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seventh edition
International Trauma Life Support
for Emergency Care Providers
Standard
Precautions in the
Prehospital Setting
CHAPTER 22
Precautions
Courtesy of Louis B. Mallory, MBA, REMT-P
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Overview
• Bloodborne viral illnesses
– Most common for EMS exposure
• Signs and symptoms of tuberculosis
– Protective measures
• Potentially infectious materials precautions
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Overview
• Appropriate personal protective equipment
use
• Accidental exposure procedures
• Multidrug-resistant organisms
• Vaccines and immunizations
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Standard Precautions
Exposure does not mean infection.
Exposure can be treated.
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Standard Precautions
• Common bloodborne viral infections
– Hepatitis B (HBV)
– Hepatitis C (HBC)
– HIV infection
• Primary modes of exposure
– Contaminated blood
– Other potentially infectious materials (OPIM)
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Potentially Infectious
• Other potentially infectious materials:
– CSF
– Synovial fluid
– Amniotic fluid
– Pericardial fluid
– Pleural fluid
– Body fluid with
gross visible blood
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Potentially Infectious
• Only with gross visible blood
– Tears
– Sweat
– Saliva
– Urine
– Stool
– Vomitus
– Nasal secretions
– Sputum
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Viral Hepatitis
• Viral infections involving liver:
– Fecal transmission: Types A, E
– Bloodborne transmission: Types B, C, D
 Type D only with Type B
• Prevention is best treatment!
Courtesy of Louis B. Mallory,
MBA, REMT-P
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Hepatitis B (HBV)
• Modes of exposure
– Contaminated blood
– Other potentially infectious materials (OPIM)
– Sexual transmission
– Direct contact with nonintact skin
• Health care risk of infection: 6–30%
– Needlestick exposure to HBV blood
and no vaccination or immune response
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Hepatitis B (HBV)
• High-risk groups
– Immigrants from
areas HBV is
prevalent
– Incarcerated
– Institutionalized
– IV drug users
–
–
–
–
Male homosexuals
Hemophiliacs
Household contacts
Hemodialysis
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Hepatitis B (HBV)
• Clinical manifestation
– Acute hepatitis
– Chronic hepatitis
– Cirrhosis
– Liver cancer
• Chronic carrier risk: 5–10%
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Hepatitis B (HBV)
• Health care protection
– Hepatitis B vaccines
 Does not contain antibodies
 Lifelong protection
 Effective immunity in 90%
– Hepatitis B immunoglobulin
Courtesy of Louis B. Mallory, MBA, REMT-P
 Contains antibodies
 Passive protection for 6 months
 Effective immunity in 70%
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Hepatitis C (HBC)
• Modes of exposure
– Contaminated blood
– Other potentially infectious materials (OPIM)
– Sexual transmission
– Direct contact with nonintact skin
• Health care risk of infection
– Needlestick exposure to HCV blood: 1.5%
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Hepatitis C (HBC)
• Clinical manifestation
– Less severe than HBV
• Chronic carrier risk > HBV risk
– Liver failure, cirrhosis 10–20% of carriers
• Health care protection
– Vaccine not available
– Immunoglobulin (IG) not shown effective
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
HIV Infection
• Modes of exposure
– Contaminated blood
– Other potentially infectious materials (OPIM)
– Sexual transmission
– Direct contact with nonintact skin
• HIV does not survive outside body
– No special cleaning agents are required
– Transmitted less efficiently than HBV
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
HIV Infection
• Health care risk of infection
– Needlestick exposure to HIV blood: 0.3%
– Mucosal or nonintact skin exposure: 0.09%
– Large amounts HIV blood
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
HIV Infection
• High-risk groups
– Male homosexuals
– Bisexuals
– IV drug users
– Transfused
 Blood, pooled-plasma
– HIV sexual contact
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
HIV Infection
• Clinical manifestation
– Immune system defective
– Higher risk of unusual infections
– Many are asymptomatic
• Chronic carrier risk: 100%
– All HIV infected can transmit HIV
– Current HIV treatment reduces risk
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
HIV Infection
• Health care protection
– Vaccine not available
– Antiretroviral drug regimen
 Prolongs life, does not cure
 May reduce risk of infection by significant exposure
if administered “within hours, not days”
– Recommended for Highest Risk exposures
– Possible benefit for Increased Risk exposures
– Unlikely benefit for Low Risk exposures
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Tuberculosis
• Mycobacterium tuberculosis
– Deadliest infectious disease globally
– Not highly communicable
• Mode of exposure
– Direct contact through air, cough, sneeze
• Preventive measure
– Place surgical mask on any suspected patient
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Tuberculosis
• Health care risk of infection
– Up to 5% skin test positive
in high-prevalence environment
• High-risk groups
– HIV infected
– Immigrants from TB prevalent
– Homeless
– Live in congregate settings
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Tuberculosis
• Clinical manifestation
– Severe cough >3 weeks with two or more:
 Chest pain
 Bloody sputum
 Weakness or fatigue
 Unexplained weight loss
 Loss of appetite
 Fever, chill, night sweats
 Hoarseness
Courtesy of Louis B. Mallory, MBA, REMT-P
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Tuberculosis
• Health care protection
– TB infection
(no active disease)
 Isoniazid (INH)
or rifampin for 6–9 months
– TB disease
 Antibiotic agents
© Pearson
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
XDR-TB
• Extensively drug-resistant TB
– Resistant to:
 2 first-line oral antibiotics AND
 2 first-line IV antibiotics
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Multidrug-Resistant Organisms
• Resistant to 2 first-line antibiotics
• Increasing since 1960s
– Hospital-associated infections
– MRSA most prevalent
– CA-MRSA (Community Acquired-MRSA)
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Multidrug-Resistant Organisms
• Prehospital care personnel at low risk
– Gloves
– Handwashing
– Cleaning surfaces and equipment
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Precautions for Prevention
•
•
•
•
•
Be knowledgeable
Bandage lesions
Routine handwashing
Immunizations
Report exposures
Courtesy of Louis B. Mallory, MBA, REMT-P
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
If exposed,
wash exposed area
Immediately.
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Reporting Exposures
• Contact designated official
– Determines if exposure occurred
– Interacts with medical facility
– Coordinates needed tests
• Write incident report soon as possible
– EMS report may supplement, but not replace
• Know local laws
– Confidential exposure report form in U.S.
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians
Summary
• Health-care workers are at risk of
exposure to many contagious diseases
• Prevention:
– Health-care workers should be HBV
immunized
– Knowledge of modes of exposure, adherence
to barrier precautions, and postexposure
medical follow-up reduce risk of infection
International Trauma Life Support for Emergency Care Providers, Seventh Edition
John Campbell • Alabama College of Emergency Physicians