Ver el código de «Harbor:Non-Occupational Exposure»

==General Guidelines for Harbor-UCLA ED==
*SART candidate if within 96 hours (5d), authorized by law enforcement
*Call LASD to report and find out what PD precinct needs to come take report and approve SART exam
*LASD is your liaison to interact with outside law enforcement, call if issues with timeliness
*Call social work consult, can help with support and resources
*Consult to Violence Intervention Team
*Consult SCAN if patient 17yo and younger
**12yo or older can consent to exam, otherwise parent/guardian consents
**Still need to get pediatric patient to assent/agree to exam
*Psych or disabled patients complicated, work with SART staff/SW
*Forensic Nurse Specialist (SART Staff) available 24/7 at (562) 497-0147 if any questions/issues
* Use the '''ED Sexual Assault''' or '''ED PED Sexual Assault''' order sets
**Draw labs and STI testing in ED
**HIV Antibody/Antigen Screen, Hepatitis B Surface Antigen, Hepatitis C Viral Load-PHL, RPR, Pregnancy test, Urine Chlamydia/Neisseria gonorrhoeae RNA, TMA
**If being consented for HIV PEP, then also need CBC w/ Diff, BMP, LFT
**CCC for lab f/u and NERF through Cerner to bridge to PCP if DHS and doesn't have a PCP. If already empaneled, message PCP. 
**Outside HIV clinics or OOP network PCP
**Pediatric patients can utilize HUB clinic for f/u
*Consider STI prophylaxis, Plan B, Hep B and HPV vaccines, PEP prophylaxis within 72 hours
**Empiric antibiotic therapy
***cefTRIAXone 500 mg, IM
****cefTRIAXone 50 mg/kg, IM, Maximum dose 500 mg
***azithromycin 1,000 mg, Oral
****Pediatric dose: azithromycin 20 mg/kg, Oral, For patients who weigh < 45 kg. Maximum dose 1,000 mg per dose.
***metroNIDAZOLE 2,000 mg, Oral
****Ped dose: metroNIDAZOLE (metroNIDAZOLE 100 mg/mL oral suspension) 15 mg/kg, Oral, TID, X 7 days, mL, 0 Refill(s) For patients who weigh < 45 kg. Maximum dose 666.67 mg/dose or 2,000 mg/day
**Emergency contraceptives
***ulipristal 30 mg, Oral, Form: Tab, ONCE, STAT
* HIV post-exposure prophylaxis (PEP) guidelines
**Do not have to call HIV consult, per Drs. Witt and Wu, unless usual circumstance (e.g. disabled patient unable to swallow pills)
**Per CDC and LAC DHS best practice: only recommended if <= 72 hours since exposure AND
***assailant HIV positive
***assailant HIV status unknown, but patient’s mucous membranes or non-intact skin exposed to 
****blood, semen, vaginal secretions, or bloody body fluids
**Adult dosing:
***emtricitabine-tenofovir (Truvada) 1 tabs, Oral, Indication: HIV/PREP Restricted to HIV post-exposure prophylaxis per CDC guidelines
***raltegravir 400 mg, Oral, Indication: HIV/PREP Restricted to HIV post-exposure prophylaxis per CDC guidelines
** Pediatric dosing: liquid formulations can only be given by our pharmacy. Call ED pharmacist to bring 2 week supply to bedside for patient.
*** zidovudine Liquid, Indication: HIV/PREP Restricted to patients for HIV post-exposure prophylaxis per CDC guidelines. Target Dose: 4 to 9 kg give 12 mg/kg/dose PO BID; 9 to 30 kg give 9 mg/kg/dose PO BID; >= 30 kg give 300 mg/dose PO BID
*** lamiVUDine 4 mg/kg, Liquid, Indication: HIV/PREP patients younger than 12 years or less than 35 kg for HIV post-exposure prophylaxis per CDC guidelines. Maximum dose 150 mg.
***lopinavir-ritonavir (lopinavir-ritonavir 400 mg-100 mg/5 mL) Liquid, Indication: HIV/PREP Restricted to patients for HIV post-exposure prophylaxis per CDC guidelines. Target Dose: < 15 kg give 12 mg-3 mg/dose PO BID (0.15 mL/kg/dose); >= 15 kg give 10 mg-2.5 mg/dose PO BID (0.125 mL/kg/dose). Maximum dose 400 mg-100 mg per dose.
**Need a 2 week prescription and follow up with PEP clinic in 2 weeks for a lab check. Total 4 week course. If afterhours, give 48hr to go pack and 12d rx. OOP patients go to Bella Vida Pharmacy across the street. If peds patient, pharmacy to bring 14d supply bring to bedside. 
**Vaccines
*** Tdap
*** HPV vaccine for female patients age 9-26 and male patients age 9-21. Not required if patient already completed series of 3 vaccines.
****human papillomavirus vaccine (human papillomavirus (HPV) vaccine 9-valent) 0.5 mL, Intramuscular, ONCE
***Hep B vaccines
****Per CDC guidelines, if patient is
*****vaccinated: give hepatitis B vaccine booster (preferably within 24 hours of exposure)
*****unvaccinated: give the hepatitis B vaccine
*****unvaccinated AND the assailant is known to be hepatitis B surface antigen positive: give both hepatitis B vaccine and hepatitis B immune globulin (within 14 days of sexual exposure)
****** AMB hepatitis B vaccine Adult series (Recombivax HB or Engerix-B)
****** hepatitis B immune globulin (hepatitis B immune globulin injectable solution) 0.06 mL/kg, Intramuscular, ONCE, STAT Give in opposite arm from hepatitis B vaccine
*Preserve evidence 
**external GU exams only check for hemorrhage
**obtain dirty catch UA, NPO if oral trauma with possible DNA evidence
***If patient already ate/drank, then doesn't need to be NPO
***If patient is NPO, give Rx for oral medications to take later after SART
**clothes in brown paper bag (not plastic which can degrade DNA, promote bacterial contamination), 
**patient shouldn't wash up, 
**document patient history in quotes
*Discharging
**Give patient copy of labs
**If giving HIV PEP, call ED pharmacist to bring HIV PEP to bedside
***If outpatient pharmacy is closed, then give adult patient limited 48 hour supply of PEP to go and also Rx for 12d supply
***If pediatric patient, then give full 2 week supply to go
**For Rx, give 2 week supply
***If patient is DHS eligible, send Rx to our pharmacy
***If patient is OOP, send Rx to Bella Vida Pharmacy (across the street)
***If pediatric patient, our pharmacy will bring full supply to bedside
**Provide patients with the PEP discharge instructions (includes clinic list) so they may find clinic for follow up.
**Pediatric patients follow up in SCAN and HUB clinics
**Transportation issues - talk to SW and law enforcement
***Law enforcement usually transports to SART
***Might get law enforcement transport home if w/in the area.
***Offer transportation with SW if needed
**Refer to Trauma Recovery Center
*SART does not do labs, can give Plan B and STI prophylaxis only. Does not do PEP or medical work up. 
**Case by case basis can come to hospital for exam
**Prefer that patient's go there for 4 hour exam and evidence collection

*Stats on Risk:  https://www.wikem.org/wiki/HIV_post-exposure_prophylaxis
*CDC Information: http://stacks.cdc.gov/view/cdc/38856.

==Harbor ED Policy==
* DHS Expected Practice for Non-occupational Post-Exposure Prophylaxis (nPEP) for HIV Prevention in Adults and Adolescents age ≥13 [[:File:Non-occupational Post-Exposure Prophylaxis (nPEP) for HIV Prevention in Adults and Adolescents Expected Practice.pdf]]
* LA County Public Health HIV PEP Recommendations:  https://www.wikem.org/wiki/File:SART_-_Public_Health_HIV_PEP.pdf
* Harbor Sexual Assault algorithm and resources: [[Harbor:Sexual assault]]
** Harbor - Detailed "How to" for SART Team:  https://www.wikem.org/wiki/File:SART_ED_Protocol_Recommendations.pdf
*** Preserve all evidence (skin, urine, clothing) and protect chain of custody;  address any life-threatening emergencies as appropriate!
*** Limit detailed documentation of described events to avoid future discrepancies
*** Closest SART Center is in San Pedro. Call sheriffs at Harbor to speak to patient, they will determine precinct in which even happened and contact that local precinct to interview patient and determine if patients meets SART criteria.
*** Forensic Nurse Specialist (SART Staff) available 24/7 at (562) 497-0147;  alt 562-430-6220
**** Los Angeles SART Centers:  https://www.wikem.org/wiki/File:SART_Centers.pdf
**** OLD Resource of SART list  https://emedharbor.labiomed.org/private/Contact%20Info/ED%20Documents/Sexual%20Assault%20Protocol.pdf


* High-risk HIV exposure: shared needles with HIV+ person, or partner or assailant in the case of sexual assault has unknown HIV status, is known HIV+ or highly likely to be HIV+ with a high viral load and the sexual activity was associated with a high risk of transmission, e.g., receptive anal intercourse, sexual assault with vaginal trauma, occurring '''within the prior 72 hours'''.  
**Sexual assault victims should be offered Tenofovir/Emtricitabine (Truvada) 200/300 mg daily plus Raltegravir 400 mg BID and should be referred immediately to a SART center for STI testing and prophylaxis. Can consider offering Plan B contraception if patient is not NPO for evidence collection. 
***If the patient meets these criteria, then first dose of non-occupational PEP gave be given in ED. We are working on a process to give patient's 48 hours of medications to go home with to tie them over until they can get the 28d course needed from a PEP center. 
***For a patient that seeks post-sexual-exposure/non-occupational HIV prophylaxis (nPEP), the patient should also be referred to a PEP center http://getprepla.com/PEP/Get-PEP-Now/ to obtain the additional medications and follow up labs, such as the Los Angeles LGBT Center.  The LA LGBT Gay and Lesbian Center has a program for post-exposure prophylaxis in a number of specific circumstances; patients can be referred within 72 hours of an exposure.  Their hours are Mon-Friday 11am-6pm (telephone number is 323-860-5855, and their website is https://lalgbtcenter.org/post-exposure-prophylaxis).  
***If you happen to see a patient who meets the criteria above, then a baseline rapid HIV should be sent to make sure the patient is not already infected, in additional CBC, BMP, LFTs, Hep screen (Hep A IgG, Hep B sAg, sAb, cAb, and Hep C Ab),  needs to be sent. Tenofovir DF is contraindicated in patients with renal dysfunction (creatinine clearance ≤59 mL/min). For these cases, please consult the HIV or infectious disease team at your site, or the National Clinical Consultations Center’s PEPline at (888) 448-4911

==See Also==
*[[Harbor:Main]]
*[[Harbor:Sexual assault]]

==References==
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[[Category:Admin]]