bls 2014: infectious disease. given the worldwide concern about infectious diseases—as an ems...

© 2013 Seattle / King County EMS

BLS 2014: Infectious Disease


Given the worldwide concern about infectious diseases—as an EMS provider and a citizen—you are responsible to help recognize

infectious disease, treat your patients properly, and keep yourself safe.

Infectious disease has many potentially sources Bloodborne pathogens Airborne pathogens Bio-terrorism

Introduction


Objectives

1. Identify the types of PPE and how and when they should be applied.

2. Identify the characteristic infectious diseases that are a threat to EMS providers (HIV, HepC, HBV).

3. Identify appropriate measures for protecting yourself against infectious diseases.

4. Identify the appropriate actions to take for exposure to an infectious disease.


Terms Antibodies — Proteins made by the immune system that have a memory for an invading virus and help recognize and destroy future invasions by that virus.

Antibiotic — Medicine or drug that is effective in killing bacteria or inhibiting their growth.

Bacteria — A single-celled, microscopic organism that can cause damage to the body's cells. They multiply very quickly by dividing.


Terms, continued Epidemic — An outbreak of a contagious

disease that spreads among many individuals in an area or a population at the same time.

Pandemic — An outbreak of a contagious disease that affects an entire population over a wide geographical area. A pandemic affects a far higher number of people and a much larger region than an epidemic.

Parasite — An organism that grows, feeds, and is sheltered on or in a different organism while contributing nothing to the survival of its host.


Terms, continued Pathogen — An agent that causes disease such as a bacterium, virus or fungus.

Vaccine — A preparation of a weakened or disabled virus that stimulates antibody production and provides immunity when injected into the body.

Virus — A very small agent made of genetic information (RNA or DNA) surrounded by a protein coat. It cannot reproduce on its own but must take over a living cell to multiply.


Terms, continued Body Substance Isolation (BSI) — An infection

control practice that assumes all body substances including blood, urine, saliva, feces, tears, etc., are potentially infectious.

MRSA — Methicillin-resistant Staphylococcus Aureus (MRSA) are a type of staphylococcus or "staph" bacteria that are resistant to many antibiotics.

Personal Protective Equipment (PPE) - Specialized clothing or equipment worn for protection against health and safety hazards.

Universal Precautions - Universal precautions should be should be observed on every incident. Universal precautions include personal protective equipment (PPE) and body substance isolation (BSI).


Infectious Diseases


MRSA

Methicillin-resistant Staphylococcus Aureus Type of staph bacteria

resistant to common antibiotics

Traditionally associated with hospitals but now is epidemic of community-acquired MRSA

Multiplies rapidly causing many types of infection ranging from skin infections to septicemia and toxic shock syndrome

Cutaneous abscess caused by MRSA


MRSA, continued Transmission

Found commonly on human skin, in nose & throat and, less commonly, in colon & in urine

Can infect other tissues when skin or mucosal lining have been breached

Occupational Exposure Can be spread through contact with pus

from infected wound, skin-to-skin contact with infected person, & contact with objects such as towels, sheets, or clothing used by infected person.


MRSA, continued

Pre-hospital Presentation Staph infections, including MRSA,

generally start as small red bumps that resemble pimples, boils, or spider bites

Can quickly turn into deep, painful abscesses

Rarely, may also burrow deep into body, causing potentially life-threatening infections in bones, joints, surgical wounds, the bloodstream, heart valves, & lungs.


MRSA, continued

Prevention Best defense against MRSA – wash

hands often, especially after contact with other people Thorough washing with soap & water or alcohol hand

disinfecting gels is effective against MRSA

Wear a gown when caring for patients with a known or suspected MRSA infection of the skin

In some cases MRSA is a respiratory infection Patient has known or suspected MRSA skin infection

& has a cough, or has MRSA respiratory infection, wear fitted mask

Put surgical or procedure mask on the patient if they can tolerate it.


HIV AIDS caused by Human Immunodeficiency

Virus (HIV) HIV attacks cells of immune system Immune system fails & patient becomes

susceptible to "opportunistic" diseases & infections

Chest x-ray of HIV-infected man with pulmonary Kaposi sarcoma

Kaposi's sarcoma on the skin of an AIDS patient


HIV, continued

Transmission: Unprotected sex with an infected

partner Sharing of needles by IV drug users Infected mother to her baby Infected blood given during a

transfusion (extremely rare) Occupational transmission usually by

a needle stick of infected blood (also extremely rare)


HIV, continued

Pre-hospital Presentation: Depends on which opportunistic

disease or infection the person develops: Dehydration & hypotension secondary

to diarrheal diseases Seizures or altered mental status

secondary to nervous system infection Dyspnea secondary to respiratory

infection Medication reactions End of life issues


HIV, continued

Occupational Risk: The occupational risk of acquiring

AIDS is VERY LOW (less than 2% after a needlestick with infected blood; much lower after exposure to mucus membranes)

Prevention: Prevention should focus on

preventing significant blood exposures (needlesticks).

Post-exposure prophylaxis (PEP) if available if there is a significant exposure.


Hepatitis C Four million persons infected

with Hepatitis C in United States

Caused by hepatitis C virus (HCV) found in blood of persons who have disease

Spread by contact with blood of infected person

Most common chronic bloodborne viral infection in United States

Can cause cirrhosis of liver & liver cancer.

Cirrhosis of the liver and liver cancer


Hepatitis C Transmission

Blood & other bodily fluids Sharing needles with infected person Sex with infected person From a woman to her baby during birth

Pre-hospital Presentation Hepatitis C infection generally produces no

signs or symptoms during its early stages; may produce none for years

If encountered, symptoms may include: Fatigue Nausea Vomiting

Poor appetite Muscle & joint pain Low-grade fever


Hepatitis C

Occupational Risk After needle stick or sharps exposure

to HCV positive blood, about 2 healthcare workers out of 100 become infected with HCV

Approximately 20% of patients with Hepatitis C recover completely following treatment with interferon and ribavirin

Prevention No effective vaccine for hepatitis C Only way to protect yourself – avoid

exposure to infected blood


Hepatitis B Caused by hepatitis B virus (HBV), which

damages liver Vaccination against HBV has been available

since 1982 Spread by contact with blood of person

infected with the disease or by sexual transmission

Hepatitis B Virus


Hepatitis B, continued

Transmission: Sex with infected person Blood & other bodily fluids Sharing needles with infected person From a woman to her baby during

birth


Hepatitis B, continued Pre-hospital Presentation:

Most signs & symptoms of Hep B mild Unlikely you will be called to respond

to acute illness caused by this virus However you may on occasion see a

patient with end stage liver cancer or other complications from the disease


Hepatitis B, continued

Occupational Risk: Occupational risk for acquiring HBV

from unvaccinated person is significant. The risk for a vaccinated person is VERY LOW.

Prevention: Best way to prevent occupational

exposure to HBV, in addition to taking care to protect yourself from blood exposure, is to be vaccinated against the disease


Tuberculosis (TB)

Caused by small bacteria that travels from small airways to cells of lungs

Less than 10% of people infected with TB develop active disease

In the others, bacteria hides, causing no disease until host (patient) becomes immuno-compromised or otherwise debilitated


Tuberculosis, continued

Transmission: Via small airborne particles expelled

by cough, sneezing, or speaking Particles are inhaled into small

airways Prolonged exposure in confined space

confers highest risk



Pre-hospital Presentation: Cough, often productive of blood-

tinged sputum Fatigue & weakness Night sweats Low-grade fever Loss of appetite & weight loss



Occupational Risk: Occupational risk low but difficult to

quantify Prevention:

Maintain high index of suspicion among patients who are at risk of having TB

Take precautions if patients present with suspicious signs & symptoms


Influenza (flu) Caused by the influenza virus which attacks the respiratory system. Occurs seasonally from November to April in the northern hemisphere. The structure of the virus changes slightly but frequently over time; this accounts for the appearance of different strains each year.


Influenza (flu), continued

Transmission: Coughed droplets Touching contaminated surfaces (less

common)


Influenza (flu), continued

Pre-hospital Presentation Sudden onset of:

High fever Malaise Headache Dry cough Body aches


Influenza (flu), continuedOccupational Risk: Varies depending on the strain.

Prevention: Hand washing, clean surfaces Place mask on patient or ask

patient to cover mouth when coughing

Best prevention is the flu vaccine, which must be taken yearly

Best flu prevention is the

flu vaccine


Pandemic Flu Outbreak of contagious disease that affects

entire population over a wide geographical area

Caused by influenza virus to which humans have little or no natural resistance

Such an outbreak has potential to cause many deaths & illnesses

Past pandemic flu viruses known for virulence causing rapid death, especially in young people

It is difficult to accurately predict which strain of influenza may give rise to next pandemic


Pandemic vs. Seasonal Pandemic outbreaks different from

seasonal outbreaks of influenza Seasonal outbreaks caused by subtypes of

influenza viruses that already circulate among humans

Pandemic outbreaks caused by new subtypes Subtypes never circulated

among people or subtypes not circulated among people for a long time

Microbiologist examining reconstructed 1918 Pandemic Influenza Virus


Norovirus Highly contagious virus responsible for outbreaks of gastrointestinal disease on cruise ships, nursing homes, etc. Norovirus is the general name given to viruses of this type. Responsible for many cases of severe but short-lived illnesses causing vomiting, diarrhea, and stomach cramps. "Stomach flu" and "food poisoning" are typical infections of a Norovirus.


Norovirus, continued

Transmission Occurs via fecal-oral route

For example, food handler does not wash his hands after using bathroom; a person then ingests food that has been contaminated with small amounts of fecal matter



Pre-hospital Presentation Nausea, vomiting & diarrhea Stomach cramps Low-grade, transient fever General feeling of malaise, headache,

body aches

Symptoms begin suddenly, may last one to three days, and usually resolve on their own.

Because the disease is caused by a virus, antibiotics are useless.



Occupational Risk: Community-acquired, usually

situations where large numbers share same food or living space (cruise ships, college dorms)

Several outbreaks of noroviruses among staff at hospitals & nursing homes



Prevention: Wear gloves Wash your hands thoroughly Consider use of protective eyewear &

mask Surfaces contacted by the patient

must be thoroughly disinfected

If you become sick, wait two days after the last of your symptoms before returning to

work.


Personal Safety and PPE


Personal Protective Equipment Consider possible infectious

disease for every patient that you see.

Avoid infection from fluids and airborne particles by using PPE

Wash your hands frequently Decontaminate equipment and

surfaces after use.


Types of PPE

Fit-tested masks (such as N95 and N100 masks)

Eye protection (such as glasses, face shields and goggles)

Gowns (or suits) Gloves


Donning PPE

Put on PPE before entering the patient area. Base the PPE you use on your assessment of risk.

The sequence for donning PPE is MEGG:

MaskEye protectionGownGloves


Doffing PPE Remove PPE once call is complete or

crew has left patient area Be careful not to contaminate yourself

taking it off To remove PPE, reverse the order that

you put it on:

GlovesGown—hand washing min 20 sec.Eye protectionMask—hand washing min 20 sec.


Hand Washing is Vital

Single most effective way to prevent spread of disease

Soap & water for at least 20 seconds or with waterless alcohol

After all patient contact, even if you wore gloves


Equipment DecontaminationAfter completing a response to an infectious patient, must decontaminate everything touched including:

All equipment that was exposed or cross-contaminated

Outside of kits Stethoscopes Radios AEDs, etc.

Wear new gloves while decontaminating equipment.

Wear clean eye protection and mask if there is splash risk or vapors.


Masks

Don a fit-tested mask before entering the scene.

Place a mask on the patient, if tolerated.

Fitted masks provide the highest level of protection.

Remove and dispose of the mask without self contamination.


Eye Protection Wear eye protection on all calls. You

must prepare for unanticipated splashes such as: Vomiting Blood flicked from bloody hand Violent spit Glucometer strips Splashing fluids Respiratory infection Violent cough or sneeze


Gloves Wear medical gloves on all calls Most bodily fluids, such as vomit or

urine, do not typically carry blood borne viruses

While working in rescue or extrication environment where risk of both cut & body substance exposure present, wear latex or nitrile inner gloves & other protective outer gloves

Glove Up!


Limits of Gloves

Gloves are for use during patient contact.

Wash your hands after all patient contact, even if you wore gloves.

Gloves will not protect you from sharp objects such as needles.


Sharps

Needlesticks represent greatest risk of occupational blood borne transmission

Many "exposures" involve cases where EMS providers inadvertently stuck themselves with used needles!

Keep eye on paramedics & needles Watch where you put your hands


Needlestick

For needlestick exposures: Wash area well with soap & water Do NOT use bleach or other harsh

chemicals These may damage the skin, making it

more likely for the virus to enter the body Report exposure immediately to your

officer for testing and possible post-exposure prophylaxis


Skin/Mucus

For exposures to non-intact skin: Wash with soap and water. Report the exposure immediately to

your officer for testing and possible post-exposure prophylaxis.

Blood on intact skin is not considered a significant exposure. Non-intact skin

includes abrasions and cuts.

Blood on intact skin is not considered a significant exposure. Non-intact skin

includes abrasions and cuts.


Skin/Mucus, continued

For exposures to mucus membranes (eyes, mouth): Flush liberally with water Report exposure immediately to your

officer for testing & possible post-exposure prophylaxis


Airborne Report possible exposure to your

company officer The hospital may notify exposed

responders if patient is diagnosed with airborne disease (e.g., TB or bacterial meningitis)

Some diseases may require automatic & immediate post-exposure prophylaxis

Others may require post-exposure testing & then treatment only if you become positive


PEP for HIV

Any possible exposure to a blood borne disease must be reported immediately to your company officer

Post-exposure prophylaxis reduces the already very low risk of acquiring the disease

Medications taken for PEP are TOXIC

If patient is determined to be HIV-negative, PEP medications can be stopped


Summary


Summary

Hand washing is the most effective method of preventing infectious disease

Clean visible contamination first, then disinfect surface

Wear gloves when disinfecting equipment

Occupational risk of acquiring AIDS is VERY LOW


Summary, continued Best way to prevent occupational exposure to HBV, in addition to taking care to protect yourself from blood exposure, is to be vaccinated Remove gloves when you are done with patient contact, before getting into your rig, talking on the radio, or driving


Summary, continued If you suspect TB, put a mask on patient (if tolerated), & wear a mask yourself Needlesticks represent the greatest risk of occupational blood borne transmission If PEP is to be started, it should be started IMMEDIATELY after exposure, if at all possible within two hours


Resources

The recertification exam for this module is based on a variety of resources. We recommend that you review the following:

Chapter 2 – Wellbeing of the EMT in Emergency Care and Transportation of the Sick and Injured, 9th edition (AAOS).


Questions

Dr. Mickey EisenbergMedical DirectorAsk the Doc: http://www.emsonline.net/doc.asp

EMS OnlineGuidelines and Standing Ordershttp://www.emsonline.net/downloads.asp

Susan KolwitzProgram ManagerEmail support: [email protected]

http://www.emsonline.net/doc.asp

http://www.emsonline.net/downloads.asp

http://www.emsonline.net/downloads.asp

http://www.emsonline.net/

bls 2014: infectious disease. given the worldwide concern about infectious diseases—as an ems...

Documents

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mrsa slide

infectious diseasesas

contagious disease

continued epidemic

disabled virus

invading virus

type of staphylococcus