Module 3 VHF Prevention and Control Training CASE DEFINITIONS TRIAGE AND MANAGEMENT
- 1. VHF PREVENTION AND CONTROLTRAINING MODULE 3 CASE DEFINITIONS, TRIAGE AND MANAGEMENT Updated: April 2014 1
- 2. Case Definition Based on 4 factors 1. History of contact with confirmed or probable case 2. Fever 3. Bleeding 4. Three (3) or more general symptoms 2
- 3. No Contact Not a case Yes Probable Suspect EVD OUTBREAK Triage Decision-making Flowchart Alert case Unexplained deathFever 3 of the symptoms* Unexplained Bleeding Unexplained Death OR Yes *Symptoms include: headache, vomiting, nausea, loss of appetite, diarrhoea, intense fatigue, abdominal pain, general muscular or articular pain, difficulty in swallowing, difficulty in breathing, hiccoughs Note: Confirmed cases requires positive laboratory test Liberia, 2014 NoYes Yes OR No NoYes No No 3 of the symptoms* Yes Fever 3
- 4. 4 Triage: required for all ALERT cases • Done by a trained heath worker. • Done with standard precautions from distance of 2 meters and avoiding unnecessary examinations. • Extra precautions if needed. • Not all “alert” cases will become “suspected” cases • If the case is re-classified as “suspected,” the triage team will undertake the proper response (transport, disinfect, etc).
- 5. Actions Based on Categorization of Patient: Complete: 1. Ebola Case Report Forms 2. List all close contacts 3. Isolate patient and use barrier nursing 4. Notify higher level Authority immediately Refer to Isolation Unit for further assessment, testing and management Probable Case 5
- 6. Actions Based on Categorization of Patient: Complete: 1. Ebola Case Report Forms 2. List all close contacts 3. Isolate patient and use barrier nursing 4. Notify higher level Authority immediately Keep in ‘Holding Area’ if no isolation unit is near (Fever Observation Ward) where patient will be monitored & tested, treated empirically for other conditions, and referred to Isolation Ward if s/he tests positive Suspect Case 6
- 7. Actions Based on Categorization of Patient: • Mark as a Contact • List on the Tracing Form Educate contracts on symptoms and need for early reporting Alert Case 7
- 8. Recommended medications for the care of patients with Confirmed, Probable or Suspected Ebola Antibiotics In case the patient has a bacterial infection eg typhoid +/- ebola Ceftriaxone 2g daily iv Or Ampicillin 2 g q6h + gentamicin 5mg/kg as a stat dose then review need/renal function Or oral ciprofloxacin (not in children) Antiemetic Symptom relief for nausea or vomiting and assist with hydration For adults give chlorpromazine 25-50 mg Q6H IM or orally or metoclopramide 10 mg IV/ orally q8h until vomiting stops. For children give promethazine Anti diarrheals Symptom relief and assist with hydration imodium analgesics Relieve pain Paracetomol, codeine, morphine especially if palliative phase Avoid aspirin and NSAIDs eg diclofenac, ibuprofen due to their antiplatelet effects anxiolytics To ease anxiety or stress Always try communication and education before drug approaches. Diazepam – adults: 5-15 mg/day in 3 divided doses If more severe: give haloperidol 5 mg oral or IM antipruritics For itch Calamine lotion or antihistamines antipyretics Reduce high fever Paracetomol Avoid aspirin and NSAIDs eg diclofenac, ibuprofen due to their antiplatelet effects Antacids Relieve Dyspepsia Omeprazole 20mg daily or magnesium trisilicate, 2 tabs q8h until symptoms resolved. In children 5- 12 years, give magnesium trisilicate: 5-10 mls, q8h Anticonvulsants Treatment of epileptic fit Test glucose Diazepam iv or rectal Adult upto 20 mg, child 0.5mg/kg Antimalarial Treatment of Malaria ACT recommended. Avoid Amodiaquine containing antimalarial as an adjoin treatment. 8
- 9. Recommended approach to fluid administration in a patient presenting with Probable or Suspected Ebola Give ORAL REHYDRATION SOLUTION (ORS) if: • The patient can tolerate oral fluids AND • The patient is not deemed to be severely dehydrated 9
- 10. Recommended approach to fluid administration in a patient presenting with Probable or Suspected Ebola Give IV FLUIDS rapidly if severely dehydrated or oral fluids not practical First give an initial 1000 ml IV • Then continue Ringers lactate (LR) or Normal saline (NS) at 20 ml/kg/hour, not to exceed a maximum of 60 ml/kg in the first 2 hours (including the initial bolus). • Monitor systolic blood pressure (SBP) and clinical signs of perfusion (urine output, mental status). • Consider adding vasopressors (dopamine or epinephrine) if SBP remains <90 and signs of poor perfusion continue after fluid resuscitation (estimated 60 ml/kg) even within first 2 hours. 10
- 11. Recommended approach to fluid administration in a patient presenting with Probable or Suspected Ebola At 2–6 hours: • If SBP remains below 90 and signs of poor perfusion, continue fluids at 5–10 ml/kg/hour. • If SBP rises above 90, continue fluids at 2 ml/kg/hour. However, if the pulse is still high and there are other signs of poor perfusion, patient may still be volume-depleted and need more fluids. • Watch carefully for signs of fluid overload (increased jugular venous pressure, increasing crepitation on auscultation). If present, decrease the rate of fluid administration. Call for help from more senior clinician to further evaluate overload and decide fluids. 11