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CASE PRESENTATION

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A previously well 50-year-old physician presented to hospital with fever, lethargy, nausea, and diarrhea. He had returned from Sierra Leone 5 days prior where he had worked in an Ebola treatment facility.

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Because of his recent exposure to Ebola virus disease (EVD) and presentation with fevers, he was immediately transferred to the nominated Ebola center in Canada and isolated. A small team of nurses and doctors were assembled to care for him on a rotating shift roster.

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On admission he was hypovolemic from vomiting and diarrhea, requiring treatment with intravenous fluids and low-dose norepinephrine. On day 2 of his admission, he was noted to have escalating oxygen requirements and there was a suspicion that he had coexisting pneumonia. He became increasingly delirious, pulling at lines, and removing supplemental oxygen. An arterial blood gas revealed pH 7.47, pCO2 29 mm Hg, and pO2 55 mm Hg with an inspired oxygen concentration of 0.70 via face mask with oxygen reservoir.

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A decision was made to secure the airway prior to further deterioration and to avoid rushing in response to a sudden decline. The assembled team comprised of an experienced anesthesia practitioner to perform the intubation, an intensive care physician to manage the hemodynamics during intubation, and a critical care nurse to assist.

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Airway examination revealed a slim build patient (75 kg) with a beard and normal dentition. Reassuring features for an easy direct laryngoscopic intubation included a Mallampati score of II, good mouth opening and thyromental distance of 6 cm, and unrestricted head and neck extension.

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INTRODUCTION

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What Is EVD?

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Ebola virus is a member of the Filoviridae virus family that can cause viral hemorrhagic fever,1 a severe illness associated with high case fatality rates. The first case of Ebola occurred in 1976 in Equatorial Africa, in two simultaneous outbreaks, one of which was in the Democratic Republic of Congo near the Ebola river after which the disease is named.2 Since that time there have been 24 outbreaks.

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How Severe Was the 2014 Outbreak?

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Since the first cases in the most recent epidemic were notified to the World Health Organization (WHO) on March 21, 2014, this outbreak has caused more cases and more deaths than any previous Ebola epidemic.3 The West African countries of Guinea, Liberia, and Sierra Leone were the hardest hit with almost all cases occurring across these three countries. As of August 2015, there were reported 27,862 cases and 11,281 deaths. Case fatality rates in Guinea, Liberia, and Sierra Leone were 66.6%, 45.05%, and 29.47% respectively4—many times higher than the case fatality rates seen in the 2003 severe acute respiratory syndrome (SARS) epidemic which were approximately 7% to 17%.5 Outside of Africa, Ebola cases were seen in Spain, Italy, the United Kingdom, ...

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