McGraw-Hill/Irwin © 2013 McGraw-Hill Companies. All Rights Reserved.

Chapter 9: Bloodborne Pathogens, Universal

Precautions, and Wound Care

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• Healthcare facility must be maintained as clean and sterile to prevent spread of disease and infection

• Must take precautions to minimize risk and prevent contaminations

• Must be aware of potential dangers associated with exposure to blood or other infectious materials

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Bloodborne Pathogens

• Pathogenic organisms, present in human blood and other fluids – Cerebrospinal fluid, semen, vaginal secretion and

synovial fluid) that can potentially cause disease

• Most significant pathogens are Hepatitis B, C and HIV

• Others that exist are hepatitis A, D, E and syphilis

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Hepatitis B (HBV)• Major cause of viral infection, resulting in

swelling, soreness, loss of normal liver function• Signs and symptoms

– Flu-like symptoms like fatigue, weakness, nausea, abdominal pain, headache, fever, and possibly jaundice

– Possible that individual will not exhibit signs and symptoms -- antigen always present

– Can be unknowingly transferred

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– May test positive for antigen w/in 2-6 weeks of symptom development

– 85% recover within 6-8 weeks

• Prevention– Good personal hygiene and avoiding high risk

activities– Be cautious as HBV can survive in blood and fluids, in

dried blood and on contaminated surfaces for at least 1 week

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• Management– Vaccination against HBV should be provided

by employer to those who may be exposed– Athletic trainers and allied health

professionals should be vaccinated– Three dose vaccination over 6 months– Post-exposure vaccination is also available

after coming into contact with blood or fluids

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Hepatitis C (HCV)• Acute and chronic form of liver disease caused by

HCV• Most common chronic bloodborne infection in United

States• Leading indication for liver transplant• Signs & Symptoms

– 80% of those infected have no S&S– May be jaundice, have mild abdominal pain, loss of

appetite, nausea, fatigue, muscle/joint pain, and/or dark urine

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• Prevention– Occasionally spread through sexual contact– Spread via contact with blood of infected

person, sharing needles, or sharing items that may carry blood (razors, toothbrush)

– Consider the risks of getting a tattoo or body piercing

– ATC should always follow routine barrier precautions

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• Management– No vaccine for preventing HCV

– Multiple tests available to check for HCV• Single positive = infection• Single negative = does not necessarily mean no

infection

– Interferon and ribavirin are 2 drugs used in combination and appear to be the most effective for treatment

– Drinking alcohol can make liver disease worse

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Human Immunodeficiency Virus (HIV)

• A retrovirus that combines with host cell

• Virus has potential to destroy immune system

• According to World Health Organization 42 million people were living with HIV/AIDS in 2004

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• Symptoms and Signs– Transmitted by infected blood or other fluids– Fatigue, weight loss, muscle or joint pain, painful or

swollen glands, night sweats and fever– Antibodies can be detected in blood tests within 1

year of exposure– May go for 8-10 years before signs and symptoms

develop– Most that acquire HIV will develop acquired

immunodeficiency syndrome (AIDS)

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Acquired Immunodeficiency Syndrome (AIDS)

• Collection of signs and symptoms that are recognized as the effects of an infection

• No protection against the simplest infection• Positive test for HIV cannot predict when

the individual will show symptoms of AIDS• After contracting AIDS, people generally

die w/in 2 years of symptoms developing

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• Management– No vaccine or cure for HIV– Research looking for preventive vaccine and effective treatment– Some antiviral drug combinations help to slows replication of virus

• Prevention– Education is critical– Greatest risk is through intimate sexual contact with infected

partner– Emphasis safe sexual practices

• Choose non-promiscuous partners• Use latex condoms to provide HBV & HIV barrier• Vaginal spermicides

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Bloodborne Pathogens in Athletics

• Chance of transmitting HIV among athletes is low

• Minimal risk of on-field transmission

• Some sports have potentially higher risk for transmission because of close contact and exposure to bodily fluids– Martial arts, wrestling, boxing

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Policy Regulation

• Athletes are subject to procedures and policies relative to transmission of bloodborne pathogen

• A number of sport professional organizations have established policies to prevent transmission

• Organizations have also developed educational programs concerning prevention, and medical assistance

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• Institutions should educate student athletes– Greatest risk is involved in off-field activities

• Athletic trainer should take responsibility of educating and informing student athletic trainers of exposure and control policies

• Institutions should follow universal precautions and implement policies concerning bloodborne pathogens

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HIV and Athletic Participation

• Bodily fluid contact should be avoided• Avoid exhaustive exercise that may lead to

susceptibility to infection

• According to American with Disabilities Act infected athletes cannot be discriminated against and may only be excluded with medically sound basis

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Testing Athletes for HIV

• Should not be used as screening tool

• Mandatory testing may not be allowed due to legal reasons

• Testing should be secondary to education

• Athletes engaged in risky behavior should undergo voluntary anonymous testing for HIV

• Multiple tests are available to test for antibodies for HIV proteins

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• Detectable antibodies may appear from 3 months to 1 year following exposure– Testing should occur at 6 weeks, 3 months, and 1

year

• Many states have enacted laws that protect confidentiality of HIV infected person– Athletic trainer should be familiar with state laws

and maintain confidentiality and anonymity of testing

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Universal Precautions • Occupational Safety and Health Administration

(OSHA) established standards for employer to follow that govern occupational exposure to blood-borne pathogens

• Developed to protect healthcare provider and patient

• All sports programs should have exposure control plan– Include counseling, education, volunteer testing,

and management of bodily fluids

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• Preparing the Athlete– All open wounds and lesions should be covered

with dressing that will not allow for transmission– Occlusive dressing lessens chance of cross-

contamination• Hydrocolloid dressing reduces chance that wound will

reopen, maintains moist and pliable wound

• When Bleeding Occurs– Athletes must be removed from participation and

returned when deemed safe– Bloody uniform must be removed or cleaned

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• Personal Precautions– Use appropriate equipment

• Latex gloves, gowns, aprons, masks and shields, eye protection, disposable mouthpieces for resuscitation

• Emergency kits should contain, gloves, resuscitation masks, and towelettes for cleaning skin surfaces

• Non-latex gloves can be used when long term exposure to blood and bodily fluids is not likely

– Doubling gloves is suggested with severe bleeding and use of sharp instruments

– Extreme care must be used with glove removal– Hands and skin surfaces coming into contact with blood and fluids should

be washed immediately with soap and water (anti-germicidal agent)– Hands should be washed between patients

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• Availability of Supplies and Equipment– Chlorine bleach, antiseptics, proper receptacles

for soiled equipment and uniforms – Wound care equipment, and sharps container– Biohazard warning labels should be affixed to:

• Containers for regulated waste• Refrigerators containing blood • Shipping containers for infectious material

– Gloves and bandages should be placed in sealed white bags prior to disposal in regular trash receptacles

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– Disinfectant• Contaminated surfaces should be clean with

solution of 1:10 ratio approved disinfectant to water

• Contaminated towels should be bagged, labeled, and separated from other soiled laundry, then transported in biohazard container

– Sharps• Needles, razorblades, and scalpels• Do not recap, bend needles

or remove from syringe• Scissors and tweezers should

be sterilized and disinfected regularly

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• Protecting the Caregiver– OSHA guidelines are designed to protect coaches,

athletic trainers and other employees.

– Responsibility of institution to protect athletic trainer and other staff

• Provide necessary supplies and education

– All staff have personal responsibility to follow guidelines and to enforce them

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• Protecting the Athlete From Exposure– The USOC suggests use of mouthpieces in

high-risk sports– Shower immediately after practice or

competition– Athletes exposed to HIV or HBV should be

evaluated and immunized against HBV

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Post-exposure Procedures

• Athletic trainer should have confidential medical evaluation that documents exposure route, identification of source/individual, blood test, counseling and evaluation of reported illness

• Laws that pertain to reporting and notification of results relative to confidentiality vary from state to state

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Caring for Skin Wounds

• Skin wounds are extremely common in sports

• Soft pliable nature of skin makes it susceptible to injury

• Numerous mechanical forces can result in trauma– Friction, scrapping, pressure, tearing,

cutting and penetration

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• Types of wounds– Abrasions

• Skin scraped against rough surface• Top layer of skin wears away exposing numerous

capillaries• Often involves exposure to dirt and foreign materials =

increased risk for infection

– Laceration• Blunt force delivered over a sharp bone or a bone that is

poorly padded results in wound with jagged edges• May also result in tissue avulsion

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– Puncture wounds• Can easily occur during activity and can be fatal• Penetration of tissue can result in introduction of tetanus bacillus to

bloodstream• All severe lacerations and puncture wounds should be referred to a

physician

– Avulsion wounds• Skin is torn from body = major bleeding• Place avulsed tissue in moist gauze (saline), plastic bag and

immerse in cold water• Take to hospital for reattachment

– Incision• Wounds with smooth edges

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Immediate Care• Should be cared for immediately

• All wounds should be treated as though they have been contaminated with microorganisms

• To minimize infection clean wound with copious amounts of soap, water and sterile solution– Avoid hydrogen peroxide and bacterial solutions

initially

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• Dressing– Sterile dressing should be applied to keep

wound clean– Occlusive dressing are extremely effective

in minimizing scarring– Antibacterial ointments are effective in

limiting bacterial growth and preventing wound from sticking to dressing

– Saline solution is recommended for repeated cleaning

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• Are sutures necessary?– Deep lacerations, incisions and occasionally

punctures will require some form of manual closure– Decision should be made by a physician– Sutures should be used within 12 hours– Area of injury and limitations of blood supply for

healing will determine materials used for closure– Physician may decide wound does not require

sutures and utilize steri-strips or butterfly bandages

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• Signs of Wound Infection – Same as those for inflammation

• Pain• Heat• Redness• Swelling• Disordered function

– Pus may form due to accumulation of WBC’s– Fever may develop as immune system fights

bacterial infection

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• Most wound infections can be treated with antibiotics

• Staphylococcus aureus has become resistant to some antibiotics– Methicillin-resistant staphylococcus aureus

(MRSA) is more difficult to treat – Infection could spread significantly if cause

is not discovered and improper antibiotics are used initially

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• Tetanus– Bacterial infection that may cause fever and

convulsions and possibly tonic skeletal muscle spasm for non-immunized athletes

– Tetanus bacillus enters wound as spore and acts on motor end plate of CNS

– Following childhood vaccination, boosters should be supplied once ever 10 years

– If not immunized, athlete should receive tetanus immune globulin (Hyper-Tet) immediately following skin wound