1. © 2007 McGraw-Hill Higher Education. All rights reserved. Chapter 8: Bloodborne Pathogens, Universal Precautions and Wound Care

2. © 2007 McGraw-Hill Higher Education. All rights reserved. Healthcare facility must be maintained as clean and sterile to prevent spread of disease and infection Must take precautions to minimize risk Coaches must be aware of potential dangers associated with exposure to blood or other infectious materials Must take whatever measures to prevent contamination

3. © 2007 McGraw-Hill Higher Education. All rights reserved. Bloodborne Pathogens Pathogenic organisms, present in human blood and other fluids (cerebrospinal fluid, semen, vaginal secretion and synovial fluid) that can potentially cause disease Most significant pathogens are Hepatitis B, C and HIV Others that exist are hepatitis A, D, E and syphilis

4. © 2007 McGraw-Hill Higher Education. All rights reserved. Hepatitis B Major cause of viral infection, resulting in swelling, soreness, loss of normal liver function Signs and symptoms –Flu-like symptoms like fatigue, weakness, nausea, abdominal pain, headache, fever, and possibly jaundice –Possible that individual will not exhibit signs and symptoms -- antigen always present –Can be unknowingly transferred

5. © 2007 McGraw-Hill Higher Education. All rights reserved. –May test positive for antigen w/in 2-6 weeks of symptom development –85% recover within 6-8 weeks Prevention –Good personal hygiene and avoiding high risk activities –Proceed with caution as HBV can survive in blood and fluids, in dried blood and on contaminated surfaces for at least 1 week –Vaccination against HBV should be provided by employer to those who may be exposed –Athletic trainers and allied health professionals should be vaccinated

6. © 2007 McGraw-Hill Higher Education. All rights reserved. Prevention (cont.) –Three dose vaccination over 6 months –Post-exposure vaccination is also available after coming into contact with blood or fluids

7. © 2007 McGraw-Hill Higher Education. All rights reserved. Hepatitis C Both an acute and chronic form of liver disease caused by hepatitis C virus (HCV) Most common chronic bloodborne infection in United States Leading indication for liver transplant Signs & Symptoms –80% of those infected have no S&S –May be jaundice, have mild abdominal pain, loss of appetite, nausea, fatigue, muscle/joint pain, and/or dark urine

8. © 2007 McGraw-Hill Higher Education. All rights reserved. Prevention –Occasionally spread through sexual contact –Spread via contact with blood of infected person, sharing needles, or sharing items that may carry blood (razors, toothbrush) –Consider the risks of getting a tattoo or body piercing –ATC should always follow routine barrier precautions

9. © 2007 McGraw-Hill Higher Education. All rights reserved. Management –No vaccine for preventing HCV –Multiple tests available to check for HCV Single positive = infection Single negative = does not necessarily mean no infection –Interferon and ribavirin are 2 drugs used in combination and appear to be the most effective for treatment –Drinking alcohol can make liver disease worse

10. © 2007 McGraw-Hill Higher Education. All rights reserved. Human Immunodeficiency Virus A retrovirus that combines with host cell Virus that has potential to destroy immune system According to World Health Organization 42 million people were living with HIV/AIDS in 2002

11. © 2007 McGraw-Hill Higher Education. All rights reserved. Symptoms and Signs –Transmitted by infected blood or other fluids –Fatigue, weight loss, muscle or joint pain, painful or swollen glands, night sweats and fever –Antibodies can be detected in blood tests within 1 year of exposure –May go for 8-10 years before signs and symptoms develop –Most that acquire HIV will develop acquired immunodeficiency syndrome (AIDS)

12. © 2007 McGraw-Hill Higher Education. All rights reserved. Acquired Immunodeficiency Syndrome (AIDS) Collection of signs and symptoms that are recognized as the effects of an infection No protection against the simplest infection Positive test for HIC cannot predict when the individual will show symptoms of AIDS After contracting AIDS, people generally die w/in 2 years of symptoms developing

13. © 2007 McGraw-Hill Higher Education. All rights reserved. Management –No vaccine for HIV, no cure even though drug therapy is available –Research looking for preventive vaccine and effective treatment –Most effective drug combination Antiviral drug cocktail Slows replication of virus, improving prospects for survival

14. © 2007 McGraw-Hill Higher Education. All rights reserved. Prevention –Greatest risk is through intimate sexual contact with infected partner –Choose non-promiscuous sex partners and use condoms for vaginal or anal intercourse –Latex condom provides barrier against HBV and HIV –Condoms with reservoir tip reduces chance of ejaculate being released from sides –Water-based, greaseless spermicides or lubricants should be avoided –If condom breaks, vaginal spermicide should be used immediately –Condom should be carefully removed and discarded

15. © 2007 McGraw-Hill Higher Education. All rights reserved. Bloodborne Pathogens in Athletics Chance of transmitting HIV among athletes is low Minimal risk of on-field transmission Some sports have potentially higher risk for transmission because of close contact and exposure to bodily fluids –Martial arts, wrestling, boxing

16. © 2007 McGraw-Hill Higher Education. All rights reserved. Policy Regulation Athletes are subject to procedures and policies relative to transmission of bloodborne pathogen A number of sport professional organizations have established policies to prevent transmission Organizations have also developed educational programs concerning prevention, and medical assistance

17. © 2007 McGraw-Hill Higher Education. All rights reserved. Institutions should take responsibility to educate student athletes At high school level, parents should also be educated Make athletes aware that greatest risk is involved in off-field activities Athletic trainer should take responsibility of educating and informing student athletic trainers of exposure and control policies Institutions should implement policies concerning bloodborne pathogens Follow universal precautions mandated by OSHA

18. © 2007 McGraw-Hill Higher Education. All rights reserved. HIV and Athletic Participation No definitive answer as to whether asymptomatic HIV carriers should participate in sport –Bodily fluid contact should be avoided –Avoid exhaustive exercise that may lead to susceptibility to infection American with Disabilities Act says athletes infected cannot be discriminated against and may only be excluded with medically sound basis –Must be based on objective medical evidence and must take into consideration risk to patient and other participants and means to reduce risk

19. © 2007 McGraw-Hill Higher Education. All rights reserved. Testing Athletes for HIV Should not be used as screening tool Mandatory testing may not be allowed due to legal reasons Testing should be secondary to education Athletes engaged in risky behavior should undergo voluntary anonymous testing for HIV Multiple tests are available to test for antibodies for HIV proteins

20. © 2007 McGraw-Hill Higher Education. All rights reserved. Detectable antibodies may appear from 3 month to 1 year following exposure –Testing should occur at 6 weeks, 3 months, and 1 year Many states have enacted laws that protect confidentiality of HIV infected person –Athletic trainer should be familiar with state laws and maintain confidentiality and anonymity of testing

21. © 2007 McGraw-Hill Higher Education. All rights reserved. Universal Precautions in Athletic Environment OSHA (Occupational Safety and Health Administration) established standards for employer to follow that govern occupational exposure to blood-borne pathogens Developed to protect healthcare provider and patient All sports programs should have exposure control plan –Include counseling, education, volunteer testing, and management of bodily fluids

22. © 2007 McGraw-Hill Higher Education. All rights reserved. Preparing the Athlete –Prior to participation, all open wounds and lesions should be covered with dressing that will not allow for transmission –Occlusive dressing lessens chance of cross- contamination Hydrocolloid dressing is considered a superior barrier Reduces chance that wound will reopen, as wound stays moist and pliable When Bleeding Occurs –Athletes with active bleeding must be removed from participation and returned when deemed safe –Bloody uniform must be removed or cleaned to remove infectivity

23. © 2007 McGraw-Hill Higher Education. All rights reserved. Personal Precautions –Those in direct contact must use appropriate equipment including Latex gloves, gowns, aprons, masks and shields, eye protection, disposable mouthpieces for resuscitation Emergency kits should contain, gloves, resuscitation masks, and towelettes for cleaning skin surfaces –Doubling gloves is suggested with severe bleeding and use of sharp instruments –Extreme care must be used with glove removal –Hands and skin surfaces coming into contact with blood and fluids should be washed immediately with soap and water (antigermicidal agent) –Hands should be washed between patients

24. © 2007 McGraw-Hill Higher Education. All rights reserved. Availability of Supplies and Equipment –Must also have chlorine bleach, antiseptics, proper receptacles for soiled equipment and uniforms, wound care equipment, and sharps container –Biohazard warning labels should be affixed to containers for regulated waste, refrigerators containing blood and containers used to ship potentially infectious material –Labels are fluorescent orange or red –Red bags or containers should be used for potentially infectious material

25. © 2007 McGraw-Hill Higher Education. All rights reserved. –Disinfectant Contaminated surfaces should be clean immediately with solution of 1:10 ratio approved disinfectant to water Should inactivate HIV Contaminated towels should be bagged, labeled, and separated from other soiled laundry, then transported in biohazard container –Wash in hot water (159.8 degrees F for 25 minutes) –Laundry done outside institution should be OSHA certified –Sharps Needles, razorblades, and scalpels use extreme care in handling and disposing all sharps Do not recap, bend needles or remove from syringe Scissors and tweezers should be sterilized and disinfected regularly

26. © 2007 McGraw-Hill Higher Education. All rights reserved. Protecting the Caregiver –OSHA guidelines are designed to protect coaches, athletic trainers and other employees. –Coaches generally do not come into contact with blood and therefore risk is greatly reduced –Responsibility of institution to protect athletic trainer and other staff Provide necessary supplies and education –All staff have personal responsibility to follow guidelines and to enforce them

27. © 2007 McGraw-Hill Higher Education. All rights reserved.

28. Protecting the Athlete From Exposure –Use mouthpieces in high-risk sports –Shower immediately after practice or competition –Athletes exposed to HIV or HBV should be evaluated and immunized against HBV

29. © 2007 McGraw-Hill Higher Education. All rights reserved. Post-exposure Procedures Athletic trainer should have confidential medical evaluation that documents exposure route, identification of source/individual, blood test, counseling and evaluation of reported illness Laws that pertain to reporting and notification of results relative to confidentiality vary from state to state

30. © 2007 McGraw-Hill Higher Education. All rights reserved. Caring for Skin Wounds Skin wounds are extremely common in sports Soft pliable nature of skin makes it susceptible to injury Numerous mechanical forces can result in trauma –Friction, scrapping, pressure, tearing, cutting and penetration

31. © 2007 McGraw-Hill Higher Education. All rights reserved. Types of wounds –Abrasions Skin scraped against rough surface Top layer of skin wears away exposing numerous capillaries Often involves exposure to dirt and foreign materials = increased risk for infection –Laceration Sharp or pointed object tears tissues – results in wound with jagged edges May also result in tissue avulsion –Incision Wounds with smooth edges

32. © 2007 McGraw-Hill Higher Education. All rights reserved. –Puncture wounds Can easily occur during activity and can be fatal Penetration of tissue can result in introduction of tetanus bacillus to bloodstream All severe lacerations and puncture wounds should be referred to a physician –Avulsion wounds Skin is torn from body = major bleeding Place avulsed tissue in moist gauze (saline), plastic bag and immerse in cold water Take to hospital for reattachment

33. © 2007 McGraw-Hill Higher Education. All rights reserved. Immediate Care Should be cared for immediately All wounds should be treated as though they have been contaminated with microorganisms To minimize infection clean wound with copious amounts of soap, water and sterile solution –Avoid hydrogen peroxide and bacterial solutions initially

34. © 2007 McGraw-Hill Higher Education. All rights reserved.

35. Dressing –Sterile dressing should be applied to keep wound clean –Occlusive dressing are extremely effective in minimizing scarring –Antibacterial ointments are effective in limiting bacterial growth and preventing wound from sticking to dressing –Utilization of hydrogen peroxide can occur several times daily before reapplication of ointment

36. © 2007 McGraw-Hill Higher Education. All rights reserved. Are sutures necessary? –Deep lacerations, incisions and occasionally punctures will require some form of manual closure –Decision should be made by a physician –Sutures should be used within 12 hours –Area of injury and limitations of blood supply for healing will determine materials used for closure –Physician may decide wound does not require sutures and utilize steri-strips or butterfly bandages

37. © 2007 McGraw-Hill Higher Education. All rights reserved. Signs of Wound Infection –Same as those for inflammation Pain Heat Redness Swelling Disordered function –Pus may form due to accumulation of WBC’s –Fever may develop as immune system fights bacterial infection

38. © 2007 McGraw-Hill Higher Education. All rights reserved. Most wound infections can be treated with antibiotics Staphylococcus aureus has become resistant to some antibiotics –Methicillin-resistant staphylococcus aureus (MRSA) is more difficult to treat and infection is extremely difficult to treat –If cause of infection is not discovered early and improper antibiotics are used initially infection that starts in skin could spread into more serious infection

39. © 2007 McGraw-Hill Higher Education. All rights reserved. Tetanus –Bacterial infection that may cause fever and convulsions and possibly tonic skeletal muscle spasm for non-immunized athletes –Tetanus bacillus enters wound as spore and acts on motor end plate of CNS –Following childhood vaccination, boosters should be supplied once ever 10 years –If not immunized, athlete should receive tetanus immune globulin (HyperTET) immediately following skin wound