POTD: Needle Sticks

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You're in a hectic trauma, the patient is stabbed all over the chest and loses pulses. You crack open the chest. In the chaos, a surgery resident (she-who-will-not-be-named) nicks your palm with a suture needle. You inspect your hand and...shoot, it's definitely a needle stick. Sigh.


So what is my actual risk?

High risk:

- inoculation from deep or wound

- stick with a hollow bore needle/needle used for blood draw

Low risk:

- suture needle

- discarded needle

No risk:

- unused needle

- no break in skin


What bloodwork should I get?

From both the source patient and the exposed patient you will need:

Hep B surface antigen

Hep C antibody

HIV 1/2 Antibody

CBC, BMP, LFT, and UHCG


What exactly is the risk of transmission?

Thankfully, the risk of transmission from a positive source is fairly low!

HIV: 1 in 300, or approximately 0.3%

Hepatitis C: 1.8%, although studies have shown up to 7%

Hepatitis B: Rates vary depending on infectiousness of source patient and whether the exposed patient is vaccinated. prior to vaccinations, infectious rates could be as high as 30-60%. Full vaccination against hep B can reduce transmission to as little was 1-6%. Vaccination is the best protection against Hepatitis B transmission!


So who really needs PEP? and how effective is PEP against transmission?

the answer to that is it depends, and pretty darn effective!


Hepatitis B PEP:

- Hepatitis B immunoglobulin with vaccination series

- Decreases risk of infection by 75%

- If source patient has unclear or positive, the following should be done:

  • If exposed patient is fully vaccinated, no PEP is required

  • if exposed patient is not fully vaccinated or nonresponder, must be started on PEP

- initiate ASAP. Unknown effectiveness after 7 days post-exposure

- if exposed patient is unvaccinated, they should be initiated on hepatitis vaccination series regardless of status of source patient


HIV PEP:

- triple cocktail (preferred): Truvada (Tenofovir 300 mg + Emtricitabine 200 mg) + Raltegavir 400 mg BID

- 2nd line: nucleoside Reverse Transcriptase Inhibitor + (Integrase vs Protease vs non-nucleoside reverse transcriptase inhibitor)

- decreases risk of infection by 80%

- initiate ASAP, unknown effectiveness after 72 hours

- 28 day regimen. our pharmacy can give 1 week supply and f/u ID for rest of regimen


Hepatitis C PEP:

- sadly none exists, and no vaccines exist. bummer. Best management is close followup and continuous blood work


Regardless of exposure risks, patients should be followed up with ID in 48 hours for further testing!


POTD: Tamiflu? Tami-boooo

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 Flu season is in full throttle, and if you were lucky like me and experienced all nine circles of hell while fighting off this single-stranded RNA menace, perhaps you too would want - nay, BEG - for a magic bullet that would ease your suffering.

Fear not! For there is such a panacea! TAMIFLU - it's safe! It's effective and reduces complications! It's supported by the WHO! It's - oh wait...all fake?

Perhaps fake is a strong word, but these original claims made by the pharmaceutical-run clinical trials were...questionable to say the least. Since 1999, oseltamavir, or Tamiflu, had been recommended as an oral antiviral for influenza that reduced symptom duration and secondary complications. Tamiflu was promoted like crazy and earned Roche 18 billion dollars in profits, and it was backed by WHO and CDC. However, in 2009 when the H1N1 variant "swine flu" emerged, more pressure was placed to verify the effectiveness of this drug. When the rapid review began, unsettling evidence of manufactured data and claims based on largely unpublished data emerged. The lead author of the Tamiflu trial admitted that he "did not perform an independent analysis of the primary data...and [he did] not have access to the primary data." 

After many years of legal battle, the reviewers were finally able to access all the data, and what they found was that Tamiflu just doesn't work. At least, not as well as it should, and it came with far more harmful side effects than benefits. What they found was:

  • It does NOT decreased hospitalization in influenza patients

  • It does NOT decreased risks of complications

  • It makes you vomit (NNTH = 22 in adults, NNTH = 19 in children)

  • It gives you headaches (NNTH = 32)

  • It gives you renal injury (NNTH = 150 for adverse renal event)

  • It makes you go kinda crazy (NNTH = 94 for neuropsychiatric adverse event)

Specifically in children:

  • had NO significant effect in children with asthma

  • had NO significant effect in prophylaxis

  • did NOT reduce otitis media or sinusitis

The only benefit the trial showed was symptoms alleviation by 17 hours in adults and 29 hours in children. Now in children, at least there is a subjective benefit of having to not deal with a fussy child for one additional day. But for adults? A grand total of 0.7 day relief from the flu seems awfully little compared to the very real side effects, but that's just me.

After this exposé was published, predictably providers started backtracking and taking a far more conservative approach to Tamiflu. WHO downgraded the status of Tamiflu on its essential medication list, and Roche is now in the middle of a pretty large lawsuit. 

So, have I convinced you that Tamiflu really stinks and no one should use it?

Disembodied voice, offstage: "But Lisa, wasn't there that Lancet paper in 2020 claiming the benefits of Oseltamavir?"

Sigh. Ok, let's review the paper (https://pubmed.ncbi.nlm.nih.gov/31839279/). Performed in Europe, it was a multi-centered open-label randomized control trial. Oseltamavir was prescribed in the primary care setting to relatively healthy patients 1-65 years with the primary outcome being days until symptom recovery. They concluded a decreased in length of illness in patients who took oseltamavir (6.7 --> 5.7 days). Similarly, they did not conclude a decreased rate of hospitalizations or complications, and they also found an increased of side effects such as vomiting and headaches. 

There are a few questions that come up regarding the conclusion of this paper:

  1. This is an unblinded trial, therefore there is a significant placebo effect that may contribute to this conclusion

  2. This study was done in Europe, where flu vaccinations are not as heavily enforced in the general populace as the USA, which may affect symptom presentation

  3. they essentially had the same conclusion! Which was a subjective improvement of symptoms but no objective improvement in hospitalizations or complications

OKAY - I'm stepping off my soapbox. We can now conclude that Tamiflu provides moderate improvement in influenza symptom duration, however it comes with significant side effects and does not reduce serious complications or hospitalizations. While you may know at this point how I feel about Tamiflu, there are many many articles out there, of which many have their own views on the subject. I encourage you all to look up your resources and read the trials and come to your own conclusions.

https://www.bmj.com/tamiflu

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4375804/

https://pubmed.ncbi.nlm.nih.gov/31839279/

https://first10em.com/tamiflu-doesnt-work/

https://journals.lww.com/em-news/fulltext/2017/04000/myths_in_emergency_medicine__still_prescribing.3.aspx

Unstable Pelvic Ring Fractures

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The pelvic ring consists of the sacrum and two innominate bones, which are made up of the pubis, ilium, and ischium. These bones are held together by strong ligaments to give the pelvis stability.

A pelvic ring fracture is a severe fracture with 2 breaks in the circular ring, leading to an unstable pelvis and a potentially unstable patient. Fractures that disrupt the pelvic ring predispose patients to bleeding given the large network of arterial and venous anastomoses. Patients who have an isolated pelvic fracture and are hypotensive carry a mortality of 15-40%. Most vascular injuries in the pelvis are venous (90%). While rare, arterial bleeds (10%) should be suspected when a pelvic binder is placed but the patient remains hemodynamically unstable. The retroperitoneal space can accumulate 4 liters of blood before venous tamponade occurs. Pelvic binders are useful in that they can help tamponade bleeding veins, decrease total pelvic volume, and prevent the shifting of bony fragments.

Other unstable pelvic fractures include lateral compression fractures, "open book" pelvic fractures, and vertical shear fractures. Lateral compression fractures occur when a lateral force vector (t-bone in an MVC) causes an anterior ring disruption and sacral fracture.

“Open book” fractures occur as a result of anteroposterior compression injury to the pelvis, commonly caused by high-speed trauma or elderly falls. There is a disruption to the pubic symphysis and the pelvis opens like a book. Diastasis of > 1 cm (blue arrow) can indicate instability. Disruption of the pubic symphysis, one of the strongest ligamentous structures in the human body, requires a lot of force and should be a red flag to look for other injuries to the head, spine, chest, or abdomen.

Vertical shear pelvic fractures are seen when one-half of the pelvis shifts upward as a result of a fracture of ipsilateral anterior and posterior pelvic ring fractures. They typically occur as a result of high-energy force applied in the axial direction (aka from the gas pedal to the femur and up to the pelvis). Patients may have an unstable pelvis and leg length discrepancy.

For all unstable fractures, you should appropriately resuscitate and stabilize the patient. Give blood as needed but avoid transfusing through lower limb access because it may drain into the retroperitoneal space. If there is a pelvic ring fracture, consider binding the pelvis. Your binder should lay over the greater trochanters and have enough force to close the pelvic ring (video:https://www.youtube.com/watch?v=tWLBZKeWEkg).