• Admit all patients with focal neurologic findings or

abnormal CT scan or LP findings; with CMV retinitis; and with severe drug reactions.

..... Discharge

• Fever without a source if the CD4 count is >500/j.tL

and the patient appears well (outpatient follow-up).

• Patient with a headache who appears well with normal

CT and LP. Outpatient follow-up should be arranged

to check CSF cryptococcal antigen test.

SUGGESTED READING

Marco CA, Rothman RE. HIV infection and complications in

emergency medicine. Emerg Med Clin North Am.

2008;26:367-387.

Rothman RE, Marco CA, Yang S. Human immunodeficiency

virus infection and acquired immunodeficiency syndrome:

Introduction. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline

DM, Cydulka RK, Meckler GD. Tintinalli's Emergency

Medicine: A Comprehensive Study Guide. 7th ed. New York,

NY: McGraw-Hill, 20 1 1, pp. 1031-1042.

Torres M, Chin RL. HIV in the Emergency Department. Emerg

Med Clin North Am. 201 0;28:xii-429.

B lood and Body Fl uid

Exposure

Ra hul G. Patwa ri, MD

Key Points

• A blood or body fluid exposure refers to contact with

potentially infected fluids through non-i ntact skin, mucous membranes, or skin penetrated by a sharp object.

• Prevention is the cornerstone to reducing infectious

exposures.

• Admin istering postexposure prophylaxis for human

immunodeficiency virus is a time-sensitive decision,

INTRODUCTION

The Centers for Disease Control and Prevention define an

exposure to blood and body fluids as contact with potentially infectious fluids that put health care workers at risk

of infectious disease. This may come from a break in the

skin by a sharp object ( eg, a needle or scalpel) or contact

with mucous membranes or already present breaks in the

skin. The infectious diseases for which a health care

necessitating that the exposed patient visit the emergency department when the employee health office is

closed.

• Hepatitis B vaccination greatly reduces the seroconversion rate when a health care worker is exposed to blood

and body fluid.

are administered to decrease the seroconversion rate for

HIV and HBV.

Blood or any specimen visibly contaminated with

blood is the most common vector for transmission; however, other potentially infectious fluids include semen,

vaginal secretions, and cerebrospinal, synovial, pleural,

peritoneal, pericardia!, and amniotic fluids. The risk of

transmission of disease in these fluids is unknown. Fluids

that are not considered infectious include feces, nasal

worker is at risk include human immune deficiency syn- secretions, saliva, sputum, sweat, tears, urine, and vomitus,

drome (HIV), hepatitis B virus (HBV), and hepatitis C unless of course they contain blood.

virus (HCV). The best defense against a blood and body fluid expoNot surprisingly, most needlestick injuries come from sure is prevention. Standard precautions should be used

teaching hospitals, usually within operating rooms or the when caring for all patients. Standard precautions include

emergency department (ED) where sharp instruments are proper hand washing; the use of gloves, masks, and gowns;

used routinely. Syringe and suture needles are the most and proper disposal of medical waste and safe needle

common offending devices. The risk of seroconversion usage. Health care workers should wash hands before and

after needlestick exposures varies depending on the patho- after contact with every patient, even if gloves were worn.

gen. For hepatitis B, the risk of transmission is up to 30% The use of soap and water (or an alcohol-based gel or

if the source patient is e-antigen positive. If the source foam) is the most important factor in decreasing the transpatient is e-antigen negative, the risk drops to 1-6%. The mission of disease.

risk of transmission of hepatitis B substantially decreases Personal protective equipment (PPE), namely gloves,

in those who have received the hepatitis B vaccine. The risk masks, gowns, and eye shields, is an important part of preventof transmission of hepatitis C is 1 .8%, whereas the risk of ing the transmission of organisms; however, it is not perfect.

HIV risk is 0.3%. Postexposure prophylactic medications Microperforations in gloves can allow contamination of the

1 62

BLOOD AND BODY FLUID EXPOSU RE

hands. Infection can also occur when removing gloves.

Hence hand washing is recommended after removing

gloves. Sharp instrwnents should always be disposed of in

proper sharps bins and blood and body fluid contaminated

objects in proper biohazard bags.

CLINICAL PRESENTATION

� History

An exposure consists of a break in the skin by a sharp object

(eg, a needle or scalpel) or contact with mucous membranes or non-intact skin by blood or other body fluids. If

a needle is involved, determine whether it was a "less severe"

(solid bore, superficial scratch) or "more severe" (large bore

hollow needle, deep puncture, visible blood on the device,

or the needle was used in the source patient's artery or v ein)