There is a paucity of data regarding management strategies in the United States compared to low-resource settings where outbreaks of EVD have occurred. In all cases, proper infection prevention and isolation measures are essential. Patients suspected of having EVD should be placed in single rooms with private bathrooms and separate spaces for donning and doffing PPE.54 Healthcare personnel should be well trained in donning and doffing PPE, and hospitals should assist and monitor for close adherence. Detailed guidance regarding PPE is available on the CDC website at http://www.cdc.gov/vhf/ebola/healthcare-us/ppe/guidance.html.
All persons entering the patient room should wear at least the following equipment: (1) respiratory protection with either a fit-tested N95 mask and full face shield or an air-purifying respirator with full face shield helmet or headpiece; (2) a single-use surgical hood that extends to the shoulders and fully covers the neck; (3) a single-use, fluid-resistant or impermeable gown and boot covers; (4) 2 pairs of single-use nitrile gloves with extended cuffs; and (5) a single-use, fluid-resistant or impermeable apron if the patient has vomiting or diarrhea.54 Although airborne transmission of Ebola has not occurred, airborne precautions are recommended in the event of unexpected aerosol-generating procedures such as noninvasive ventilation and tracheal intubation.
Nonemergency tracheal intubation may be considered to lower the risk to the patient and healthcare team. For example, when treating a patient with EVD at the University of Nebraska Medical Center, the team had a predetermined plan for nonemergency intubation to address the following issues: (1) the need for expertise in airway management, (2) allowance of time needed for appropriate donning of PPE, and (3) ensuring all necessary equipment would be available.55
There is no approved Ebola-specific prophylaxis or treatment. Management currently consists of early, aggressive supportive care. This includes volume resuscitation, blood pressure support, oxygenation/ ventilator support, pain control, nutritional support, and treatment of secondary infections.28 Prevention of intravascular depletion is a cornerstone of treatment;1 this includes volume resuscitation, correction of electrolyte disturbances, and prevention of complications of hypovolemic shock.54 Lactated Ringer’s solution is preferred over normal saline in cholera, which is also characterized by large-volume secretory diarrhea, and may be considered for initial resuscitation for patients with EVD.56 There are no studies that directly compare lactated Ringer’s solution, normal saline, or other fluid and electrolyte therapy specifically in patients with EVD. Case reports from the United States have varied in the fluids used; lactated Ringer’s solution, normal saline with 5% dextrose, and half-normal saline with potassium chloride were all utilized at some point during hospitalization of patients with EVD.55,57 Electrolyte abnormalities commonly encountered include hypokalemia, hypocalcemia, hypoalbuminemia, metabolic acidosis, and hyponatremia. Although treatment data are limited in patients with EVD, hypovolemia with hypokalemia increase the risk for cardiac dysrhythmias and sudden cardiac death.57 Hypokalemia is common and should be corrected and monitored closely to prevent cardiac dysrhythmia.
Patients with severe sepsis or septic shock should be managed according to the international sepsis guidelines, with early goal-directed therapy, vasopressor/inotropic support, glucose control, and enteral nutrition.14 Vasopressors (such as norepinephrine or dopamine) may be added after initial volume repletion in the setting of persistent hypotension.56
Patients may have severe coagulopathy with laboratory findings consistent with disseminated intravascular coagulation. Correction of coagulopathy with fresh-frozen plasma and platelet transfusions is necessary with severe or uncontrolled bleeding.57 Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided due to the risk of bleeding.
Patients with EVD are likely to be at risk for malaria and should be tested and treated if there is evidence of concomitant infection. Empiric broad-spectrum antibiotics may also be necessary due to the risk of secondary bacterial infection.58 Médecins Sans Frontières (Doctors Without Borders) recommends empiric oral antibiotics with amoxicillin, co-trimoxazole (trimethoprim-sulfamethoxazole), cefixime, or ciprofloxacin when EVD outbreaks occur in sub-Saharan African settings.58 There is a case report from Germany where a patient with EVD complicated by paralytic ileus developed gram-negative septicemia on day 12 of illness.29 This would, anecdotally, suggest that empiric coverage for gram-negative organisms is reasonable. There are no specific recommendations for empiric antimicrobial therapy in resource-rich settings.
Investigational therapies are further discussed in the "Controversies And Cutting Edge" section. These therapies can be offered on a compassionate-use basis through the manufacturers and with an Investigational New Drug application through the FDA.
Marlie Dulaurier, MD;Katherine Moyer, DO;Rebecca Wallihan, MD
July 2, 2016
August 2, 2019
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 0.5 Pharmacology CME credits