Download to get the file - IU Department of Emergency Medicine

EMS Blood Borne
Pathogens and Other
Dangers
Dan O’Donnell
Indiana University Emergency Mecicine
2/19/06
Goals
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Recognize infectious disease risks assumed by
EMS personnel
Understand post-exposure management of
needlestick injuries, respiratory exposure, and
contact exposure involving EMS personnel
Review the Clarian policy on post-exposure HIV
prophylaxis
Why should we care
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Estimated 4.1 million Americans infected with
HCV
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3.2 million chronic infection
Estimated 946,00 people in US with HIV/AIDS
Estimated rate in Indiana 6.5 per 100,000
14,097 new cases of TB reported in the US in
2005
Source: www.cdc.gov
Early Universal Precautions
WEAR GLOVES
It is A LOT Different Now
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You are called for unresposive person
As you get vitals and begin to start an IV, the
patient begins to seize and you stick yourself
What information do you need?
Do you need to get any shots?
Can we draw blood on him?
Infectious Diseases & EMS
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Hepatitis B
Hepatitis C
HIV/AIDS
Tuberculosis
Meningitis
Terrorist Attacks
New Case
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Called to the local dialysis center for chest pain
As you they are unhooking his port some blood
splashes onto your arm
Patient is HBV + and HCV +
What testing do you need?
Hepatitis B Virus
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Blood-borne exposure
Risk of infection after percutaneous exposure
reported from 2-40%
OSHA requires EMS employers to provide
HBV vaccination series free of charge
Vaccination given at 0, 1, 6 month intervals
Follow-up testing at 1-3 months to ensure
immunity
Hepatitis B Virus
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Prevention is important
Associated with 6-10% incidence of chronic
liver disease and primary hepatocellular
carcinoma
HBV Prophylaxis for Needlestick
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Exposed EMT is unvaccinated
If source patient not tested or unknown
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If source patient HBsAg negative
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initiate HBV vaccine series
initiate HBV vaccine series
If source patient HBsAg positive
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HBIG (0.06 ml/kg IM up to 10 ml) single dose and
initiate HBV vaccine series
HBV Prophylaxis for Needlestick
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Exposed EMS provider is previously vaccinated
and known responder (anti-HBsAB >10
mIU/ml)
Source patient not tested or unknown: no tx
Source patient HBsAg negative: no tx
Source patient HBsAg positive: test exposed and
if titer >10 mIU/ml: no tx; if titer < 10
mIU/ml: HB vaccine booster dose
HBV Prophylaxis for Needlestick
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Exposed EMT is previously vaccinated and is
known non-responder
Source patient not tested or unknown: if a highrisk source may treat as HBsAg +
Source patient HBsAg negative: no tx
Source patient HBsAg positive: HBIG two
doses or HBIG one dose and HBV vaccine one
dose
HBV Prophylaxis for Needlestick
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Exposed EMT previously vaccinated but
response unknown
Source patient not tested or unknown: test EMT
for anti-HBsAb and if adequate no tx, if
inadequate, give one HB vaccine booster
Source patient HBsAg negative: no tx
Source patient HBsAg positive: test exposed, if
inadequate HBIG x 1 & booster
HBV Exposure and Work Duty
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Does not need to be removed from pt care
Counsel to practice safe sex for 6 mos
Document baseline and 6 mos HB titer
If infected with acute HBV should wear gloves
for invasive procedures or those involving
mucous membrane contact until antigenemia
resolves
HB carriers: avoid invasive procedures
Hepatitis C Virus
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Blood-borne exposure
Risk of infection after percutaneous exposure
reported from 3 - 10%
No current vaccine
Ig prophylaxis post-exposure no proven benefit
and not currently recommended
? Role for alpha-interferon
Hepatitis C Virus
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Prevention is important
Causes chronic liver disease in up to 67%
affected and associated with hepatocellular
carcinoma
HCV and Needlestick Injury
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Test source patient for HCV
If source patient positive for HCV: Provider
testing for hepatitis C antibody titer and LFTs at
baseline and in 6 mos
HCV Exposure and Work Duty
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Does not need to be removed from pt care
Counseling regarding safe sex for 6 mos
Same precautions with invasive procedures as
with HBV
Next Case
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Called for possible overdose
Upon arrival find a 20ish male obtunded with
needle sticking from arm
You go to start an 18g IV and stick yourself
His girlfriend is HIV+ but doesn’t know his
status
What do you do now?
HIV/AIDS
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Blood-borne as well as other body fluids to
lesser extent
Risk of infection after percutaneous exposure
reported from 0.2 - 0.5%
No existing vaccine
Prevention important for obvious reasons of
currently incurable disease, devastating financial
and emotional aspects, etc.
HIV and Needlestick
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Increased risk
deep injury
 viremic blood on device causing injury
 device used in pt vein or artery (hollow needle)
 source pt dies from AIDS within 60 days of
exposure (assumes pt had high viral load)
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HIV and Mucous Membranes
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Risk approximate 0.1%
For intact skin even <0.1%
Increased risk
high volume of blood
 high viral load of HIV
 prolonged contact
 membrane/skin integrity compromised
 extensive area of contact
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HIV Exposure Prophylaxis
“A Walk Through the EMTC”
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Initial
Clean affected area as promptly as possible with
copious amounts of water or sailine and cleansing
with soap or alcohol based products
 Notify EMS supervisor
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Taken from the 2007 Clarian Guidelines for EMS needlestick exposures
Once You Get to the EMTC
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You will be immediately triaged to the fast track
EMTC health care provider witll assess the
exposure
The provider will esnure the affected areas are
clean as promptly as possible
The OUCH nurse will be notified
Then What?
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Blood draws
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1st dose of emtricitabine and tenofovir,
lopinavir/ritonavir
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CBC, CMP, b-HCG
If very high risk this will be broadened
You will be d/c with
Emtricitabine
 Tenofovir
 kaletra
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The Next Day
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Occupational health will be responsible for
drawing baseline Hepatits B, C and HIV lab
work
What About the Patient?
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The Clarain OUCH nurse will coordinate getting
blood for Rapid HIV, HBV, HCV
What if they refuse draws?
The employer or the Indiana State Health
department may petition the court
 Physical restraint may NEVER be used
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What if we are not going to EMTC?
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The staff physician or charge nurse will complete all
steps
HIV Exposure Prophylaxis
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Other drugs
Zidovudine (AZT)
 Lamivudine (Epivir)
 Indinavir (Crixivan)
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All have shown to have great results at
preventing seroconversion
Issues in HIV Prophylaxis
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Current ZDV doses well tolerated
Short term toxicity seen in higher doses includes
GI symptoms, fatigue, headache
Contraindicated in pregnancy/breastfeeding
Toxicity of other antiretrovirals not well studied
in HIV negative individuals
In HIV +, 3TC can cause GI symptoms,
pancreatitis
Issues in HIV Prophylaxis
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IDV toxicity in HIV + individuals includes GI
symptoms and with prolonged use, increased
incidence of:
hyperbilirubinemia
 kidney stones (<5%)
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Prophylaxis should be initiated ASAP, preferably
within 1-2 hours post-exposure.
No absolute cut-off for prophylaxis start
HIV Exposure and Work Duty
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Does not need to be removed from pt care
Counsel to practice safe sex for 6 mos
Baseline and follow-up HIV testing at 6 weeks, 3
months, and 6 months
For HIV positive EMTs, avoid invasive
procedures
Needle stick Prevention in EMS
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No needle recapping
Avoid two handed techniques
Needle less drug administration
Proper and immediate disposal of needles
Attention to task and patient behavior
Communication with EMS driver
Reassessment of need for IV, meds
Next Case
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Called for Cough and Fever
Find a homeless gentelman on the streets.
Claims he has been coughing up blood for the
past year progressively worsening
Tuberculosis
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Airborne transmission in droplets < 5
micrometers in diameter
Symptoms associated with active TB:
persistent cough > 3 weeks
 bloody sputum
 night sweats
 weight loss
 fever
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Tuberculosis Exposure
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CXR most useful study for contemporaneous
assessment of exposure risk
Exposed EMT should have Mantoux skin test
for TB at baseline and again in 12 weeks
Mantoux Skin Test
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< 5mm: negative
> 5mm and < 10 mm: negative UNLESS:
HIV + or risk factors for HIV
 recent TB contact
 CXR shows fibrotic changes of TB
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>10 mm and < 15 mm: negative UNLESS:
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several risk factors for TB
> 15 mm: positive
Tuberculosis Prevention
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HEPA filter masks to filter particles 1
micrometer diameter or more
Suspected patients wear surgical masks over
mouth and nose
Open windows of ambulance
Air conditioning/heat on nonrecirculation mode
Tuberculosis Treatment
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Refer to pulmonary/infectious disease
consultants
Multidrug resistent TB increasing
Selection of antituberculosis meds based on
local sensitivities and profiles
Tuberculosis and Work Duty
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Does not need to be removed from pt care
unless EMT has active disease
If EMT has a prior history of treated TB needs
to be counseled on symptoms of active TB
Last Case
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Called to a local ECF for “Altered Mental
Status”
Find an 87 y/o female who has had fever 104
and headache
Transport
2 days later the doc lets you know that she was
diagnosed with meningitis
What do you do?
Bacterial Meningitis
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Neisseria meningitidis
Haemophilus influenzae
Streptococcus pneumoniae
Who needs prophylaxis
Meningitis Exposure Prophylaxis
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Neisseria meningitidis
if contact with oral secretions, intubation, suctioning
 rifampin 10 mg/kg/dose max 600mg BID x 2d
 ciprofloxacin 500mg single dose
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Haemophilus influenzae
same exposures as with n. meningitidis
 rifampin 600mg qd x 4 days
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Meningitis Exposure Prophylaxis
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Streptococcus pneumoniae
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no specific post-exposure prophylaxis recommended
All meningitis exposures
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counsel exposed providers on signs and symptoms
of meningitis
Meningitis and Work Duty
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Does not need to be removed from pt care
unless signs and symptoms of meningitis
develops
Summary
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Universal precautions at all times
Practice good needle safety
Be aware of the HIV post-exposure prophylaxis
Remember respiratory isoloation as part of
universal precautions
When in doubt…ask!