CCCS - CAL - AMMl
2014 2014
venLllaLor assoclaLed pneumonla, such as keeplng Lhe head of Lhe bed elevaLed and chlorhexldlne mouLh care,
should be followed. Cl bleeds are frequenL ln severe Lvu, and sLress ulcer prophylaxls wlLh elLher a hlsLamlne-
2 recepLor anLagonlsL or a proLon-pump lnhlblLor ls recommended for paLlenLs who are mechanlcally
venLllaLed. lf paLlenLs develop coagulopaLhles Lhey should noL recelve deep-venous Lhrombosls prophylaxls.
nuLrlLlon
ln less severely lll paLlenLs wlLh Lbola, oral rehydraLlon fluld should be provlded Lo malnLaln lnLravascular
volume and normal elecLrolyLes. Smaller volume, more frequenL eaLlng may be beLLer LoleraLed. rophylacLlc
anLlemeLlc medlcaLlon may be helpful Lo encourage oral lnLake. Cral nuLrlLlonal supplemenLs could be
consldered for Lhose paLlenLs wlLh subopLlmal lnLake. ln paLlenLs Loo unwell Lo safely swallow, placemenL of a
nasogasLrlc Lube may be consldered Lo allow provlslon of enLeral feeds Lo meeL nuLrlLlonal and fluld
needs. Slmllarly, lnLubaLed paLlenLs should have early placemenL of an orogasLrlc Lube and lnlLlaLlon of
enLeral feeds. use exLreme cauLlon ln placlng a nasogasLrlc Lube ln paLlenLs already experlenclng mucosal
bleedlng due Lo haemaLologlcal compllcaLlons of Lbola lnfecLlon. aLlenLs already experlenclng dlarrhea may
noLe worsenlng of Lhelr sympLoms wlLh enLeral feeds, and Lherefore conslderaLlon of feeds wlLh lower
osmolallLy or seml-elemenLal feeds may help avold worsenlng of dlarrhea. LnLeral feeds are hlghly preferred
Lo parenLeral nuLrlLlon, and Lhere are no daLa descrlblng Lhe rlsks and beneflLs of uslng parenLeral nuLrlLlon ln
paLlenLs wlLh Lbola lnfecLlon. Larly consulLaLlon wlLh a dleLlclan ls sLrongly recommended Lo asslsL wlLh
chooslng approprlaLe enLeral feeds, and ensurlng LhaL adequaLe calorlc, proLeln and oLher nuLrlenL needs are
belng meL.

LxperlmenLal AnLlvlral MedlcaLlons
1he lnformaLlon regardlng varlous experlmenLal medlcaLlons conLlnues Lo evolve rapldly. Lach lnsLlLuLlon
should have ln place a mechanlsm for rapld lnformed consenL should uLlllzaLlon of such medlcaLlons be
conLemplaLed. lL ls llkely LhaL cllnlcal Lrlals lnvolvlng some of Lhese medlcaLlons wlll become avallable, and
lnsLlLuLlons should conslder expedlLed revlew of Lhese proLocols as Lhey are developed, so LhaL Lhey can be
lmplemenLed ln a Llmely fashlon.

alllaLlve Care
key Messages:
! SympLom managemenL ls lmporLanL for paLlenLs, and should be provlded early even for paLlenLs who are
expecLed Lo survlve.


CCCS - CAL - AMMl
2014 2014
! PonesL communlcaLlon allows Lhe paLlenL and famlly Lo parLlclpaLe ln good declslon-maklng, and recelve
supporL durlng Lhelr grlef and bereavemenL.
aLlenLs may presenL lo exttemls, or Lhey may deLerloraLe afLer recelvlng aggresslve medlcal care for some
Llme. PealLhcare provlders (PC) have an obllgaLlon Lo provlde approprlaLe sympLom managemenL for Lhelr
paLlenLs.
1here ls a common bellef LhaL sympLomaLlc Lheraples such as oplolds or benzodlazeplnes hasLen deaLh, so
Lhese Lheraples are ofLen avolded unLll deaLh ls lmmlnenL. ln facL, sLudles have rouLlnely shown LhaL
approprlaLe sympLom managemenL does noL shorLen llfe. SympLomaLlc LreaLmenLs should noL be delayed
unLll Lhe flnal momenLs, and should also be provlded for paLlenLs who are expecLed Lo survlve Lhelr lllness.
1he followlng are suggesLed medlcaLlons and doses for common sympLoms assoclaLed wlLh Lvu. lor complex
sympLom managemenL lssues, consulL a speclallsL alllaLlve Care physlclan.
SecreLlons
! Scopolamlne hydrobromlde 0.4mg SC/lv q4h 8n
uyspnea (from pulmonary hemorrhage or oLher compllcaLlon)
! Morphlne 2.3-3mg lv/SC q30mln 8n
! Pydromorphone 0.3-1mg lv/SC q30mln 8n
o 1hese are sLarLlng doses for oplold-naive paLlenLs. aLlenLs already recelvlng oplolds would
llkely need hlgher doses. Clve for reporLed dyspnea. ln an unconsclous paLlenL, glve for
Lachypnea (>23/mln) or accessory muscle use.
! AfLer 24h, add up LoLal dose of morphlne/hydromorphone glven. lf >13mg morphlne or 3mg
hydromorphone, sLarL a sLandlng dose. 1ake Lhe LoLal 24h dose from Lhe prevlous day and dlvlde by 6 Lo
geL Lhe q4h dose. ConLlnue 8n dose.
o 5AMll Okuk.
o uoy 1. OtJet 2.5mq motpbloe lv pJ0mlo lkN.
o uoy 2. lo fltst 24b, potleot tecelves 12 Joses.
o 12 Joses x 2.5mq motpbloe = J0mq totol motpbloe. ulvlJe by 6 = 5mq.
o New otJet. 5mq lv motpbloe p4b stooJloq, llu5 2.5mq pJ0mlo lkN.


CCCS - CAL - AMMl
2014 2014
Sudden 1ermlnal LvenLs (Masslve hemopLysls, asphyxlaLlon)
! Mldazolam 3-10mg lv/SC q3mln 8n
! uellberaLe Lermlnal sedaLlon may be lmporLanL Lo avold severe sufferlng aL Lhe Llme of deaLh. 1hls would
be sLandard pracLlce for such evenLs ln palllaLlve care unlLs around Lhe world, and ls noL consldered
euLhanasla. lL may be necessary Lo keep Lhls medlcaLlon near Lhe bedslde so LhaL lL can be glven ln a Llmely
fashlon.

CommunlcaLlon ls anoLher lmporLanL componenL of palllaLlve care. aLlenLs dylng of vlral hemorrhaglc fevers
such as Lbola are dlfferenL from our classlcal model of alllaLlve Care because Lhe paLlenLs are ofLen young
and prevlously healLhy. ln such slLuaLlons, physlclans may heslLaLe Lo communlcaLe dlre prognoses. lL ls
lmporLanL Lo communlcaLe honesLly and openly wlLh famlly members, so LhaL Lhey can parLlclpaLe effecLlvely
ln care declslons, and be supporLed Lhrough Lhelr grlef and bereavemenL.

regnancy & CbsLeLrlcs
Lbola vlrus dlsease may affecL women of chlld-bearlng age, and lL ls posslble LhaL pregnanL women may
presenL wlLh Lhls lnfecLlon. LlLeraLure regardlng Lvu ln pregnancy ls llmlLed buL lncludes a slngle case-serles of
13 women[29], whlch suggesLs an lncreased severlLy of lllness, hlgh lncldence of sponLaneous aborLlon and
rlsk of severe genlLal bleedlng.
ManagemenL should lnclude conslderaLlon of alLernaLlve dlagnoses, parLlcularly Lhose assoclaLed wlLh fever
and/or coagulopaLhy, such as puerperal sepsls, 11, PLLL as well as benlgn gesLaLlonal LhrombocyLopenla.
regnancy normally ls assoclaLed wlLh a mlld leukocyLosls buL plaLeleL counLs are usually unchanged. regnanL
women have frlable upper alrway mucosa, lncreaslng Lhe llkellhood of bleedlng relaLed Lo Lube lnserLlons and
manlpulaLlon. Cllnlcal managemenL would noL be very dlfferenL Lo Lhe non-pregnanL paLlenL, wlLh a few
excepLlons. lever ls llkely harmful Lo Lhe feLus and should be avolded. LefL laLeral poslLlonlng ls lmporLanL Lo
prevenL Lhe suplne hypoLenslon syndrome, ln Lhe 2
nd
half of pregnancy. usual lnfecLlon conLrol precauLlons
should be supplemenLed wlLh for plannlng for managemenL of excesslve blood loss, wlLh hlgher blood loss
anLlclpaLed posL Cesarean secLlon. lannlng for sponLaneous dellvery should lnclude adequaLe L and
equlpmenL for obsLeLrlc and neonaLal Leams, as well as an assessmenL of vlablllLy of Lhe feLus (by CbsLeLrlcs
and neonaLology), Lo avold Lhe rlsks assoclaLed wlLh fuLlle neonaLal resusclLaLlon.


CCCS - CAL - AMMl
2014 2014
aedlaLrlc ConslderaLlons
All of Lhe above lssues are appllcable wlLh Lhe chlld wlLh suspecLed or proven Lvu. Chlldren are especlally
suscepLlble Lo elecLrolyLe abnormallLles and hypovolemla, hence early recognlLlon and aggresslve LreaLmenL
should be Lhe sLandard of care. Clven Lhe experLlse and lnfrasLrucLure avallable, Lhese chlldren should be
consldered early for LransporL Lo Lhe reglonal paedlaLrlc faclllLy for on-golng evaluaLlon and care, especlally
glven Lhe challenges ln obLalnlng lnLravenous and/or lnLra-arLerlal access and Lhe avallablllLy of lCu beds.

lmpacL on PealLh Care Worker's Carlng for Lvu aLlenLs
lL ls undersLandable for PCWs Lo be concerned abouL Lhe rlsk of becomlng lnfecLed and LransmlLLlng lnfecLlon
Lo Lhelr famlly or frlends. Powever, carlng for Lvu paLlenLs whlle followlng recommended lnfecLlon
prevenLlon guldellnes, lncludlng wearlng approprlaLe L, presenLs a very low rlsk Lo PCWs of becomlng
lnfecLed. As such Lhere are no resLrlcLlons (e.g. quaranLlne) placed upon PCWs who care for Lvu paLlenLs wlLh
no lnfecLlon conLrol breaches. PCWs carlng for Lvu paLlenLs are recommended Lo self-monlLor for fever, for
Lhe full deLalls on currenL guldance please refer Lo
13
. PosplLals should have pollcles ln place LhaL provlde
necessary supporLs for PCWs provldlng care Lo Lvu paLlenLs, lncludlng proLocols for self-monlLorlng for fever,
and for managemenL of blood exposures, ln Lhe unllkely evenL LhaL Lhey occur.

sychologlcal SupporL (aLlenLs, lamllles & rovlders)
8are and llfe LhreaLenlng lnfecLlous dlseases can be assoclaLed wlLh slgnlflcanL psychologlcal sLress for boLh
Lhe paLlenLs who are lnfecLed wlLh Lhe dlseases and Lhelr famllles as well as Lhe provlders who care for
Lhem.[30-33] 1he WPC vlral Paemorrhaglc lever handbook sLaLes:
"#$%&'()(*+&,) $-..(/0 1(/ 0'2 .,0+230 ,34 0'2 1,5+)% ,/2 62/% +5.(/0,30 +3 0'2
5,3,*25230 (1 789: ;3<+20% ,34 12,/ ,/2 3(/5,) *+623 0'2 '+*' 5(/0,)+0% /,02
1(/ &(31+/524 789: =0 +$ +5.(/0,30 0( &(55-3+&,02 >2)) >+0' 0'2 .,0+230 ,34
1,5+)%? 2<.),+3+3* 0'2 3224 1(/ +$(),0+(3 ,34 ##@? ,34 0( ./(6+42 .$%&'()(*+&,)
$-..(/0 1/(5 0'2 A2*+33+3* (1 &,/2:B
PosplLals should plan Lo provlde supporLs for boLh paLlenLs and Lhelr famllles. 1hls lncludes ensurlng LhaL
processes are ln place Lo allow communlcaLlon and vlslLaLlon beLween paLlenLs and famllles. Clven Lhe

1J


CCCS - CAL - AMMl
2014 2014
concerns regardlng Lransmlsslon and deslre Lo mlnlmlze paLlenL exposure leveraglng Lechnologles such as
lnLerneL vldeo chaL should be consldered and Lhe necessary l1 lnfrasLrucLure should be provlded. SupporL
servlces lncludlng Soclal Work, Chaplalncy and sychlaLrlsLs should be avallable Lo supporL Lvu paLlenLs and
Lhelr famllles. AddlLlonally, Lhe sLresses assoclaLed wlLh coplng wlLh an Lvu lnfecLlon should be 'normallzed'
and acknowledged.
SupporL servlces for sLaff should also be provlded. PosplLals should have a plan ln place Lo supporL healLh care
workers carlng for Lvu paLlenLs. lf aL all posslble, reslllence Lralnlng should be provlded ln advance of sLaff
provldlng care for Lvu paLlenLs Lo poLenLlally proLecL Lhem from Lhe sLress of Lhe slLuaLlon.[34] SLaff carlng
for Lvu paLlenLs may face a varleLy of sLressors lncludlng: fear of conLracLlng Lhe lllness, concern for lnfecLlng
famlly members, prolonged perlods ln L, soclal lsolaLlon, and faLlgue from long hours of work.


CCCS - CAL - AMMl
2014 2014
lnLer-faclllLy 1ransporL of aLlenLs wlLh Lvu
Ceneral ConslderaLlons for Aeromedlcal LvacuaLlon
1o daLe Lhere ls very llLLle experlence wlLh aeromedlcal evacuaLlon of paLlenLs wlLh Lvu, however all of Lhe
baslc prlnclples of aeromedlcal evacuaLlon apply[33]. 1ransporL of a hlgh-rlsk paLlenL should occur on an
alrcrafL dedlcaLed Lo slngle paLlenL, wlLhouL addlLlonal paLlenLs on board. Crew should be kepL Lo Lhe
mlnlmum requlred Lo carry ouL Lhe fllghL and paLlenL care duLles ln a safe manner. 1hose noL dlrecLly lnvolved
ln alrcrafL operaLlon or paLlenL care should noL be presenL on board. A prlmary careglver(s) should be asslgned
Lo Lhe paLlenL, based on Lhe paLlenL's needs for care. 1he Lype and scope of pracLlce should be deLermlned
based on Lhe paLlenL's needs prlor Lo LransporL and allow for medlcal managemenL of any deLerloraLlon ln
cllnlcal condlLlon LhaL could occur durlng LransporL. All paLlenLs and equlpmenL musL be secured wlLhln Lhe
alrcrafL ln accordance wlLh 1ransporL Canada regulaLlons. AddlLlonally all equlpmenL used on Lhe alrcrafL musL
meeL alrworLhlness LesLlng sLandards. llnally, fllghL safeLy musL remaln a prlmary conslderaLlon for Lhe
alrcrew, medlcal sLaff and Lhe paLlenL lncludlng response Lo ln-fllghL emergencles and emergency egress.

AlrcrafL SelecLlon
Cabln alrflow characLerlsLlcs may reduce exposure of occupanLs Lo alrborne lnfecLlous parLlcles. Whenever
posslble, alrcrafL used Lo LransporL paLlenLs wlLh dlseases LransmlLLed by alrborne spread should have
separaLe alr-handllng sysLems for Lhe cockplL and cabln, wlLh cockplL alr aL poslLlve pressure relaLlve Lo Lhe
cabln.
! llxed-wlng pressurlzed alrcrafL:
o rovlders should consulL Lhe alrcrafL manufacLurer Lo ldenLlfy cabln alrflow characLerlsLlcs,
lncludlng PLA fllLraLlon and dlrecLlonal alrflow capablllLles, alr ouLleL locaLlon, presence or
absence of alr mlxlng beLween cockplL and paLlenL-care cabln durlng fllghL, and Llme and
alrcrafL conflguraLlon requlred Lo perform a posL- mlsslon alrlng-ouL of Lhe alrcrafL.
o AlrcrafL wlLh forward-Lo-afL cabln alr flow and a separaLe cockplL cabln are preferred. AfL-Lo-
forward cabln alr flow may lncrease Lhe rlsk of exposure of cabln and fllghL deck personnel lf
aerosol generaLlng procedures are conducLed. AlrcrafL LhaL re-clrculaLe cabln and fllghL-deck
alr wlLhouL PLA fllLraLlon ldeally should be avolded. AlrcrafL venLllaLlon should remaln on aL
all Llmes durlng LransporL, lncludlng durlng ground delays.
! 8oLor-wlng and non-pressurlzed alrcrafL


CCCS - CAL - AMMl
2014 2014
o ln alrcrafL wlLh unconLrolled lnLerlor alr flow, such as roLor-wlng and small, non- pressurlzed
flxed-wlng alrcrafL, all personnel should wear dlsposable n93 or hlgher-level masks durlng
LransporL of paLlenLs where alrborne spread of dlsease ls posslble. lor cockplL crews, alrcrafL
avlaLor LlghL-flLLlng face pleces capable of dellverlng alr/oxygen LhaL has noL mlxed wlLh cabln
alr may be used ln lleu of a dlsposable n93 resplraLor.

1he Lype and slze of alrcrafL wlll deLermlne Lhe exLenL Lo whlch opLlmal capablllLles and pracLlces can be
carrled ouL. 1he greaLesL separaLlon posslble beLween Lhe alrcrew and paLlenL ls deslrable parLlcularly for
longer duraLlon fllghLs glven LhaL a lack of sufflclenL separaLlon would requlre Lhe alrcrew Lo wear L whlch ln
Lurn could degrade Lhelr flylng performance.

LoglsLlcal re-fllghL lannlng and osL-fllghL rocedures
! SufflclenL lnfecLlon conLrol supplles should be on board Lhe alrcrafL Lo supporL Lhe expecLed LransporL
duraLlon plus addlLlonal Llme ln Lhe evenL of delays or weaLher dlverslons.
! A lllghL Surgeon or Alr Ambulance Medlcal ulrecLor should valldaLe Lhe paLlenL for medlcal sulLablllLy for
aeromedlcal evacuaLlon. 1hls wlll lnvolve balanclng mulLlple facLors lncludlng: Lhe medlcal sLablllLy of Lhe
paLlenL, poLenLlal for deLerloraLlon, beneflL of Lhe Lransfer Lo Lhe paLlenL's cllnlcal care, and ablllLy Lo
sulLably mlLlgaLe Lhe lnfecLlous rlsk posed by Lhe paLlenL Lo Lhe medlcal sLaff, alrcrew and Lhe alrcrafL.
! lllghL plannlng should ldenLlfy locaLlons for poLenLlal emergency dlverslon and coordlnaLe loglsLlcal
supporL ln Lhe evenL of an ln-fllghL emergency.
! upon LermlnaLlon of Lhe LransporL, Lhe alr medlcal Leam should lnclude ln Lhelr paLlenL care reporL Lhe
esLlmaLed duraLlon of paLlenL conLacL, descrlpLlon of L used, and any recognlzed breach(es) ln lnfecLlon
conLrol precauLlons encounLered ln fllghL.
! ApproprlaLe cleanlng and deconLamlnaLlon of Lhe alrcrafL (or lsolaLlon unlL) wlll be requlred and should be
conducLed by approprlaLely Lralned sLaff wearlng Lhe necessary L.
14

Lmergency procedures
1here should be a wrlLLen plan addresslng paLlenL handllng durlng ln-fllghL or ground emergency slLuaLlons
relaLed Lo Lhe alrcrafL. All crew and passengers should be brlefed on Lhe emergency procedures prlor Lo
deparLure and crew should have been Lralned ln and exerclsed Lhe procedures. AcLlvlLles such as donnlng llfe

14


CCCS - CAL - AMMl
2014 2014
vesLs and emergency paLlenL egress may creaLe speclal exposure rlsks. use of L musL be welghed agalnsL
Llme consLralnLs and on-board emergency condlLlons such as cabln decompresslon or smoke ln Lhe cabln.
WasLe dlsposal
All wasLe should be consldered hazardous, handled wlLh Lhe uLmosL care, and dlsposed of ln accordance wlLh
local and reglonal requlremenLs for regulaLed medlcal wasLe. ersonnel handllng wasLe should adhere Lo Lhe
same precauLlons and L use as Lhose provldlng paLlenL care.

Cleanlng and dlslnfecLlon
! ulslnfecLanLs should be avallable durlng LransporL Lo manage evenLs LhaL resulL ln conLamlnaLlon.
! Compressed alr should noL be used for alrcrafL cleanlng.
! non-paLlenL-care areas of Lhe alrcrafL should be cleaned and malnLalned accordlng Lo manufacLurer's
recommendaLlons.
! aLlenL care areas and equlpmenL should be cleaned and dlslnfecLed wlLh a dlslnfecLanL sulLable for Lbola
as ouLllned ln Lhe PAC lAC guldellnes LhaL has approved by Lhe alrcrafL manufacLurer.
! ersonnel cleanlng Lhe alrcrafL and lLs equlpmenL should wear L LhaL ls, aL mlnlmum, conslsLenL wlLh
precauLlons for conLacL and dropleL precauLlons. AddlLlonal L should be consldered for cleanlng of
heavlly conLamlnaLed envlronmenLs or lf aerosols could be generaLed.
! ConLamlnaLed seaL cushlons or webbed seaLs should be removed, placed ln a blohazard bag, labeled, and
senL for cleanlng and dlslnfecLlon or dlsposal.
! ConLamlnaLed reusable paLlenL care equlpmenL should be placed ln blohazard bags, labeled, and senL for
cleanlng and dlslnfecLlon, accordlng Lo Lhe manufacLurer's lnsLrucLlons.

8eglonal Aeromedlcal LvacuaLlon
8eglonal aeromedlcal evacuaLlon refers Lo shorL duraLlon fllghLs, Lyplcally less Lhan 3 hours, conducLed by
provlnclal alr ambulance resources wlLhln Canada.
aLlenL lsolaLlon & L
A deslgnaLed lsolaLlon area should be esLabllshed on Lhe alrcrafL and paLlenL movemenL resLrlcLed Lo Lhls
deslgnaLed area. ln general, paLlenLs should be placed as far away from Lhe fllghL crew as posslble. lf avallable
paLlenLs should be placed ln a porLable lsolaLlon unlL Lo creaLe Lhe lsolaLlon area, however Lhese are rarely
avallable glven Lhe Lype and slze of alrcrafL Lyplcally used for reglonal aeromedlcal evacuaLlon. Medlcal sLaff


CCCS - CAL - AMMl
2014 2014
should wear L ln accordance wlLh Lhe same recommendaLlons as for healLh care workers wlLhln Lhe hosplLal
seLLlng. Powever, glven Lhe LlghL quarLers, need for greaLer moblllLy, lack of ablllLy Lo exlL Lhe paLlenL care
envlronmenL lf Lhere ls noL an lsolaLlon unlL, and Lhe varlablllLy of seLLlngs durlng Lhe LransporL envlronmenL
more durable, comforLable and modlfled L may be requlred ln Lhe LransporL seLLlng. aLlenLs should wear a
surglcal mask Lo reduce Lhe rlsk of dropleL producLlon.
aLlenL Lransfers from bed Lo sLreLcher and movemenL ln and ouL of Lhe alrcrafL can be parLlcularly hlgh-rlsk
exposure perlods glven Lhe close conLacL and physlcal manlpulaLlon of Lhe paLlenL LhaL ls ofLen requlred.
1herefore, Lhese LranslLlons should be mlnlmlzed as much as posslble. lf Lhe paLlenL cannoL be separaLed from
Lhe alrcrew by a sufflclenL dlsLance and/or Lhe use of an lsolaLlon unlL, Lhe alrcrew wlll also have Lo wear L.
Any poLenLlal aerosol generaLlng procedures, such as lnLubaLlon, LhaL are llkely Lo be requlred durlng
LransporL should be anLlclpaLed and done elecLlvely prlor Lo LransporL whlle ln Lhe sendlng hosplLal ln a
negaLlve pressure lsolaLlon room. AlLernaLlves Lo aerosol generaLlng procedures (e.g. use of meLered-dose
lnhalers lnsLead of nebullzers for lnhaled medlcaLlons) should be soughL for essenLlal medlcal care whlle ln
LranslL.
lf an lsolaLlon unlL ls noL avallable, a deslgnaLed lsolaLlon area should be esLabllshed ln whlch L approprlaLe
for alrborne and dropleL precauLlons musL be malnLalned. 1he mlnlmum radlus of 2 meLers around Lhe
paLlenL ls recommended for such an area. Surfaces wlLhln Lhe lsolaLlon area musL be smooLh, nonporous, and
lmpermeable Lo permlL Lhorough cleanlng and dlslnfecLlon. WasLe recepLacles should be placed lnslde Lhe
lsolaLlon area. MaLerlals requlred for paLlenL care musL be organlzed ouLslde Lhe lsolaLlon area.

naLlonal & lnLernaLlonal Aeromedlcal LvacuaLlon
1he LransporLaLlon of paLlenLs wlLh Lvu over long dlsLances elLher wlLhln a counLry or beLween counLrles or
Lransoceanlc, lnvolves many complex medlcal, loglsLlcal, and poLenLlally dlplomaLlc lssues. Many of Lhe same
baslc prlnclples apply as dlscussed above, however, lssues such as Lhe long duraLlon of Lhe LransporL and
poLenLlal Lransoceanlc aspecLs of long dlsLance aeromedlcal evacuaLlon lead Lo addlLlons challenges ln
LransporLlng a paLlenL wlLh Lbola such as:
! 8equlremenL for addlLlonal medlcal sLaff Lo allow crew resL ouL of L whlch musL be balanced agalnsL Lhe
need Lo mlnlmlze Lhe number of crew/sLaff exposed.
! need for a conLalnmenL unlL for Lhe paLlenL or some oLher way Lo creaLe a separaLe cold (clean) zone
separaLe from Lhe paLlenL care area (hoL zone) ln order for medlcal sLaff Lo resL wlLhouL L.
! 1olleL faclllLles for Lhe paLlenL or a process for conLalnlng and dlsposlng of paLlenL body flulds.


CCCS - CAL - AMMl
2014 2014
! lncreased rlsk of paLlenL deLerloraLlon Lo occur over Lhe course of Lhe LransporL.
! oLenLlal requlremenL for refuellng sLops and Lherefore clearance Lo land ln addlLlonal counLrles.
! 8equlremenL of a process Lo occur, on shorL noLlce, for a healLh care faclllLy aL an alLernaLe desLlnaLlon Lo
assume care of Lhe paLlenL ln Lhe evenL of a dlverslon due Lo weaLher or mechanlcal lssues, alLernaLlvely
Lhe ablllLy Lo for Lhe medlcal sLaff Lo conLlnue Lo care for Lhe paLlenL for a prolonged perlod (days) on Lhe
alrcrafL or ln a Lemporary locaLlon.
! LoglsLlcal lssues assoclaLed wlLh reLrlevlng a paLlenL from a developlng counLry healLh care faclllLy
lncludlng LransporLaLlon lssues, securlLy LhreaLs, and lodglng for Lhe alrcrew and medlcal sLaff ln a counLry
wlLh a ma[or Lbola ouLbreak glven Lhe llmlLaLlons of fllghL duLy day and requlremenL for crew resL.

aLlenL lsolaLlon & L
Clven Lhe requlremenL Lo creaLe separaLe envlronmenLs (llgure 1) wlLhln Lhe alrcrafL durlng prolonged
LransporL, Lvu paLlenLs should be LransporLed ln an lsolaLlon unlL. 1he prlmary purposes of Lhe lsolaLlon unlL
are Lo conLaln body flulds so LhaL:
! ConLamlnaLlon of Lhe alrcrafL ls mlnlmlzed
! roLecLlon of Lhe alrcrew ls enhanced and Lhey are noL requlred Lo wear L on Lhe fllghL deck
! Medlcal sLaff are able Lo have a crew resL area where Lhey do noL requlre L

Isolation Unit
(Hot Zone)
Isolation Unit
(Hot Zone)
Anteroom
(Warm Zone)
Anteroom
(Warm Zone)
Crew Rest Area
(Cold Zone)


CCCS - CAL - AMMl
2014 2014

ln addlLlon Lo Lhe medlcal and lnfecLlon conLrol requlremenLs, Lhe fllghL loglsLlcal requlremenLs (range of Lhe
alrcrafL) wlll also facLor lnLo Lhe declslon as Lo whlch alrcrafL ls mosL approprlaLe. 1he exacL naLure of Lhe
conLalnmenL unlL and Lhe layouL of Lhe zones wlll vary based upon Lhe Lype and slze of Lhe alrcrafL used.
leaLures of Lhe lsolaLlon unlL should lnclude:
! AblllLy Lo properly secure Lhe lsolaLlon unlL wlLhln Lhe alrcrafL and Lhe paLlenL wlLhln Lhe lsolaLlon unlL
durlng Lakeoff, landlng and Lurbulence.
! AblllLy for sLaff Lo vlew and monlLor Lhe paLlenL from ouLslde Lhe unlL Lo mlnlmlze Lhelr exposure.
! AblllLy for Lhe paLlenL Lo communlcaLe wlLh Lhe sLaff from lnslde Lhe unlL and vlce versa.
! SufflclenL space for sLaff Lo provlde medlcal care, lncludlng procedures lf necessary, sLorage of essenLlal
medlcal supplles, equlpmenL and monlLors properly secured. MosL medlcal supplles and all L should be
sLored ouLslde of Lhe lsolaLlon unlL.
! 1olleL faclllLles (chemlcal) or a meLhod Lo conLaln and dlspose of body flulds as well as medlcal wasLe.
! lluld lmpermeable Lo conLaln body flulds and prevenL conLamlnaLlon of Lhe alrcrafL and crew.
! negaLlve pressure or PLA fllLers ln Lhe evenL LhaL aerosol generaLlng procedures are conducLed.
! CapablllLy Lo be dlslnfecLed and/or dlsposed.
1he 'warm zone' lncludes Lhe area, ldeally a conLalned anLeroom, where L ls donned and doffed. 1he space
musL be large enough Lo allow L Lo be applled and removed wlLhouL cross-conLamlnaLlon. 1here should
also be a shelf or Lable upon whlch Lo place supplles whlle puLLlng on L before enLerlng Lhe lsolaLlon unlL.
1he 'cold zone' ls reserved for crew resL and Lhe sLorage of clean L and medlcal supplles.
ln general, paLlenLs should be placed as far away from Lhe fllghL crew as posslble buL also Laklng lnLo
conslderaLlon Lhe paLLern of alrflow paLLern wlLhln Lhe alrcrafL. Medlcal sLaff should wear L ln accordance
wlLh Lhe same recommendaLlons as for healLh care workers wlLhln Lhe hosplLal seLLlng when ln Lhe 'hoL zone'.
As wlLh reglonal aeromedlcal evacuaLlon, Lhe LlghL quarLers, need for greaLer moblllLy, prolonged duraLlon of
Lhe fllghL and Llme wlLh paLlenL conLacL, and Lhe varlablllLy of seLLlngs durlng Lhe LransporL may mandaLe more
durable, comforLable and modlfled L.
aLlenL Lransfers from bed Lo sLreLcher and movemenL ln and ouL of Lhe alrcrafL can be parLlcularly hlgh-rlsk
exposure perlods glven Lhe close conLacL and physlcal manlpulaLlon of Lhe paLlenL LhaL ls ofLen requlred.
I|gure 1: Lxamp|e of |nfect|on contro| zones for aeromed|ca| evacuat|on


CCCS - CAL - AMMl
2014 2014
Agaln, Lhese LranslLlons should be mlnlmlzed as much as posslble. uesplLe Lhe lsolaLlon unlL, any poLenLlal
aerosol generaLlng procedures, such as lnLubaLlon, LhaL are llkely Lo be requlred durlng LransporL should be
anLlclpaLed and done elecLlvely prlor Lo LransporL whlle ln Lhe sendlng hosplLal ln a negaLlve pressure lsolaLlon
room. AlLernaLlves Lo aerosol generaLlng procedures (e.g. use of meLered-dose lnhalers lnsLead of nebullzers
for lnhaled medlcaLlons) should be soughL for essenLlal medlcal care whlle ln LranslL.


CCCS - CAL - AMMl
2014 2014
8esearch
1he currenL welghLed case faLallLy raLe of nearly 70 for all Lbola vlrus ouLbreaks ls an unaccepLable ouLcome.
ln addlLlon Lo lmprovlng local, naLlonal and lnLernaLlonal response wlLh personnel and supporLlve care,
epldemlology, conLacL Lraclng and soclal moblllzaLlon ln WesL Afrlca, we musL also conslder observaLlonal and
experlmenLal research as a core componenL of an Lvu ouLbreak response. Whlle lmprovlng Lhe care of
lnfecLed paLlenLs Lakes precedence, we musL concurrenLly lmprove our research response by lmplemenLlng
observaLlonal sLudles, blologlcal sampllng proLocols and lnLervenLlonal sLudles. Such sLudles should ldeally be
prevlously developed, veLLed, funded and Lhen approved ln Lhe [urlsdlcLlons llkely Lo be affecLed. lf we
aLLempL Lo lnlLlaLe cllnlcal research only Jotloq Lhe ouLbreak, lL rarely occurs. AlLhough Lhe hlsLory of crlLlcal
care LherapeuLlcs Leaches us LhaL Lhe greaLesL beneflL Lo paLlenLs ls llkely Lo emerge from conslsLenL
appllcaLlon of a sysLem of crlLlcal care focused upon Llmely recognlLlon, early resusclLaLlon, supporLlve care
and prevenLlon of compllcaLlons, promlslng lnLervenLlons such as vacclnaLlon, convalescenL plasma or
monoclonal anLlbodles requlre lnvesLlgaLlon Lo deLermlne Lhelr value. A lack of hlsLory of research accepLance
ln many [urlsdlcLlons ls a common challenge, however, noL engaglng Lhese challenges represenLs an
lrresponslble approach Lo lmprovlng medlcal care.
1he World PealLh CrganlzaLlon has recenLly released a sLaLemenL
13
on Lhe role of lnvesLlgaLlonal Lheraples
durlng Lhls Lbola vlrus ouLbreak concludlng:
lo tbe pottlcolot cootext of tbe cotteot bolo ootbteok lo west Aftlco, lt ls etblcolly occeptoble to offet ooptoveo
lotetveotloos tbot bove sbowo ptomlsloq tesolts lo tbe lobotototy ooJ lo oolmol moJels bot bove oot yet beeo
evolooteJ fot sofety ooJ efflcocy lo bomoos os poteotlol tteotmeot ot pteveotloo.

tblcol, scleotlflc ooJ ptoqmotlc ctltetlo most qolJe tbe ptovlsloo of socb lotetveotloos. 1be etblcol ctltetlo
locloJe ttoospoteocy oboot oll ospects of cote, so tbot tbe moxlmom lofotmotloo ls obtoloeJ oboot tbe effects of
tbe lotetveotloos, foltoess, ptomotloo of cosmopolltoo sollJotlty, lofotmeJ cooseot, fteeJom of cbolce,
cooflJeotlollty, tespect fot tbe petsoo, ptesetvotloo of Jlqolty, lovolvemeot of tbe commoolty ooJ tlsk-beoeflt
ossessmeot.
lf ooJ wbeo ooptoveo lotetveotloos tbot bove oot yet beeo evolooteJ fot sofety ooJ efflcocy lo bomoos bot bove
sbowo ptomlsloq tesolts lo tbe lobotototy ooJ lo oolmol moJels ote oseJ to tteot potleots, tbose lovolveJ bove o
motol obllqotloo to collect ooJ sbote oll tbe scleotlflcolly televoot Joto qeoetoteJ, locloJloq ftom tteotmeots
ptovlJeJ fot composslooote ose.

15
wotlJ neoltb Otqoolzotloo. tblcol cooslJetotloos fot ose of ooteqlsteteJ lotetveotloos fot bolo vltos Jlseose (vu). Avolloble ftom.
bttp.//wbo.lot/cst/tesootces/pobllcotloos/ebolo/etblcol-cooslJetotloos/eo/


CCCS - CAL - AMMl
2014 2014
keseotcbets bove o motol Joty to evoloote tbese lotetveotloos (fot tteotmeot ot pteveotloo) lo cllolcol ttlols tbot
ote of tbe best posslble Jeslqo lo tbe cotteot exceptloool cltcomstooces of tbe west Aftlcoo bolo ootbteok, lo
otJet to estobllsb tbe sofety ooJ efflcocy of tbe lotetveotloos ot to ptovlJe evlJeoce to stop tbelt ose. cootloooos
evolootloo sboolJ qolJe fotote lotetveotloos.
A number of resources exlsL Lo asslsL wlLh ldenLlflcaLlon of pre-exlsLlng observaLlonal and experlmenLal
research proLocols LhaL may be assessed by approprlaLe research eLhlcs boards, and offered Lo paLlenLs ln an
acceleraLed fashlon, and may help Lo lmprove Lhe undersLandlng of Lhls lllness, and lmprove Lhe care dellvery
durlng Lhls and fuLure ouLbreaks (e.g. lSA8lC
16
).

16
l5Aklc - lotetootloool 5evete Acote kespltototy ooJ metqloq lofectloo coosottlom - bttps.//lsotlc.tqbo.otq/


CCCS - CAL - AMMl
2014 2014
8eferences

1. ChrlsLlan Mu, kollek u, SchwarLz 8. Lmergency preparedness: whaL every healLh care worker needs Lo
know. cIM 2003,7:330-337.
2. SLelfox P1, 8aLes uW, 8edelmeler uA. SafeLy of paLlenLs lsolaLed for lnfecLlon conLrol. IAMA . tbe
jootool of tbe Ametlcoo MeJlcol Assoclotloo 2003,290:1899-1903.
3. CrganlzaLlon WP. Cllnlcal ManagemenL of aLlenLs wlLh vlral Paemorrhaglc lever: A ockeL Culde for
Lhe lronL-llne PealLh Worker. ln. Ceneva, SwlLzerland: World PealLh CrganlzaLlon, 2014.
4. leldmann P, CelsberL 1W. Lbola haemorrhaglc fever. loocet 2011,377:849-862.
3. korLepeLer MC, 8ausch uC, 8ray M. 8aslc cllnlcal and laboraLory feaLures of fllovlral hemorrhaglc
fever. I lofect uls 2011,204 Supp| 3:S810-816.
6. Scales uC, Creen k, Chan Ak, ouLanen SM, losLer u, nowak k, et ol. lllness ln lnLenslve care sLaff afLer
brlef exposure Lo severe acuLe resplraLory syndrome. metq. lofect. uls. 2003,9:1203-1210.
7. ChrlsLlan Mu, LouLfy M, Mcuonald LC, MarLlnez kl, Cfner M, Wong 1, et ol. osslble SA8S coronavlrus
Lransmlsslon durlng cardlopulmonary resusclLaLlon. metqloq lofectloos ulseoses 2004,10:287-293.
8. Wllls 8A, nguyen Mu, Pa 1L, uong 1P, 1ran 1n, Le 11, et ol. Comparlson of Lhree fluld soluLlons for
resusclLaLlon ln dengue shock syndrome. N oql I MeJ 2003,3S3:877-889.
9. uelllnger 8, Levy MM, 8hodes A, Annane u, Cerlach P, Cpal SM, et ol. Survlvlng sepsls campalgn:
lnLernaLlonal guldellnes for managemenL of severe sepsls and sepLlc shock: 2012. ctlt cote MeJ
2013,41:380-637.
10. ?unos nM, 8ellomo 8, PegarLy C, SLory u, Po L, 8alley M. AssoclaLlon beLween a chlorlde-llberal vs
chlorlde-resLrlcLlve lnLravenous fluld admlnlsLraLlon sLraLegy and kldney ln[ury ln crlLlcally lll adulLs.
IAMA 2012,308:1366-1372.
11. 8aghunaLhan k, Shaw A, naLhanson 8, SLurmer 1, 8rookharL A, SLefan MS, et ol. AssoclaLlon beLween
Lhe cholce of lv crysLallold and ln-hosplLal morLallLy among crlLlcally lll adulLs wlLh sepsls*. ctlt cote
MeJ 2014,42:1383-1391.
12. C'Malley CM, lrumenLo 8!, Pardy MA, 8envenlsLy Al, 8renL[ens 1L, Mercer !S, et ol. A randomlzed,
double-bllnd comparlson of lacLaLed 8lnger's soluLlon and 0.9 naCl durlng renal LransplanLaLlon.
Aoestb Aoolq 2003,100:1318-1324, Lable of conLenLs.
13. Zhou l, eng Z?, 8lshop !v, Cove ML, SlngbarLl k, kellum !A. LffecLs of fluld resusclLaLlon wlLh 0.9
sallne versus a balanced elecLrolyLe soluLlon on acuLe kldney ln[ury ln a raL model of sepsls*. ctlt cote
MeJ 2014,42:e270-278.
14. 8eld l, Lobo un, Wllllams 8n, 8owlands 8!, Alllson S. (Ab)normal sallne and physlologlcal ParLmann's
soluLlon: a randomlzed double-bllnd crossover sLudy. cllo 5cl (looJ) 2003,104:17-24.
13. klraly Ln, ulfferdlng !A, LnomoLo 1M, Sawal 8S, Muller !, ulggs 8, et ol. 8esusclLaLlon wlLh normal
sallne (nS) vs. lacLaLed rlngers (L8) modulaLes hypercoagulablllLy and leads Lo lncreased blood loss ln
an unconLrolled hemorrhaglc shock swlne model. I 1toomo 2006,61:37-64, dlscusslon 64-33.


CCCS - CAL - AMMl
2014 2014
16. hllllps C8, vlnecore k, Pagg uS, Sawal 8S, ulfferdlng !A, WaLLers !M, et ol. 8esusclLaLlon of
haemorrhaglc shock wlLh normal sallne vs. lacLaLed 8lnger's: effecLs on oxygenaLlon, exLravascular lung
waLer and haemodynamlcs. ctlt cote 2009,13:830.
17. WaLers !P, CoLLlleb A, Schoenwald , opovlch M!, Sprung !, nelson u8. normal sallne versus lacLaLed
8lnger's soluLlon for lnLraoperaLlve fluld managemenL ln paLlenLs undergolng abdomlnal aorLlc
aneurysm repalr: an ouLcome sLudy. Aoestbeslo ooJ ooolqeslo 2001,93:817-822.
18. uelaney A, uan A, McCaffrey !, llnfer S. 1he role of albumln as a resusclLaLlon fluld for paLlenLs wlLh
sepsls: a sysLemaLlc revlew and meLa-analysls. ctlt cote MeJ 2011,39:386-391.
19. Zarychanskl 8, Abou-SeLLa AM, 1urgeon Al, PousLon 8L, MclnLyre L, Marshall !C, et ol. AssoclaLlon of
hydroxyeLhyl sLarch admlnlsLraLlon wlLh morLallLy and acuLe kldney ln[ury ln crlLlcally lll paLlenLs
requlrlng volume resusclLaLlon: a sysLemaLlc revlew and meLa-analysls. IAMA 2013,309:678-688.
20. Paase n, WeLLerslev !, Wlnkel , erner A. 8leedlng and rlsk of deaLh wlLh hydroxyeLhyl sLarch ln
severe sepsls: posL hoc analyses of a randomlzed cllnlcal Lrlal. loteoslve cote MeJ 2013,39:2126-2134.
21. erner A, Paase n, CuLLormsen A8, 1enhunen !, klemenzson C, Aneman A, et ol. PydroxyeLhyl sLarch
130/0.42 versus 8lnger's aceLaLe ln severe sepsls. N oql I MeJ 2012,367:124-134.
22. Asfar , Mezlanl l, Pamel !l, Crelon l, Megarbane 8, Anguel n, et ol. Plgh versus low blood-pressure
LargeL ln paLlenLs wlLh sepLlc shock. N oql I MeJ 2014,370:1383-1393.
23. ue 8acker u, 8lsLon , uevrlendL !, Madl C, Chochrad u, Aldecoa C, et ol. Comparlson of dopamlne and
noreplnephrlne ln Lhe LreaLmenL of shock. N oql I MeJ 2010,362:779-789.
24. kumar A, 8oberLs u, Wood kL, LlghL 8, arrlllo !L, Sharma S, et ol. uuraLlon of hypoLenslon before
lnlLlaLlon of effecLlve anLlmlcroblal Lherapy ls Lhe crlLlcal deLermlnanL of survlval ln human sepLlc
shock. ctlt cote MeJ 2006,34:1389-1396.
23. Zakl S8, ColdsmlLh CS. aLhologlc feaLures of fllovlrus lnfecLlons ln humans. cott 1op Mlctoblol
lmmoool 1999,23S:97-116.
26. Cershengorn P8, Ll C, kramer A, Wunsch P. Survlval and funcLlonal ouLcomes afLer cardlopulmonary
resusclLaLlon ln Lhe lnLenslve care unlL. Iootool of ctltlcol cote 2012,27:421.e429-421.e417.
27. 1lan !, kaufman uA, Zarlch S, Chan S, Cng , AmoaLeng-Ad[epong ?, et ol. CuLcomes of CrlLlcally lll
aLlenLs Who 8ecelved Cardlopulmonary 8esusclLaLlon. Ametlcoo Iootool of kespltototy ooJ ctltlcol
cote MeJlcloe 2010,182:301-306.
28. Pensley LL, ?oung PA, !ahrllng 8, CelsberL 1W. rolnflammaLory response durlng Lbola vlrus lnfecLlon
of prlmaLe models: posslble lnvolvemenL of Lhe Lumor necrosls facLor recepLor superfamlly. lmmoool
lett 2002,80:169-179.
29. Mupapa k, Mukundu W, 8waka MA, klpasa M, ue 8oo A, kuvula k, et ol. Lbola hemorrhaglc fever and
pregnancy. I lofect uls 1999,179 Supp| 1:S11-12.
30. Maunder 8, PunLer !, vlncenL L, 8enneLL !, eladeau n, Leszcz M, et ol. 1he lmmedlaLe psychologlcal
and occupaLlonal lmpacL of Lhe 2003 SA8S ouLbreak ln a Leachlng hosplLal. cMAI 2003,168:1243-1231.
31. Maunder 8C, Lancee W!, 8alderson kL, 8enneLL !, 8orgundvaag 8, Lvans S, et ol. Long-Lerm
psychologlcal and occupaLlonal effecLs of provldlng hosplLal healLhcare durlng SA8S ouLbreak.
metqloq lofectloos ulseoses 2006,12:1924-1932.


CCCS - CAL - AMMl
2014 2014
32. 8ambaldlnl C, Wllson k, 8aLh u, Lln ?, Cold WL, kapral Mk, et ol. 1he lmpacL of severe acuLe
resplraLory syndrome on medlcal house sLaff: a quallLaLlve sLudy. Iootool of qeoetol lotetool meJlcloe
2003,20:381-383.
33. SLyra 8, Pawryluck L, 8oblnson S, kasaplnovlc S, lones C, Cold WL. lmpacL on healLh care workers
employed ln hlgh-rlsk areas durlng Lhe 1oronLo SA8S ouLbreak. Iootool of psycbosomotlc teseotcb
2008,64:177-183.
34. Alello A, khayerl M?, 8a[a S, eladeau n, 8omano u, Leszcz M, et ol. 8eslllence Lralnlng for hosplLal
workers ln anLlclpaLlon of an lnfluenza pandemlc. I cootlo Joc neoltb ltof 2011,31:13-20.
33. Purd WW, !ernlgan !C. AetomeJlcol evocootloo . moooqemeot of ocote ooJ stoblllzeJ potleots. new
?ork: Sprlnger, 2003.


CCCS - CAL - AMMl
2014 2014
Appendlx 1 - Lu Screenlng for & 8esponse Lo osslble Lvu Cases
1he flgure below provldes an example of a general approach Lo screenlng and response Lo Lvu paLlenLs.

A ueLalled Lvu Lpl-llnk screen changes as Lhe dlsease moves and Lhls should be a downloadable from a slLe
LhaL conLlnual updaLes Lhls lnformaLlon. lL should be slmllarly formaLLed ln a check llsL manner AS Lu wlll noL
do lL lf prolonged-Lhey can'L-Lhey are way Lo busy wlLh slcker paLlenLs, and wlll over lnvesLlgaLe and over-
consulL lf Lhls Lakes Lo much Llme. Language and lllness may make lL lmposslble Lo conducL a screen well=
equlvocal. lf Lhe susplclon ls even remoLely Lhere.Lu Should lnvesLlgaLe.
CLher examples:
uk: hLLp://www.hpa.org.uk/webc/PAwebllle/PAweb_C/1317133133030


CCCS - CAL - AMMl
2014 2014
ALnulx 2 - 8edslde nurslng Care
- pendlng, wlll be updaLed when avallable.

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