FRCA Notes

Needlestick Injury

Needlestick injuries aren't explicitly mentioned in the curriculum, so one may deem this page expendable.

It does, however, cover the curriculum item asking for knowledge of 'the types of infection transmitted through contaminated blood including but not limited to HIV &Hepatitis B and C'

It also appeared in a Final CRQ past paper, so is included here for that reason if no other.

Resources

  • Needlestick injuries can have a huge impact on the individual, due to:
    • Anxiety and psychological strain whilst awaiting test results
    • The risk of blood borne disease transmission
    • The sequelae of positive results inc. occupational roles

Disease Risk
Hepatitis B 30%
Hepatitis C 3%
HIV 0.3%

Factors increasing risk

High-risk fluids Mechanism Needle-related Patient-related
Blood Deep injuries Hollow needle High viral load
CSF Percutaneous injuries Blood visible on needle Advanced or end-stage disease
Semen/vaginal secretions Exposure of broken skin or mucous membranes
Amniotic, pleural or peritoneal fluid


Generic precautions

  • Vaccination e.g. against Hepatitis B
  • Training and awareness
  • Management plans for exposure

Clinician-specific precautions

  • Donning appropriate PPE e.g. gloves, mask, gown, visor/goggles
  • Cover open cuts/grazes
  • Good sharps practice
    • Don't re-sheath needles
    • Use auto-sheathing cannulas or needles with safety guards
    • Sharps bin close by; sharp straight into bin
    • Counting sharps

  • This describes assessment of a patient from whom you have suffered a needlestick injury
  • Explain what has happened to the patient and that for your safety a formal assessment of risk is require
  • Ensure it is done in private to maintain confidentiality

History

  • Hep B, Hep C and HIV status
  • Engaging in risky behaviours such as unprotected intercourse, IVDU, tattoos, needle-sharing, casual partners including prostitutes
  • Blood transfusions inc. abroad
  • Any history of jaundice
  • Recent holiday or residency in a country with high HIV incidence

Examination

  • Tattoos
  • Needle track marks
  • Lymphadenopathy

Testing

  • Gain patient's consent for blood tests for Hep B, Hep C and HIB

  • What if the patient lacks consent?
    • Current GMC guidance does not permit routinely testing the incapacitous patient for the benefit of the doctor
    • There may be a benefit vs. risk decision made, however, that falls on the side of testing the patient
    • See the BMA Guidance on this topic

Immediate management

  • Call for help so that someone else can relieve you and finish the procedure e.g. suturing in a line

  • Immediately:
    • Encourage free bleeding of the wound
    • Wash with soap and water (do not scrub or suck)

  • Follow local needlestick injury policy, which is usually OH in-hours and ED out-of-hours, with bloods for Hepatitis B

  • Ask a colleague to risk assess the patient (see above) to decided whether HIV PEP is required
  • They should take blood from the patient if consent is obtained
  • PEP should ideally be started within 1hr of exposure and taken for 28 days if felt necessary

Subsequent management

  • Clinical incident form
  • Document in patients notes
  • Inform OH and clinical lead
  • May need Hepatitis B booster vaccine
  • NB airway manipulation with gloves is not an exposure-prone procedure

  • The recommended first-line PEP regimen is Truvada (tenofovir 245mg + emtricitabine 200mg) + raltegravir 1200mg OD
    • Tenofovir is a nucleotide reverse transcriptase inhibitor
    • Emtricitabine is a nucleoside reverse transcriptase inhibitor
    • Raltegravir is an integrase inhibitor

  • It should be started within 1hr of exposure, and certainly within 24hrs
  • Duration of the course minimum 28 days

  • Side-effects are mostly non-specific constitutional symptoms including D&V, dizziness, headache, muscle ache, lethargy and weight loss