CHAPTER 77: Management of the Critically Ill Traveler

KEY POINTS

• The critically ill traveler can provide a diagnostic dilemma for the clinician given the wide array of causative agents.

• The patient’s travel history can lay a foundation for an epidemiological-based approach to therapy.

• Certain infectious agents that respond to antimicrobial therapy must be considered early, with rapid administration of the appropriate treatment medications. These include malaria, rickettsial disease, meningococcus, plague, tularemia, and influenza.

• Viral syndromes such as Middle East respiratory syndrome coronavirus (MERS-CoV), viral hemorrhagic fever (VHF), Ebola, and dengue are managed with supportive care only, as there are no available treatment medications.

• The management of the critically ill traveler includes early isolation and HCW protection should be initiated until a diagnosis can be determined.

INTRODUCTION

International travel is a fact of modern life. In 2000, nearly 700 million people worldwide visited a separate country from their residence.^1-3 In 2006, roughly 30 million US citizens left the country and in 2007, 14% of the US population made a total of 64 million trips outside the borders of the USA.^4-8 First- and second-generation immigrants in the developed world, who return to countries of origin while visiting friends and relatives, constitute up to 40% of all travelers from the United States.⁹

Both returning travelers and local visitors can present with disease related to travel. Much of this disease will be present on arrival, or develop shortly thereafter. Only a minority will occur while undergoing travel, requiring a return to the home country, and of these returns, an even smaller minority will be critically ill.^4,6,7 Of 100,000 travelers to the developing world, roughly 300 will undergo hospitalization, 50 will be air evacuated, and 1 will die.^2,3 The major causes of mortality and serious morbidity associated with travel are cardiovascular disease and trauma sustained from motor vehicle accidents.^2,3,5 Studies performed in the late 20th century suggest that infectious diseases account for less than 5% of travel-associated mortality.^4,6,7 Trends in international migration and travel, however, are likely to cause an increase in people returning to the developing world with severe infections. Currently 50 million people from developed countries visit the developing world yearly, and this number appears to be increasing.^2,3,10 In addition, preliminary data suggest that visitors and expatriates are expanding subpopulations with increased risk for both injurious and infectious consequences of international travel.^8,9,11 More recent estimates state that 8% of travelers to the developing world seek medical attention for infectious illness.^1,12-14 While the management of critical trauma and cardiovascular disease can be difficult, the varying exposures and subsequent infectious diseases associated with critical illness present the most difficult cases for the critical care practitioner.

This chapter offers an approach to the critically ill traveler, ranging from ...