If you’re not sure what you’re dealing with, use gloves, gown, face shield, and eye protection.

“Standard precautions” applies to EVERY patient, every time. Most of this is second nature for us, but it doesn’t hurt to review the facts once in a while. This is one of those times.

It all starts with hand washing. We need to wash our hands after every patient contact. No exceptions. If soap and (preferably HOT) water are not available, use a water-based gel product, but get the hands squeaky clean.

In the continuing battle against all things germ-ridden, gloves are second only to hand washing (really, it’s that important!) Gloves are indicated for contact with all body fluids. While most protocols don’t require them for contact with sweat and unbroken skin, it’s a good idea to use them anyway. Bear in mind that just because you were called to treat a possible closed fracture, it doesn’t mean you can ignore the rash on the kid’s chest!

While we’re on the subject, two often-overlooked glove-related issues come to mind: first, latex versus synthetic gloves; and second, the frequency with which you change them.

Latex gloves can cause allergic reactions in those who are sensitive, including both patients and providers. If you’re not sensitive to latex now, remember that it’s never too late: sensitivity may develop over time through frequent contact. Allergic reactions range from localized urticaria to full-blown anaphylaxis. The solution is simple: Synthetic gloves. Use them early and often.

Which brings us to the next point: Gloves should be changed whenever necessary. The Association for Professionals in Infection Control cautions that gloves—especially latex gloves—need to be changed frequently (see their informative pamphlet on the subject at http://www.apic.org/pdf/gloveuse.pdf). If your gloves become soiled or torn, punctured or compromised, dispose of them properly and put on a new pair. Don’t nurture them along.

Masks, eye protection, face shields, and gowns should all be included in standard precautions as needed. Wear them as protection against splashes and sprays associated with frank bleeding or emesis. Wear them during such procedures as intubation, when fluid splashes are predictable.

On the subject of mouthpieces, resuscitation bags, and other ventilation devices, here’s the word on the street: Avoid mouth-to-mask if at all possible. Admittedly, mouth-to-mask is better than no adjunct at all, but there are two problems with it: First, it’s risky. Second, exhaled air contains only 16% oxygen while room air contains 21%. So using a completely isolated adjunct (like a bag-valve-mask) is safer for you and better for your patient.

How germs get around

There are 3 kinds of transmission to worry about: airborne, droplet, and contact. See Table 1 for a list of illness associated with each route.

Table 1. Routes of Transmission

MRSA indicates methicillin-resistant Staphylococcus aureus; RSV, respiratory syncytial virus

*Airborne transmission involves minute infectious particles (smaller than 5 µm), which can hang in the air for extended periods

When you’re dealing with potential infection, the level of protection that’s required depends on the route of disease transmission. Here are the general guidelines:

C       Use standard precautions (gown and gloves) when the presentation involves contact transmission.

C       When the infection may involve droplet or airborne transmission (including aerosolized droplets), add a fitted, sealing N–95 mask or respirator to your other protective garb if there’s any chance you’ll find yourself within 3 feet of patient. Consider putting a mask on the patient as well if you have one available and the patient can (and will) tolerate it.

And as a general rule, whenever you’re dealing with disease entities for which immunizations exist (eg, chickenpox, smallpox, measles), health care providers who don’t have immunity should not approach the patient if immunized health care providers are available!

Which illness is this?

Since you may not be sure which infectious process is present during the initial phases of care (due to an ambiguous history, unfamiliar physical findings, or nonspecific signs), it’s a good idea to err on the side of caution. At minimum, you should be using gloves and a gown. Wear a mask as well any time you’re not sure what you’re dealing with. Table 2 lists precautions and prophylaxis according to the type of presentation.

Table 2. BSI Precautions for Communicable Pathogens

BSI indicates body substance isolation; RSV, respiratory syncytial virus

* Transmission of HIV requires direct, intimate contact (ie, through mucous membranes or broken skin) with an infected patient’s blood, semen, cervical secretions, CSF, or synovial fluid

Some parting thoughts on body substance isolation

1. Do it.

2. If it’s wet, sticky, and/or not yours, don’t touch it!

3. In this age of do-it-yourself bioterrorism, the rules have not changed significantly; only our awareness has changed.

Reference

Recommendations for care of children in special circumstances. In: Pickering LK, ed. 2000 Red Book: Report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2000:84–130,132–133.

Mr Skomorowsky is the paramedic education specialist at the Center for Pediatric Emergency Medicine.