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Chapter22 standard precautions
1. International Trauma Life Support
for Emergency Care Providers
CHAPTER
eighth edition
International Trauma Life Support for Emergency Care Providers, Eighth Edition
John Campbell • Alabama Chapter, American College of Emergency Physicians
Standard Precautions
and Transmission-
Based Precautions
22
Key Lecture Points
Explain that trauma care involves exposure to blood and body fluids, and to the diseases that are spread by these means.
Explain the difference between active and passive immunity.
Describe the diseases caused by hepatitis B, hepatitis C, and HIV.
Discuss tuberculosis and why it is making a comeback.
Explain precautions to prevent contracting these diseases.
Describe personal protection and handling and cleaning of items exposed to blood or other potentially infectious materials (OPIM).
Describe reporting of exposure to blood or OPIM.
Describe multidrug-resistant organisms.
Discuss the three most common bloodborne viral illnesses emergency care providers are likely to be exposed to in the provision of patient care
Discuss signs and symptoms of airborne and droplet-transmitted diseases, and describe protective measures to reduce possible exposure to them
Describe precautions emergency care providers can take to prevent exposure to blood and other potentially infectious materials
Cerebrospinal fluid, synovial fluid, amniotic fluid, pericardial fluid, pleural fluid, or any fluid with gross visible blood
Describe procedures for emergency care providers to follow if they are accidentally exposed
Discuss precautions for care of patients with multidrug-resistant illnesses and airborne/droplet diseases
Be able to identify those situations in which a higher level of personal protective equipment is needed, beyond basic equipment used in daily patient care
List vaccines and immunizations recommended for EMS
Provision of patient care may present possibility of exposure to bloodborne and other diseases. Precautions markedly reduce these risks.
If personal protective equipment (PPE) could not be used or have failed, treatment is available to reduce risk of acquiring these diseases following an exposure event.
Three most common diseases encountered are:
Hepatitis B (HBV).
Hepatitis C (HCV).
HIV infection.
All primarily bloodborne diseases
NOTE: OPIM—Other Potentially Infectious Materials
Alone, these body fluids are not a risk. However, if they contain blood or other body fluids known to carry the disease, they can be infectious.
At least 5 identified types of hepatitis viruses: hepatitis A, B, C, D, and E.
Hepatitis D is transmitted through blood and body fluid exposure to patients already infected with hepatitis B.
Use precautions.
Discard all biohazards into approved receptacles.
Protective equipment.
Needle-safe or needleless systems.
NOTE: Nonintact skin includes mucous membrane and open wounds.
Due to frequent contact with blood and needles, healthcare workers considered at risk of becoming infected with HBV. Fortunately, HBV is one form of hepatitis for which there is an effective vaccine.
In 2011, CDC reported that HBV in healthcare workers acquired through occupational exposure was rare.
Exposures may be treated.
Routine testing of donor blood for HBV makes transmission from blood transfusion very rare.
Passage of Needlestick Safety and Prevention Act of 2000 by U.S. Congress requires use of needle-safe or needleless devices.
This legislation has cut number of sharps injuries by more than half since 2003.
HBV infection is uncommon in general population; members of certain groups are considered much more likely to harbor virus.
HBV is a major cause of acute and chronic hepatitis, cirrhosis, and liver cancer.
Following acute infection, 5 to 10% of these patients continue to be chronic carriers of virus. These carriers are potentially infectious.
Estimated 3,000 people in U.S. are infected each year.
Universal vaccination program in U.S.
In 1995, 800 healthcare workers acquired disease through occupational exposure (OSHA). Since 1992, this number has decreased by almost 90%.
Vaccines
Heptavax
Recombivax-B
Engerix-B
Offers lifelong protection
Recombinant: contains no human components
A titer (blood test) is performed 1–2 months after completion of vaccine series to document response to vaccine. If positive, no further titer testing is needed or recommended.
The vaccine is safe and produces immunity in more than 90% of people vaccinated.
Hepatitis B immunoglobulin (HBIG)
Contains antibodies to HBV and provides temporary, passive protection against HBV.
HBIG is only 70% effective and, when effective, provides protection for only 6 months.
HBIG is used only when there has been a significant exposure to HBV in an unimmunized person, but is given in conjunction with vaccine to offer full coverage postexposure.
NOTE: Nonintact skin includes mucous membrane and open wounds.
This virus is thought to be responsible for majority of what had been identified as non-A, non-B hepatitis infections.
Incubation period is 6–7 weeks. Those exposed to HCV are test-positive 5–6 weeks after exposure.
Healthcare workers can acquire infection through hollow-bore needlesticks with contaminated needles.
Likelihood of becoming infected with HCV after a single high-risk needlestick is estimated at 1.5%.
This risk is further reduced by use of needle-safe devices.
Rapid HCV testing can be performed on source patient and, if positive, exposed provider can be offered a follow-up test (HCV-RNA) in 4–6 weeks postexposure.
Reduces concern about having acquired disease to 4–6 weeks instead of 6 months of follow-up. Treatment is available for people who acquire disease.
Current treatment is with peginterferon alfa-2a (Pegasys), a combination of long-acting interferon and another antiviral agent, ribavirin.
Together, this treatment has resulted in 56% of persons clearing their infection.
Patients with HIV have difficulty fighting off infection and are susceptible to illnesses that otherwise healthy adults are immune to.
Pneumocystitis jirovecii (formerly known as “P. carinii”) pneumonia (PCP).
Secondary to yeast like fungus in the lungs, common in the environment and rarely causes illnesses in healthy people.
HIV may never present with symptoms in patients that may have been exposed but never developed the disease, yet they test positive for HIV and therefore cannot transmit the disease.
Patients being treated may be free of virus circulating in blood and pose only minute risk.
Studies show after 48 weeks of treatment, 96% treated have no circulating virus in their blood.
Human immunodeficiency virus (HIV)
Nonintact skin includes mucous membrane and open wounds.
Although virus has been cultured from variety of body fluids, only blood has been implicated in transmission of virus in workplace.
Other body fluids do not carry enough virus particles to transmit disease. Semen and vaginal secretions have been shown to transmit virus during sexual activity.
No evidence to suggest that HIV is transmitted by casual contact.
Nonintact skin includes mucous membrane and open wounds.
Transmission to health care workers has been documented only after accidental parenteral exposure (needlestick) or exposure of mucous membranes and open wounds to large amounts of infected blood.
Needlestick exposure to HIV blood 0.3% is chance of 3 in 1,000.
Mucosal or nonintact skin exposure to large amounts HIV blood 0.09% is chance of 9 in 10,000.
One documented case of transmission from infected blood on nonintact skin. This case was reported in 2002 and involved a health care worker with extensive dermatitis who did not always use gloves when caring for a patient coinfected with HIV and HCV.
NOTE: See Figure 22-1: Risk Assessment for HIV therapy.
Antiretroviral drug regimens
The decision to administer such agents should be based on nature of exposure, likelihood that patient is infected with HIV, and duration of time following exposure (Figure 22-1).
In general, hollow-needle exposures are more significant than solid instruments (such as a scalpel).
Testing the source patient can prevent unnecessary treatment, is inexpensive, and quick (10–20 min. results)
If post exposure meds are to be administered, the attending physician should contact PEP hotline at 1-888-448-4911 for second opinion.
Globally, tuberculosis is still deadliest infectious disease with 8 million new infections annually and 3 million deaths.
In the U.S., tuberculosis has been declining in last several years.
Cases decreased by 71.4% from 1997 to 2007. In fact, number of cases in 2007–09 was lowest ever reported in United States.
Only persons with active infection of lung or throat spread tuberculosis.
U.S. Centers for Disease Control and Prevention recommends placing surgical mask on any patient suspected of having TB; thus, care provider does not need to wear a mask of any kind.
Clinical manifestations of disease become apparent only when patient's immune system fails to keep bacteria in check.
Bacteria begins to infect lungs and may spread to other portions of body, particularly kidneys, spine, or brain. These cases are termed “extrapulmonary” and are not communicable to care provider.
Symptoms of active tuberculosis are most prominent in lungs and include a bad cough that lasts longer than three weeks in conjunction with two or more of the following: pain in chest, coughing up bloody sputum, weakness or fatigue, unexplained weight loss, loss of appetite, fever, chills, night sweats, or hoarseness.
A positive result to a Heaf test is triggered by an immune reaction by patient's antibodies against Mycobacterium tuberculosis, the bacteria that causes TB. This indicates exposure to TB, either through vaccination or infection.
TB infection
If positive skin test but no symptoms of active TB, isoniazid (INH) or rifampin is used for a period of 6–9 months to eradicate infection.
TB disease is term for active disease.
3–4 antibiotic agents are used when confirmed.
Although some strains of TB are developing resistance to many of agents used to treat disease, multidrug-resistant TB is still treatable and is rare (US: 116 cases in 2007).
In 2007, extensively drug-resistant TB (XDR-TB) gained media attention. XDR-TB occurs when the organism has become resistant to two of the first-line oral antibiotics and two of the first-line injectible antibiotics. There are other drugs currently available to treat XDR-TB.
NOTE: Public domain image from CDC: http://phil.cdc.gov/phil/details.asp
Public domain image from CDC: http://phil.cdc.gov/phil/details.asp?pid=4493
Chickenpox vaccination is given in two doses one month apart.
The rubeola virus is transmitted via airborne droplets.
Healthcare workers are at a higher risk for contracting the virus and should be immunized.
There is a higher incidence of rubeola due to concerns that the Measles, Mumps, and Rubeola (MMR) vaccine is associated with autism; however, there is no clinical evidence to support this.
Public domain image from CDC: http://phil.cdc.gov/phil/details.asp?pid=1150
Public domain images from CDC: http://phil.cdc.gov/phil/details.asp?pid=3168, http://phil.cdc.gov/phil/details.asp?pid=318
Pertussis causes uncontrollable coughing spells where the patient may not be able to catch his/her breath. When the patient takes deep breaths to catch his/her breath, the namesake “whoop” sound is heard from the inflamed and swollen airways.
Pertussis commonly affects infants and small children with small airways that are susceptible to the infection.
Most adults were between the age of 11 and 14 when the vaccination was developed.
The CDC in 2005 and again in 2011 recommended that all healthcare workers receive the booster dose of Tdap (tetanus, diphtheria, and pertussis).
Public Domain image from CDC: http://phil.cdc.gov/phil/details.asp?pid=130
Mumps is a childhood disease caused by viral infection.
Signs and symptoms include fever, swelling of salivary glands, and dehydration is common from poor fluid intake, especially in young children.
Public domain image from CDC: http://www.cdc.gov/rubella/about/photos.html
Public domain image from CDC: http://www.cdc.gov/rubella/about/photos.html
Public domain image from CDC: http://www.cdc.gov/rubella/about/photos.html
Public domain image from CDC: http://www.cdc.gov/flu/images.htm
Since the early 1960s, the incidence rate for multidrug-resistant organisms has been increasing.
The incidence began in the hospital care setting and hospital-associated infections (HAIs) are now the leading cause of extended hospital stay and increased costs.
Methicillin-resistant staphylococcus aureus (MRSA) is perhaps the most prevalent HAI but now there is a community acquired (CA-MRSA) strain that is more common and more easily transmissible than the HAI form.
Public domain images from CDC: http://www.cdc.gov/mrsa/community/photos/photo-mrsa-9.html, http://www.cdc.gov/mrsa/community/photos/photo-mrsa-5.html
Prehospital care personnel are not at high risk for contracting MRSA when performing job tasks. Gloves, good handwashing, and cleaning surfaces and equipment are important for protection of patients and care providers.
There is no postexposure treatment for exposure to MRSA recommended.
Public domain image from CDC: http://phil.cdc.gov/phil/details.asp
IMAGE: BSI equipment: gloves, eyewear, and respirators.
“Standard precautions” refer to treating everyone (including EMS) as if infectious. Goal is to prevent spread of infection from you to patient and from patient to you, or between patients because of you. In today's environment, you must use precautions for each and every patient.
Equipment used is task-based (See Table 22-1: Recommended PPE for Worker Protection Against HIV and HBV Transmission in Prehospital Settings) (U.S. OSHA Guidelines).
Be knowledgeable about infection from hepatitis B, hepatitis C, and HIV.
Understand etiologies, signs and symptoms, routes of transmission, and epidemiology (relationships of various factors determining frequency and distribution of a disease).
Open or weeping lesions should be covered with bandages.
If cannot be adequately protected, avoid invasive procedures, other direct patient-care activities, or handling of equipment used for patient care.
Perform routine hand washing before and after all patient contact.
Wash hands as soon as possible following exposure to blood or OPIM.
Alcohol-based foam or gel is best for in-field use.
Providers should not have artificial nails or nail extensions (U.S. Centers for Disease Control and Prevention, 2002, October 25. Hand hygiene guidelines).
Contact precautions reduce the risk of transmission by direct contact.
Wear gowns when splashes or direct contact with the individual, surfaces or objects may occur.
Be sure to clean and disinfect all reusable items such as BP cuff and stethoscope.
Using viricidal or germicidal agents, follow surface cleaning protocol for stretcher and other areas where contact is probable.
If you are within 3 feet of the patient, wearing a surgical mask will protect you.
If large droplets are produced with coughing or sneezing, a surgical mask should be placed on the patient.
Wearing a mask yourself while keeping one on the patient will provided added protection.
When known or suspected airborne disease, provider should wear N-95 respirator and goggles or face shield during contact.
NOT just when suspected splashes or sprays.
Using needle safe or needleless devices will help protect providers.
All disposable items should be collected in plastic (preferably biohazard) bag and disposed of in proper medical waste container at hospital ER or EMS facility.
All non-disposable gowns, uniforms, linens, etc., should be laundered at the EMS facility or hospital.
Clean surface spills and non-disposable equipment with low-sudsing detergent with a neutral PH. Then wet it down or soak in a 1:100 dilution of household bleach or 70% isopropyl alcohol.
Equipment that will regularly contact the skin or mucous membranes (reusable laryngoscopes, etc.) should be washed with low-sudsing detergent with a neutral PH followed by (when appropriate) soaking in a 2% alkaline glutaraldehyde such as Cidex ® for 30-40 minutes. Rinse with sterile water and repackage for next use.
Always wear gloves when exposure to blood or other infectious material is anticipated.
Almost all trauma patients are risks for exposure to blood or body fluids.
Gowns, masks, and eye protection should be used when copious amounts of body fluids or blood is anticipated such as endotracheal intubation, insertion of BIAD, vaginal deliveries, significant traumas.
Any patient with respiratory complaints should have a surgical mask placed on them or a non-rebreather mask and obtain a travel history to include any travel outside the U.S.
Direct M2M ventilation should be avoided. Instead, disposable barrier devices should be used.
Thoroughly wash or irrigate exposed area immediately following an exposure to blood or contaminated body fluids.
All employers of health care workers should have a designated official to deal with exposure incidents.
In the U.S., must contact your designated officer (mandated by U.S. federal law, March 1994)
Know your local laws and appropriate procedures.
Written report and documents
Minimum information that should be recorded on report is included in Figure 22-2.
The written ambulance report may be used to supplement, but not replace, incident report.
In the U.S., fill out confidential exposure report form.
Only exposed employee, DO, and treating physician are allowed to see form.
An exposed employee has become a patient and has a right to privacy.
