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Ouch!
SUMMARY
You sustain a substantial percutaneous injury to
your foot. What should you do?
The Health Act 2006 requires that every NHS employer has a
policy on the management of exposure to blood or other
bodily fluids. The policy must ensure that advice is available
24 hours a day.
PEP is only available following a formal risk assessment for
each individual injury. This involves determining the severity
of the injury and the risk that the patient is carrying HIV
infection.
The procedure for obtaining a formal risk assessment varies
with local circumstances. In hospitals, the infection control
consultant(s), hospital casualty or occupational health
department will perform the risk assessment and provide the
appropriate medication. Those in general practice must
contact their local hospital casualty department who will
follow their local guidelines. Each dental practitioner should
know the contact number and name/position of the
appropriate person.
When you phone you will be asked details of the injury and
patient. You will then be told whether or not the injury is
sufficient to carry a risk of transmission and whether a risk
assessment of the patient is required.
History
You are extracting a difficult tooth and have used a luxator
to loosen the tooth prior to elevation. While transferring the
luxator to the bracket table, you drop it. The luxator impales
itself in your foot.
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Risk factor
Relative risk
Parental infection
Transfusion
There is a small risk of infection to recipients of blood transfusion given between the middle 1970s and 1987.
Most of those exposed will already have developed the infection and there is a very small risk for those who are
not positive. Donor screening since 1987 has reduced this risk to a minimal level
Haemophilia
Recipients of factor VIII-containing blood products before 1985 had a high risk of infection almost 80%. Most
of those exposed will already have developed the infection and there is a very small risk for those who are not
positive. All UK factor VIII sources are now screened
The risk depends on whether the needle is shared and how much contamination occurs. Needle exchange
programmes have reduced the incidence of HIV in IDUs.
Prisoners who are IDUs without access to needle exchange programmes represent a high-risk group for
acquiring HIV
Needlestick injury
The risk is 0.3%, but depends on the type of injury, volume of blood transmitted and the infectivity of the blood
Vaginal intercourse
A risk to both partners but greater for the female. Properly lubricated condoms offer good protection
Prostitution
Unprotected intercourse with a prostitute is a high-risk practice, but the risk varies greatly in different parts of
the world
Oral sex
Transmission has been documented but the risk is considered lower than for vaginal sex
Anal intercourse
The highest-risk sexual activity. Condoms reduce risk but failure is common. Prisoners may have consensual or
coerced sex and lack of access to condoms means they represent a high-risk group for acquiring HIV
Ouch!
What questions would you ask?
Are you a regular blood donor in the UK?
(Blood donations are screened for hepatitis B and C,
and HIV. The rate of new infections among repeat
blood donors in 2007 was 1 in 100 000 in the UK.)
Have you ever had a blood donation refused?
Have you ever been diagnosed with hepatitis B or C,
or HIV?
Have you ever lived in HIV high-prevalence areas such
as Africa or Asia?
Have you ever had a blood transfusion or surgery
abroad?
Have you ever had an injury when you have been
exposed to someone elses blood?
Have you ever injected drugs into a vein?
Have you ever been to prison?
Do you have sex without using a condom?
A positive answer to any of these questions requires further
questioning to understand the degree of risk of acquiring
HIV through the activity. In practice, asking these questions
does not usually constitute a problem as in almost all cases
there will be either no risk or a very low risk. Similarly, most
HIV-positive individuals will disclose the information
readily in this situation.
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Significance
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achieved a satisfactory antibody response of 100mIU/ml to
the vaccine, a single booster is given after 5 years. Nonresponders will receive anti-hepatitis B immunoglobulin on
an occupational exposure. If recent evidence of the
effectiveness of the recipients vaccination is not available,
the recipient should have his or her antibody titre checked.
If the recipient is not immune, the risk of transmission has
been estimated at 30% if the patient is e antigen-positive.
Infection can follow transmission of as little as 0.1ml of
blood. Hepatitis B is so infectious that the degree of injury is
almost immaterial. In the unlikely event that a nonimmunized individual receives a sharps injury, specific
hepatitis B immunoglobulin provides passive immunity
and can give immediate but temporary protection after
accidental inoculation or contamination with hepatitis
B-infected blood.
Ensure that all the dental team are trained in the disposal
of sharps.
Identify and dispose of needles and other sharps
immediately after use.
Always pass instruments with the sharp end pointing
away from any person.
Remove burs and ultrasonic tips from handpieces
immediately after use.
Pick up instruments individually.
Retract the patients cheek with a mirror while
administering local analgesia.
Never resheath a needle holding the sheath in a hand:
use a one-handed technique (Figure 31.2) or dispose of
the needle immediately.
Never ever place your finger, or your assistants finger, in
front of a sharp instrument, such as a scalpel or luxator.
Always use a firm finger rest while scaling.
Dispose of sharps into a solid container (approved to
BS 7320).
Ensure that sharps are disposed of by incineration and by
an authorized person registered to collect such waste.
Use heavy-duty gloves when cleaning instruments prior
to autoclaving.
Keep your working area well organized and uncluttered
with sharps in a separate area. Do not place waste
material such as swabs or tissues over instruments.
When found
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What is your last duty before you can turn your back on this
unfortunate episode?
You must remember to fill in an incident report as required
by law (the Reporting of Injuries, Disease and Dangerous
Occurrences Regulations 1995) and submit it to the Health
and Safety Executive. This will be important evidence for
industrial injury benefit or insurance purposes, together with
the records in your notes.
This injury has ruined your day. This has all proved so
complex that next time you might just wash the injury and
ignore it. Why not?
The main reason is the worry that you might contract HIV
infection from an unsuspected carrier. The effectiveness of
PEP reducing the risk of transmission by over 80% cannot
be ignored. Also, it would be unethical for a dentist not to
follow up the possibility of developing an infection which
could jeopardize the wellbeing of his or her patients. There
would also be a risk of transmission to the dentists sexual
partner(s).
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