HERS 570 2

three primary BBP

- HBV (Hepatitis B)
-HCV (Hepatitis C)
-HIV

Universal precautions must be practiced w/ primary modes of transmission:

blood, semen, vaginal secretions, cerebrospinal fluid (CSF), synovial fluid

OSHA

Occupational Safety and Health Administration

What is OSHA responsible for?

Developing and enforcing workplace safety and health regulations

what are OSHA guidelines developed to do?

developed to protect healthcare providers AND patients against BBP

Do health care providers need mandatory annual training for OSHA

yes

Examples of BBP-related OSHA regulations:

•Education on BBP
•Education on PPE (personal protective equipment)
•Education on disposal of biohazardous & sharps materials
Education on hand washing

Universal precautions (OSHA)

•All open skin wounds & lesions must be covered before practice/competition
•Active bleeding - must remove immediately until bleeding is controlled and covered
•Personal protective equipment (PPE): gloves, gowns/aprons, masks/shields, eye protection, CPR masks

Steps to control external bleeding

1.Give patient gauze and instruct to apply pressure to the wound.
2.Put on gloves.
3.Apply pressure to wound. Add more gauze if needed.
4.If continues to bleed, apply more gauze and elevate above the heart.
•If it stops bleeding and patient is returning immediately to activity, apply more gauze and elastic tape for return.
•If it stops bleeding and patient is not returning immediately to activity, use saline solution to clean out the wound.
•Never use fingers or a sharp object to remove debris from the wound.
•If using a q-tip to clean out the wound, clean from the inside out.
•Apply bacitracin (single antibiotics) and a sterile dressing (i.e., band-aid or non-adherent gauze).
5.If the wound is long or deep, use steri-strips or butterfly strips to secure the edges of the wound. Do NOT put anything on or in the wound, in case the patient needs sutures or glue. (Tuf-skin or mastisol)

Proper glove removal

1.Avoid touching personal items while wearing contaminated gloves
2.Remove first glove & turn inside out
3.Place first glove in second gloved hand & then turn inside out to contain first glove
4.Remove second glove w/o touching soiled surfaces
5.Discard gloves in biohazard container/bag
6.Wash hands immediately (or use sanitizer if unable to wash hands)

ineffective areas for tourniquets

neck, armpit, groin, abdomen/torso

tourniquets

•Use direct pressure, and wound packing if needed

Steps to control major bleeding: Wound packing

1.Expose the wound
2.Remove excess pooled blood from the wound while preserving clots
3.Look for the source of most active bleeding & apply focused direct pressure (thumb or 2 fingers on the vessel)
4.Pack the wound
1.Do not release pressure - swap fingers if needed
2.Pack all voids
3.Pack to the bone
4.Hold direct pressure to the packed wound 3+ minutes
5.Continue adding dressing as needed

Steps to control major bleeding: Hemostatic agent

•Nonprescription topical product approved by FDA
•Granular powder or embedded dressings absorb water from the blood to concentrate the clotting factors
•Typically can be removed by soaking in hydrogen peroxide (or water) - read instructions!

•Indications: nosebleeds, wounds that won't stop bleeding, and large hemorrhages (insert into the dressing material)

Commercial tourniquets

•CAT
•SOF-T
SAM

improvised tourniquets

*only use if you don't have a real tourniquet

•Clothing
•Theraband
•BP cuff
•Belt
•Triangle bandage
•Bandana

*Avoid using wire, rope, bungee, or narrow devices

Steps to control major bleeding: Tourniquet

•Apply tourniquet above the level of the bleeding
•Tighten the Velcro as tight as possible first
•Spin the windlass until the bleeding stops (1-2x max)
•Secure the windlass & extra strap into the windlass clip
•Note the tourniquet time. Write the date & time the tourniquet was applied on the patient's skin (proximal limb or forehead)

•*Do not cover tourniquet with a bandage*

Tourniquet time

•2 hours is typically safe (Noordin S, et al. 2009)
•Upper limit for limb viability is 6 hours (Lee C, et al. 2007)
•Cooling the limb after applying the tourniquet can extend the viability of the upper limb \>6 hours (Swanson AB, et al. 1991)

Tourniquet pain

•Tourniquets hurt a lot if applied correctly! Explain to patient (has to go on very tight)
•Pain does not mean it is applied incorrectly
•Pain does not mean the tourniquet should be taken off. Monitor the patient

Tourniquet risks

•Wider tourniquets require less occlusion pressure & may cause less damage to underlying tissue
•Improper placement increases risk of ischemic tissue damage, continued bleeding, & damage to underlying tissue
•Complication rates of using tourniquets \= 0.2% - 1.7% if used correctly. (Brodie S, et al. 2009; Kragh JF, et al. 2011)
•DO NOT loosen the tourniquet to allow blood flow to the injured extremity

BBP

blood borne pathogen

what are BBP

a disease causing organisms that are present in blood

OPIM

Other potentially infectious materials

what are OPIM

are any body fluids or unfixed tissue

what year did OSHA mandate regulation standard

1991 OHSA mandated the regulation standard

2001: incorporated new regulations (Needlestick Safety and Prevention Act of 1999)

how does OSHA define bbp?

disease causing microorganisms found in human blood, as well as human blood components and products

According to OSHA what does your developer need to have

an exposure control plan

what is in an exposure control plan

Addresses the requirements of the OSHA regulation

*the OSHA exposure control plan should be reviewed annually

what does exposure control plan include

-a determination of each employee's potential exposure to BBP based on their job duties
-Methods to limit or eliminate expose and updates that reflect changes in technology that may further reduce or eliminate exposure
-procedures for investigation of exposure incidents
-documentation of the required annual update process including non managerial employee participation in the development and updating of the exposure plan

HIV

-HIV is the virus that leads to AIDS
-It is estimated that 1.1 million individuals are living with this virus in the US
-1 in 5 people being undiagnosed
-There is no cure of vaccine

Symptoms fo HIV-AIDS

1. Rapid weight loss
2. Dry cough
3. Recurring fever or profuse night sweats
4. Profound and unexplained fatigue
5. Swollen lymph glands in armpits, groin or neck
6. Diarrhea that lasts for more than a week
7. White spots or unusual blemishes on the tongue or mouth
8. Pneumonia
9. memory loss, depression and other neurological disorders

HBV

-a virus that can lead to fatal liver failure
-Current estimate shows that about 1.2 million people in the U.S. are infected with an additional 60,000 new cases each year
-Vaccine available (3 dose injection that has been proven to be safe with a 95% effective rate at preventing the disease
-OSHA requires you to sign a release form if you decline the vaccination (should be administered before any exposure, but an after the fact vaccine is available: may not always prevent the disease)

Symptoms of HBV

1. fatigue
2. abdominal pain
3. loss of appetite
4, nausea or vomiting
5. Joint pain
6. Jaundice (yellowing of the skin)

HCV

-leading cause of liver transplants an can lead to death
-Current estimates show that around 4.1 million people in the US are infected with an additional 26,000 new cases each year
-about 80% of those infected show no symptoms, but are similar to those of hepatitis B
-no vaccine

do many viruses not show symptoms immediately

yes

they can even lie dormant for several years

symptoms can be caused by other diseases as well

only way to know if you are infected is to see a health care professional

How does occupational exposure enter the body

occupational exposure to bloodborne pathogens enters the body through "parenteral" exposure

this is where pathogens enter the body through breaks in the skin or through mucus membrane

most exposures occur through

1. needle sticks
2. human bites
3. skin abrasions or cuts that come into contact with potentially infectious material

Infectious material can include:

1. blood or blood products
2. Human tissue
3. vaginal secretions
4. any other bodily fluid with blood in it

standard precautions rule

you trust all bodily fluids with the exception of sweat, as if they are infectious

Personal protective equipment should include:

-gloves
-mouth and eye protection
-gowns
-aprons
-lab coats
-caps
-shoe covers
-resuscitation barriers (CPR masks)

PPE limitations:

-properly worn
-maintained
-discarded and replaced if damaged

Engineering and work practice controls

-devices and procedures that are designed to educe the likelihood of an exposure incident, set up by employer

limitations

hand washing

Biohazard sings

-used to properly identify contaimined waste
-contianers should be closable
-constructed to contain all contents and prevent leakage
-properly labeled or color-coded
-closed prior to removal to prevent spillage or protrusion of contents during handling

the proper color for contaminated bags

red or red-orange bags

flurescentable labeled containers

needlestick safety prevention act requires

-use of safer needles
-needleless systems and
-the use of safer needles
-needleless systems and sharp disposal containers
-reevaluated each year
-dont break, recap needles
-only picked up by mechanical needs for broken glass

in exposed areas no

-eat or drinking
-smoking
-applying makeup
-putting in contacts

Exposure incident

when blood or other potentially infectious materials make contact with:

1. eyes
2. mouth
3. other mucus membrane
4. non-intact skin or open sore
5. piercing the skin

Action steps for BBP

-immediately and thoroughly wash any exposure area of skin with antiseptic soap and water
-flush eyes, nose, or mouth with water if blood or any body fluid comes into contact with those areas
-report incident to supervisor
-area of incident cleaned up

necessary steps for cleaning and affected area

-contain the spill using absorbent materials
-remove used absorbent materials
-disinfect the area with germicide or a 10% bleach solution
-dispose of contaminated materials into properly marked containers
-discard and decontaminate PPE

Heat exchange

convection, conduction, radiation, evaporation

convection

•heat loss/gain based on temperature of circulating medium
•Water is a circulating median

conduction

•: physical contact with solid object that results in heat loss or gain
•Touching something ho/cold, ice bag on you

radiation

•radiant heat from sun \= increase temperature

evaporation

•sweat glands allow transport of water to skin surface, which is removed by evaporation
•Getting rid of heat

overexposure to sun: LT effects

•Premature aging & skin cancer due to UV exposure
•Skin cancer is the most common malignant tumor found in humans
•Rate of cure is 95% with early detection
•Fair-skinned individuals are at higher risk of skin cancer
•ALWAYS WEAR SUNSCREEN!!!
•SPF \= how many times longer you can be exposed to the sun vs. not wearing sunscreen.
•60-80% of sun exposure occurs before the age of 20.

Korey Stringer Institute

Highest risk for EHI or HS during the first couple of days of practice

-How often: at youth level in America, about 1 death every 3-4 days
-July 30th -August 15th 2011: 15 deaths nationwide

heat stroke fatalities in foot (1975-2014)

Year Total
1975-1979 8
1980-1984 9
1985-1989 5
1990-1994 2
1995-1999 14
2000-2004 9
2005-2009 20
2010-2014 14
2015-2019 10

EHS

Exertional heat stroke

EHS: why are athletes still dying?

1.Improper Recognition/Diagnosis
•Differential diagnosis
•Temperature assessment
•CNS dysfunction

2.Ineffective or Delayed Cooling

7 predisposing factors for exertional heat illness

1. Intensity level, unmatched for fitness level
2. Hydration Status
3. Heat acclimatization
4. Environmental conditions
5. Clothing/equipment
6. Illness/fever
7. Sleep deprivation

what are heat illnesses cause by?

Circulatory deficiency
Electrolyte imbalances
Thermoregulatory strain

hydration status

if a person is dehydration then he/she is at higher risk of EHS

heat acclimation

•if a person has not had time to get used to working in the heat (normally takes 10-14 days) then he/she will be more at risk for EHS

environmental conditions

•in general, hot and humid conditions place individuals at risk but are not always necessary for someone to have a heat illness.

clothing

•clothing and equipment are barriers to evaporation and do not allow the body to cool itself as effectively. This will also put a person at higher risk.

intensity level

•A high intensity will cause greater increases in core body temperature placing this person at risk for EHS

illness/fever

•An individual with an illness with begin with an elevated temperature therefore placing him/her more at risk for EHS

sleep deprivation

while it is not completely known why this is common in heat stroke cases, it has become a recognized factor that can increase a persons risk for heat illness. (this sleep deprivation can be from one night or accumulated over several days).

heat illness prevention

•Education!
•Teaching people about hydration
•Monitor weight & hydration
•\>2% BW loss \= remove from activity until return to baseline
•Monitor color of urine

dehydration

•Mild" \= 2% BW loss
•Impairs CV & thermoregulatory response
•S/S: thirst, dizzy, dry mouth, irritable, excessive fatigue
•Tx: move to cool area & rehydrate to baseline weight. Return once asymptomatic & baseline weight.
•If not addressed, dehydration may lead to N/V, fainting, higher risk of EHI

*make sure thirst isn't caused from medication

fluid and electrolyte replacement

Standard population (slightly active) \= 2.5L of water intake daily

Use sports drinks when appropriate
•Flavor ↑ desire to consume
•Replace fluid & electrolytes
•Small amounts of sodium helps w/ water retention
•Evaluate a variety of sports drinks to determine best
Optimal CHO level \= 14g/8 oz.

Who is most susceptible to EHI

•Large muscle mass
•Overweight (death from EHS increases 4:1 as BW increases)
•Males (females are more efficient in regulating body temperature)
•Poor fitness level (or not ready for intensity level you are going to be doing)
•Hx of EHI
•Fever
•Young
•Elderly (don't have awareness to take care of themselves)

heat acclimatization guidelines days 1-2

days 1-2
-single 2-hour practice OR one 2-hr practice and one 1-hr on field session
-helmets only

heat acclimatization guidelines days 3-4

-single 3-hr practice OR one 2hr practice and one 1hr field session
-helmets only

heat acclimatization guidelines day 5

-single 3hr practice OR one 2hr pratice and one 1hr field session
-full pads

heat acclimatization guidelines after day 5

-1 day between days with multiple practices
- < 5hr total practice times
- walk-through

monitoring environmental conditions: heat index

•Heat + humidity
•65-75 maybe 80 for Minnesota
•Need to communicate this with coaches

monitoring environmental conditions: WBGT

•Wetbulb globe temperature (WBGT) - measure with sling psychrometer or digital sensor
•Incorporates 3 components:
•Dry bulb (air temperature)
•Wet bulb (thermometer w/ wet gauze that is swung around in the air)
•Black bulb (measures radiant heat)

EHS Tx

•Immediate cooling!!!
•Time above 104-105° plays a major role in patient survival
•Cooling within 10 minutes \= 100% survival rate
•DO NOT TRANSPORT until core temperature reaches 102° F
•
•
•Ice Water Immersion @ 35° F can reduce core temp. as quickly as 0.72° F/minute
•Ice packs & fans can reduce core temp. up to 0.09° F/min
•Example: pt. with core temperature of 108° F
•Ice water immersion: 10 minutes to cool to 102° F
Ice packs & fans: 80 minutes to cool to 102° F

immediate transport (A.K.A the dreaded ambulance)

5 minutes to call
10 minutes to arrive
10 minutes on-site
10 minutes to hospital
10 minutes at hospital before cooling

45 total minutes

cool first, transport second, every minute matters

EAP

"The key determinant for an exertional heat stroke outcome is the time above a critical temperature, not the maximum temperature obtained."(key temperature ~ 105.5-106oF)

EHS Tx at WSU

•WSU Campus Cold Water: 55-60° F \= too high to cool a patient's body
•Transport times from outdoor facilities to Memorial Hall
•3 minutes (FB, SOC, BSB)
•6 minutes (SB)
•10 minutes (Track)
•Doesn't account for frequent trains - must cross at least 1 track (can be blocked 5-15 minutes)

Acute exertional rhabomyolsis

•Catabolic destruction & degeneration of skeletal muscle (myoglobin & enzyme leak into vascular system)
•Occurs in intense exercise (including in heat and humidity)
•Results in: muscle weakness, swelling pain, dark urine, renal dysfunction
•Severe cases: sudden collapse, renal failure, death
•Tx: refer immediately!

Exertional Hyponatremia

•Definition: Fluid/electrolyte imbalance - abnormally low blood sodium level
•MOI: ingestion of too much fluid (before/during/after exercise)
•High risk populations: marathon & triathlon athletes
•Prevention: maintain balance of fluid/electrolyte ingestion
•S/S: worsening HA, N/V, swelling of hands & feet, lethargic, apathetic, agitated, low blood sodium level...worst case scenario - compromise CNS & life-threatening
•Tx: transport to medical facility if unable to check sodium levels. May need diuretics or IV solution

hypothermia

•Definition: "Decrease in body temperature below 95° F"1
•Heat loss:
•65% through radiation (50% through head & neck)
•20% through evaporation
•Low temperatures accentuated by wind and dampness can pose major problems for athletes
•A relative small drop in the core temperature will result in shivering
•Shivering stops between 85° F and 90° F
Death is imminent when temp

hypothermia prevention

•Dress for the weather
•Waterproof, breathable fabrics
•Dress in layers & cover exposed body parts
•Replace fluids
Exercise in warmer parts of the day

Common cold injuries

•Frost Nip/Frostbite
•Ears, Nose, Cheeks, Fingers, Toes
•Frost nip
•Skin is firm with cold painless areas that may peel or blister
•Frostbite
•Redness, Swelling, Tingling and pain
•Superficial vs. Deep

Superficial: warm water to warm up gradual
Deep: hot water

treatment for common cold injuries

•GENTLE vs. RAPID rewarming
•Rapid: only for deep frostbite
•Do not rub
•Use warm air or mild/warm water
100-110° F

Lightning safety

•EARLY COMMUNICATION is key!!!
•Chain of command, monitoring weather service, decision making re: removal & return to field
•Flash-to-bang method:
•Count time between lightning & first clap of thunder. Divide by 5. \= number of miles away
•30 \= inherent danger
•15 \= immediately leave the field
•Seek indoor shelter!
•Last resort: car, ravine, ditch, valley

lightning safety: things to avoid

•Large trees
•Flag/light poles
•Standing water
•Telephones
•Pools & showers
•Metal objects (bleachers, equipment, umbrellas)

when can you return after lightning

•Do not return until 30 minutes after last clap of thunder or lightning strike
•Lightning detector - can detect storm up to 40 miles away
•Emits warning tone when lightning strikes
•Inexpensive
-Fairly accurate

altitude sickenss

•What happens: Lower oxygen levels at higher elevations → fewer RBCs available to capture O2 → tachycardia & hyperventilation
•May take days to 2-3 weeks to adjust

altitude

•Lower oxygen levels at higher elevations → fewer RBCs available to capture O2 → tachycardia & hyperventilation
•May take days to 2-3 weeks to adjust

jet leg

•Prevention: depart well rested, eat according to time changes, hydrate, use caffeine when traveling west, use local time upon arrival, avoid ETOH!

air pollution

•Avoid exercise during highest pollution times (i.e., popular commuting times) and in areas of high traffic

synthetic turf

•Abrasions, higher speed injuries
-Heat

HIPPA

Health Insurance Portability and Accountability Act

What is HIPPA?

-Federal law
-Regulates dissemination of personal information and personal medical information

what does HIPPA allow?

•Allows patients to access information and control disclosure of information

What does HIPPA require patients to complete

•Typically requires the patient to complete a Release of Information (ROI) form to share information.