Question 25

Created on Thu, 05/28/2015 - 18:05
Last updated on Fri, 04/21/2017 - 01:47
Pass rate: 69%
Highest mark: ?

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You are supervising a registrar during the insertion of a central line. He suffers a needle stick injury.
Outline your approach to this problem.

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College Answer

Stop the procedure, ensure patient is safe and you take over care if required.

Advise the registrar of the following:

•           Wash the wound immediately with soap and water. Express any blood from the wound
•    Alert your supervisor and initiate the injury reporting system used in your workplace.
•    IdentifY the source patient,. who may need to be tested for HIV, hepatitis B, or
hepatitis C infections.

      Report to employee health services, or other designated treatment facility.
•    Get tested immediately and confidentially for HIV, hepatitisB, and hepatitis C infections.
•    Document the exposure in detail, for your own records as well as for the employer. When the source patient is unknown or tests positive for HIV, hepatitis B, or hepatitis C infection, get postexposure prophylaxis (PEP) in accordance with CDC guidelines.If the patient has HIV,start prophylaxis within two hours of exposure. For possible hepatitis C exposure, no treatment is currently recommended, but you may want to talk to a specialist about experimental postexposure prophylaxis.     .
•         Make sure to follow up with postexposure testing at six weeks, three months, and six months, and depending on the risat one year. If PEP is prescribed, you should be monitored  regularly for signs and symptoms of toxicity. Take precautions (especially by practicing safe sex) to prevent exposing others  until follow-up testing is complete.
•    Don't be afraid to seek additional information or a referral to an infectious disease specialist if you have any questions.

Discussion

LITFL have an approach to staff needlestick injuries.

David Tripp's notes for the fellowship exam are also a source of a nice point-form algorithm.

A list of definitive sources for this information would include the NSW Health Policy Directive: HIV, Hepatitis B and Hepatitis C - Management of Health CareWorkers Potentially Exposed, as well as the Westmead Children's Hospital procedure "Needlestick and Blood Exposure Injuries: Health Care Worker".

An answer to this question, as a summary of the abovementioned references:

Immediate management:

  • Abort the procedure
  • Ensure the patient is safe:
    • Take over the procedure and finish it yourself; or
    • Delegate the task to a competent sataff member
  • Ask the registrar to express blood from the wound
  • Wash the punctured area with soap and water
  • Report the incident

Risk assessment:

  • Is the patient known to have Hpe B, C, or HIV?

The following are associated with an increased risk of transmission:

  • Hollow needle
  • Large needle diameter
  • Needle was previously in an artery or vein
  • Absence of gloves 
  • Depth of wound 
  • Into artery or vein
  • Exposed to a large volume of blood
  • High blood titre of HIV, Hep B or C

Management

  • Document the Hep B immunisation status of the staff member
  • Perform antibody tests of both the staff member and the patient, with written consent
  • If the source is known to be Hep B C or HIV positive,
    • Solicit advice from infectious diseases authorities
    • Arrange appropriate vaccinations, antiretroviral prophylaxis and councelling
    • Arrange follow-up for the patient and staff member
  • Possible management strategies:
    • For Hep B, IV immunoglobulin may be appropriate
    • For Hep C, there is nothing.
    • For HIV, postexposure antiretroviral therapy is helpful (and needs to be commenced within 2 hours!)
  • Safe sex for 6 months
  • Follow-up testing: 6 weeks and 6 months 
  • Review unit guidelines and compliance
  • Offer emotional support to the staff member, and get help from infectious diseases authorities to aid post-exposure councelling

References