'Needle-stick Injury'
Doctor Information
Mark Hewitt, Age 45
Past Medical History:
Asthma
Anxiety
Medication History:
Salbutamol 100mcg Inhaler
Sertraline 50mg OD
Previous consultations:
Last seen 2 weeks ago by Dr Jamal:
Ongoing anxiety, has been on sertraline for 2 weeks now, tolerating well, but symptoms still present. Discussed that it may take a few more weeks before any improvement is seen. We agreed to continue at current dose, and review in 2 weeks time.
Past Medical History:
Asthma
Anxiety
Medication History:
Salbutamol 100mcg Inhaler
Sertraline 50mg OD
Previous consultations:
Last seen 2 weeks ago by Dr Jamal:
Ongoing anxiety, has been on sertraline for 2 weeks now, tolerating well, but symptoms still present. Discussed that it may take a few more weeks before any improvement is seen. We agreed to continue at current dose, and review in 2 weeks time.
Patient Information
Mark Hewitt, Age 45
Opening Line:
I’m a bit worried Doctor.
History:
4 days ago you were helping your brother clean out his rental flat between tenants. The place had been left in a bit of a mess, and you noticed that it must have been used as a “drugs den” as there were used needles in the bin. At the time, you were careful and you don’t remember getting any needle-stick injury. you didn't wear any gloves. However yesterday, you noticed that you started to get some pain in your finger, and upon closer inspection you noticed a small skin break that looked like a needle puncture wound. You now suspect that you did get a needle-stick injury at the time, and you’re very anxious. You feel well in yourself, no fever.
Past Medical History:
You’re asthmatic, but it’s very well controlled, you take no regular inhalers, and have Salbutamol that you use infrequently. You’ve also recently started medication for anxiety… Sertraline… you’re finding this hasn't really helped, but you’ve just seen your regular GP who states that it may take a few more weeks to work any way.
You’ve not had any tetanus vaccines, nor any vaccines for Hepatitis in the past.
Social History:
You don’t smoke, and you drink around 1-2 bottles of wine per week, usually shared with your partner at home. You don't use drugs yourself, and are in a stable, loving relationship at home. You have not had any sexual relations with any one else in since you met your wife 12 years ago.
Family History:
You are the Oldest of 2 brothers and one sister. There are no conditions that run in your family.
Ideas and concerns:
You’re now really worried that you’ve caught Hepatitis B and HIV, as you’ve read in the news papers that hepatitis B and HIV can be passed via dirty needles. You’re worried that the pain in your finger is actually the infection tracking up the finger and getting into the blood stream.
You’ve read about some antibiotics that can be given to those to stop them getting hepatitis and HIV from needle-stick injuries. You've read online that both hepatitis and HIV can be fatal, and you’ve got a young family at home to support and your wife doesn’t work.
Expectations:
You want some of these antibiotics as you’re now very worried that you’re going to get HIV and Hepatitis.
How to React:
Should the GP suggest you go to the local GUM clinic for further management, you will refuse. Your wife’s office is near that building and someone from there will see you go in, and they may get the wrong idea. You want all tests to be done at the practice.
Opening Line:
I’m a bit worried Doctor.
History:
4 days ago you were helping your brother clean out his rental flat between tenants. The place had been left in a bit of a mess, and you noticed that it must have been used as a “drugs den” as there were used needles in the bin. At the time, you were careful and you don’t remember getting any needle-stick injury. you didn't wear any gloves. However yesterday, you noticed that you started to get some pain in your finger, and upon closer inspection you noticed a small skin break that looked like a needle puncture wound. You now suspect that you did get a needle-stick injury at the time, and you’re very anxious. You feel well in yourself, no fever.
Past Medical History:
You’re asthmatic, but it’s very well controlled, you take no regular inhalers, and have Salbutamol that you use infrequently. You’ve also recently started medication for anxiety… Sertraline… you’re finding this hasn't really helped, but you’ve just seen your regular GP who states that it may take a few more weeks to work any way.
You’ve not had any tetanus vaccines, nor any vaccines for Hepatitis in the past.
Social History:
You don’t smoke, and you drink around 1-2 bottles of wine per week, usually shared with your partner at home. You don't use drugs yourself, and are in a stable, loving relationship at home. You have not had any sexual relations with any one else in since you met your wife 12 years ago.
Family History:
You are the Oldest of 2 brothers and one sister. There are no conditions that run in your family.
Ideas and concerns:
You’re now really worried that you’ve caught Hepatitis B and HIV, as you’ve read in the news papers that hepatitis B and HIV can be passed via dirty needles. You’re worried that the pain in your finger is actually the infection tracking up the finger and getting into the blood stream.
You’ve read about some antibiotics that can be given to those to stop them getting hepatitis and HIV from needle-stick injuries. You've read online that both hepatitis and HIV can be fatal, and you’ve got a young family at home to support and your wife doesn’t work.
Expectations:
You want some of these antibiotics as you’re now very worried that you’re going to get HIV and Hepatitis.
How to React:
Should the GP suggest you go to the local GUM clinic for further management, you will refuse. Your wife’s office is near that building and someone from there will see you go in, and they may get the wrong idea. You want all tests to be done at the practice.
Examination Findings
Examination
Afebrile
No lymphadenopathy
Hands: a small puncture mark is noted. It has scabbed over.
Afebrile
No lymphadenopathy
Hands: a small puncture mark is noted. It has scabbed over.
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic approach to data gathering, without making any assumptions Makes own assessment of history and examination Ask about social and sexual history, including any drug use. Establish other risk factors for hepatitis / HIV. Is appropriately selective in the choice of enquiries, examinations & investigations |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to enquire about social, sexual or drug use history. Is un-selective or insensitive during enquiry into sensitive history. |
Clinical Management Skills
|
POSITIVE INDICATORS
Recognises the risk associated with Needle-stick injuries in the community Offers appropriate and feasible management options Management approaches reflect an appropriate assessment of risk (In this case, not offering post exposure prophylaxis (PEP) as its after 72 hours, and the risk of infection is likely low) Makes appropriate prescribing decisions (see above) Refers appropriately & co-ordinates care with other healthcare professionals - (In this case - not referring to A+E, but onto the appropriate specialists - Genitourinary medicine, or managing yourself) Manages risk effectively, safety netting appropriately |
NEGATIVE INDICATORS
Doubtful about diagnosis Explanation lacking detail, or providing incorrect information Doesn’t use resources appropriately (referring to A+E) Prescribing inappropriately (giving or suggesting PEP) Management doesn’t reflect the assessment of risk, or the risk assessment was incorrect / inappropriate Unclear about follow up arrangements Safety-netting inappropriate or absent. |
Inter Personal Skills
|
POSITIVE INDICATORS
Identifies the patient’s health beliefs, their agenda, and their ICE Establishes concern for HIV / Hepatitis infection Uses explanations that are relevant and understandable to the patient, and lacking in jargon Shows sensitivity and empathy for the patient’s feelings Works with the patient to develop a shared management plan |
NEGATIVE INDICATORS
Fails to identify the patient’s heath beliefs, agenda or ICE Doesn’t establish concern for HIV / Hepatitis Explanation absent or filled with jargon Fails to empathise with the patient’s situation Uses a doctor centred approach |
Management
Management:
Needle-stick injuries within the community rarely present within General Practice, as most people present to A+E. The reason this case is different, is the delay in presentation. For any needle-stick injury in the community who present within 72 hours, it is appropriate to send to A+E for post exposure prophylaxis medications (PEP). Once 72 hours has passed, then PEP is no longer effective. Therefore sending to A+E is inappropriate, and not a reasonable use of NHS resources.
Needle-stick injuries within the community rarely present within General Practice, as most people present to A+E. The reason this case is different, is the delay in presentation. For any needle-stick injury in the community who present within 72 hours, it is appropriate to send to A+E for post exposure prophylaxis medications (PEP). Once 72 hours has passed, then PEP is no longer effective. Therefore sending to A+E is inappropriate, and not a reasonable use of NHS resources.
Immediate management of needle-stick Injuries
Taken from the NHS Choices Website
If you pierce or puncture your skin with a used needle, follow this first aid advice immediately:You should also seek urgent medical advice:
- encourage the wound to bleed, ideally by holding it under running water
- wash the wound using running water and plenty of soap
- don’t scrub the wound while you’re washing it
- don’t suck the wound
- dry the wound and cover it with a waterproof plaster or dressing
- go to the nearest accident and emergency (A&E) department, or
- contact your employer’s Occupational Health service, if you injure yourself at work
Given the delay in presentation, how do we manage this case?
The first thing to do is to discuss with your local Genitourinary (GU) clinic / consultant (it might be worth checking who is in charge of this service in your local area, as it maybe a different provider). They are usually the speciality who deal with needle-stick injuries in the community after the initial PEP, or if PEP is not indicated (as in this case) They will be able to give you guidance on the prevalence of HIV / Hepatitis locally and can help advise you on ongoing management. They may even want to see the patient, and take over testing / management.
Once 72 hours is over, there are no medications that can be given to reduce the risk of infection. Certainly antibiotics are going to be of no use as the infections in question are viral. In this case, picking up infection from an old needle is very unlikely. This is because HIV / Hepatitis Viruses don’t last long outside the body. The patient is at greater risk from developing Tetanus, and should be offered a Tetanus vaccine (as he has not had one in the last 10 years)
The only ongoing management option, after reassuring the patient that the risk is small, is regular blood tests to check for any developing infections. If you choose to manage this within the primary care setting, this would involve taking a baseline blood test for HIV / Hepatitis, FBC. Re-testing at 6 weeks (to check for HIV) and 3 months (to check for Hepatitis). If the user of the needle was known, then it may be possible to consent the individual to get their Hepatitis / HIV status checked, which may alleviate the need for any further testing in the patient if the user’s status is negative.
The first thing to do is to discuss with your local Genitourinary (GU) clinic / consultant (it might be worth checking who is in charge of this service in your local area, as it maybe a different provider). They are usually the speciality who deal with needle-stick injuries in the community after the initial PEP, or if PEP is not indicated (as in this case) They will be able to give you guidance on the prevalence of HIV / Hepatitis locally and can help advise you on ongoing management. They may even want to see the patient, and take over testing / management.
Once 72 hours is over, there are no medications that can be given to reduce the risk of infection. Certainly antibiotics are going to be of no use as the infections in question are viral. In this case, picking up infection from an old needle is very unlikely. This is because HIV / Hepatitis Viruses don’t last long outside the body. The patient is at greater risk from developing Tetanus, and should be offered a Tetanus vaccine (as he has not had one in the last 10 years)
The only ongoing management option, after reassuring the patient that the risk is small, is regular blood tests to check for any developing infections. If you choose to manage this within the primary care setting, this would involve taking a baseline blood test for HIV / Hepatitis, FBC. Re-testing at 6 weeks (to check for HIV) and 3 months (to check for Hepatitis). If the user of the needle was known, then it may be possible to consent the individual to get their Hepatitis / HIV status checked, which may alleviate the need for any further testing in the patient if the user’s status is negative.
Pathogens of Concern from Needle-stick Injuries
The major blood-borne pathogens of concern associated with needlestick injury are:However, other infectious agents also have the potential for transmission through needlestick injury. These include:
- Hepatitis B virus (HBV)
- Hepatitis C virus (HCV)
- Human immunodeficiency virus (HIV).
- Human T lymphotrophic retroviruses (HTLV I & II)
- Hepatitis D virus (HDV or delta agent, which is activated in the presence of
HBV) hepatitis G virus (GB virus or GBV-C)- Cytomegalovirus (CMV)
- Epstein Barr Virus (EBV)
- Parvovirus B19
- West Nile Virus (WNV)
- Malarial parasites
- Prion agents such as those associated with transmissible spongiform
encephalopathies (TSE).
Future Risk Reduction:
It might also be worth discussing with the patient whether he intends to undertake any further work clearing flats, as if his future work puts him at risk of regularly coming into contact with used needles, he may wish to be vaccinated against Hepatitis B. Further information about this can be found here.
Please note that the above only applies to needle-stick injuries that occur within the community. For needle-stick injuries within the workplace, please discuss with the occupational health department, or refer to your internal needle-stick injury policy.
Further Reading:
NICE CKS Guidance on preventing Hepatitis B Infection
NICE CKS Guidance on preventing HIV infection
NHS Choices information on the Hepatitis B Vaccine
It might also be worth discussing with the patient whether he intends to undertake any further work clearing flats, as if his future work puts him at risk of regularly coming into contact with used needles, he may wish to be vaccinated against Hepatitis B. Further information about this can be found here.
Please note that the above only applies to needle-stick injuries that occur within the community. For needle-stick injuries within the workplace, please discuss with the occupational health department, or refer to your internal needle-stick injury policy.
Further Reading:
NICE CKS Guidance on preventing Hepatitis B Infection
NICE CKS Guidance on preventing HIV infection
NHS Choices information on the Hepatitis B Vaccine