0. International Trauma Life Support, 7e
Standard Precautions in the Prehospital Setting 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.

1. Precautions
Courtesy of Louis B. Mallory, MBA, REMT-P

2. Overview Bloodborne viral illnesses Signs and symptoms of tuberculosis
Most common for EMS exposure
Signs and symptoms of tuberculosis
Protective measures
Potentially infectious materials precautions

3. Overview Appropriate personal protective equipment use
Accidental exposure procedures
Multidrug-resistant organisms
Vaccines and immunizations

4. Exposure does not mean infection. Exposure can be treated.
Standard Precautions
Exposure does not mean infection. Exposure can be treated.
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 failed, treatment is available to reduce risk of acquiring these diseases following an exposure event.

5. 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)

6. Potentially Infectious
Other potentially infectious materials:
CSF
Synovial fluid
Amniotic fluid
Pericardial fluid
Pleural fluid
Body fluid with gross visible blood
NOTE: OPIM—Other Potentially Infectious Materials.

7. Potentially Infectious
Only with gross visible blood
Tears
Sweat
Saliva
Urine
Stool
Vomitus
Nasal secretions
Sputum

8. 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!
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.
Courtesy of Louis B. Mallory,
MBA, REMT-P

9. 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
NOTE: Nonintact skin includes mucous membrane and open wounds.
Due to frequent contact with blood and needles, health-care workers considered at risk of becoming infected with HBV. Fortunately, HBV is one form of hepatitis for which there is an effective vaccine.
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.

10. Hepatitis B (HBV) High-risk groups
Immigrants from areas HBV is prevalent
Incarcerated
Institutionalized
IV drug users
Male homosexuals
Hemophiliacs
Household contacts
Hemodialysis
HBV infection is uncommon in general population; members of certain groups are considered much more likely to harbor virus.

11. Hepatitis B (HBV) Clinical manifestation Chronic carrier risk: 5–10%
Acute hepatitis
Chronic hepatitis
Cirrhosis
Liver cancer
Chronic carrier risk: 5–10%
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 health-care workers acquired disease through occupational exposure (OSHA). Since 1992, this number has deceased by almost 90%.

12. Hepatitis B (HBV) Health care protection Hepatitis B vaccines
Does not contain antibodies
Lifelong protection
Effective immunity in 90%
Hepatitis B immunoglobulin
Contains antibodies
Passive protection for 6 months
Effective immunity in 70%
Courtesy of Louis B. Mallory, MBA, REMT-P
Vaccine:
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.

13. Hepatitis C (HBC) Modes of exposure Health care risk of infection
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%
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.
Health-care 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.

14. 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
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.

15. HIV Infection Modes of exposure HIV does not survive outside body
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
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.

16. 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
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.

17. HIV Infection High-risk groups Male homosexuals Bisexuals
IV drug users
Transfused
Blood, pooled-plasma
HIV sexual contact

18. HIV Infection Clinical manifestation Chronic carrier risk: 100%
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
HIV patients develop a defect in their immune system, which predisposes them to a variety of unusual infections not generally seen in healthy patients of similar age.
Patients infected with HIV can present with a wide spectrum of clinical manifestations. Many patients with HIV infection are asymptomatic.
Any patient who carries HIV, whether symptomatic or not, can transmit the virus.
HIV patients being treated with current drugs may be virus negative and, as such, pose a minute risk.

19. 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
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).

20. Tuberculosis Mycobacterium tuberculosis Mode of exposure
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
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 In fact, number of cases in 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.

21. Tuberculosis Health care risk of infection High-risk groups
Up to 5% skin test positive in high-prevalence environment
High-risk groups
HIV infected
Immigrants from TB prevalent
Homeless
Live in congregate settings

22. 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
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.
Courtesy of Louis B. Mallory, MBA, REMT-P

23. Tuberculosis Health care protection TB infection (no active disease)
Isoniazid (INH) or rifampin for 6–9 months
TB disease
Antibiotic agents
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).
© Pearson

24. XDR-TB Extensively drug-resistant TB Resistant to:
2 first-line oral antibiotics AND
2 first-line IV antibiotics
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.

25. Multidrug-Resistant Organisms
Resistant to 2 first-line antibiotics
Increasing since 1960s
Hospital-associated infections
MRSA most prevalent
CA-MRSA (Community Acquired-MRSA)
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.

26. Multidrug-Resistant Organisms
Prehospital care personnel at low risk
Gloves
Handwashing
Cleaning surfaces and equipment
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.

27. Precautions for Prevention
Be knowledgeable
Bandage lesions
Routine handwashing
Immunizations
Report exposures
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 bandage.
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.)
Courtesy of Louis B. Mallory, MBA, REMT-P

28. If exposed, wash exposed area Immediately.
Thoroughly wash or irrigate exposed area immediately following an exposure to blood or contaminated body fluids.

29. 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.
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.

30. 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