OSCE: Needlestick Injury

OSCE 5: Needlestick injuries

Scenario Stem:

You are the ED consultant in minors and a security guard has presented post needle stick injury while assisting with the sedation of a patient in the ED. This incident occurred 30 minutes ago and he is awaiting review.

You have seven minutes

Domains assessed:

  • Medical Expertise
  • Professionalism and Communication
Advice for a needle stick scenario:
  1. Thank them for doing whatever it was. I’m sure no one will have done that.
  2. Ask them straight away what’s worrying them and address this.
  3. Explain that you are going to gather more details and then give them a plan.
  4. Form your risk assessment of the situation.
  5. Confirm first aid was given and check tetanus and Hep B status.
  6. Explain there can be local damage that you will examine for, risk of bacterial infection (this will largely be monitoring unless they have a nasty wound and tetanus), and risk of viral infection.
  7. Where possible state the risks and treatment, so in needle stick HIV is 0.3%, Hep C 3% and Hep B 30%.
  8. State whether you think they need PEP and also say that you will confirm this and follow up with the specialists.
  9. You can educate that PEP is most effective if given within 2 hrs but can be given up to 72hrs later. The idea is to get the antivirals into the lymphatics before HIV get there to replicate. The most common regimen in Australasia is Truvada (Emtricitabine/tenofovir) and dolutegravir, both are very well tolerated, it’s only the tenofovir that can cause a declining eGFR and protein loss as well as osteoporosis. These side effects are not likely to impact your patient as they will only be on the treatment for 28 days. Currently Australasia seems to split the difference between a 2 and 3 drug regimen depending on whether the source is HIV positive. The majority of the world uses a 3 drug regimen so keep up to date with national guidelines.
  10. Hep B will be averted by checking their antibody level and if it is low then immunoglobulin will be given and a full booster course over the next 6 months.
  11. Hep C will need to be tested but current treatments if the patient seroconverts are highly effective when started early.
  12. If the patient is extremely worried about HIV you could reassure them that if they are so unlucky and do seroconvert then with current drug regimens people with HIV are now outliving our patients with diabetes. Whatever you want to achieve in life, HIV will not stop you.
  13. Give safe sex advice and check their mental well being, offer some time off work.
  14. Check their understanding and summarise the plan and follow up. (Depending on your ID department the patient will get retested for HIV prior to the decision to stop PEP and then Hep B and C at 3 months and 6 months).
Additional comments on this video:
  • Always good to ask the patient straight up what they are worried about.
  • Could add figures to their risk of HIV (0.3%), Hep C (3%), Hep B (30%). These are a worst case scenario in someone with a viral load.
  • Higher level answers may state the drug names (essentially Truvada and dolutegravir is the easiest to remember and it’s what most of the world is moving towards), duration of treatment (28 days) and potential side effects (Truvada can decrease eGFR and cause a proteinuria but its such a short course – in general these drugs are well tolerated).
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Dr Neil Long BMBS FACEM FRCEM FRCPC. Emergency Physician at Kelowna hospital, British Columbia. Loves the misery of alpine climbing and working in austere environments (namely tertiary trauma centres). Supporter of FOAMed, lifelong education and trying to find that elusive peak performance.

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