exposure. For mucous membrane or percutaneous exposures of non-intact skin, the volwne and duration of

exposure should be noted. Determine information about

the source individual (unless this is not possible or prohib ­

ited), specifically their HBV, HCV, and HIV infectivity.

Lastly, docwnent the patient's tetanus status.

� Physical Examination

Examine the patient's skin for any breaks or visible blood.

Make sure that the patient has cleaned the area. If not,

immediately cleanse the area with copious soap and water.

Small wounds can be cleaned with an antiseptic such as an

alcohol-based hand hygiene agent (alcohol is virucidal to

HIY, HBV, and HCV). Mucosal surfaces and eyes should

be flushed with saline or water. There is no evidence that

squeezing blood out of the wound reduces the risk of

transmission.

DIAGNOSTIC STUDIES

If it is unknown whether the source patient is infected with

hepatitis B, hepatitis C, or HIV, then the source patient's

blood should be tested after obtaining consent. This will

require contacting personnel in the location where the

patient is located (eg, operating room). In some regions,

consent for such testing is not required. All source patients

should be tested for HBsAg, HCV, and HIY, unless they are

known to be infectious. Obtaining a rapid HIV test of the

source patient's blood is valuable in making decisions about

whether to start postexposure prophylaxis from the ED.

The exposed patient's blood may be collected in the ED

or the employee health clinic. Many EDs will have a specific protocol to follow regarding what laboratory tests

should be drawn on the exposed health care worker. For

the person exposed to HBV, perform hepatitis surface

antigen testing. If this is positive, then the individual has

been vaccinated and is a known responder; no further

treatment is required.

For the person exposed to a HCV-positive source, baseline testing for anti-HCV and alanine aminotransferase

(ALT) actmty is performed, with repeat testing at

4-6 months. If earlier detection is desired, testing for HCV

RNA can be performed at 4-6 months. For the person

exposed to HIY, HIV-antibody testing should be performed for at least 6 months postexposure (at 6 weeks,

12 weeks, and 6 months). Extended HIV follow-up (for

12 months) is recommended for health care professionals

who become infected with HCV after exposure to a source

co-infected with HIV and HCV.

MEDICAL DECISION MAKING

The decision to initiate treatment is determined by assessment of the risk of the exposure and the infectivity of the

source patient (Figure 38-1). Low-risk injuries are defined

by a solid needle, superficial appearance, and a low

risk source, such as a patient with an HIV viral load

< 1,500 copies/mL. High-risk injuries include those involving a hollow bore needle with presence of visible blood on

the device or exposure from a needle that was in an artery

or vein of the source patient.

TREATMENT

In addition to cleaning the wound if it has not already been

done, the most important treatment decision for the ED is

determining whether or not to give postexposure prophylaxis for HIV. Postexposure prophylaxis should be initiated as soon as possible, with the goal being to start

treatment within 1-2 hours after exposure.

Two nucleosides are recommended for low-risk expo ­

sures. The most commonly used dual nucleoside regimens

include:

• Combivir (ZDV plus 3TC; 1 tablet daily) or

• Truvada (TDF plus FTC; 1 tablet daily)

For higher risk exposures, a boosted protease inhibitor

is added:

• Kaletra (2 tablets twice daily; 200 mg lopinavir/50 mg

ritonavir in each tablet)