Tuberculosis for Certified Emergency Nursing (CEN)

Tuberculosis:

Definition/Etiology:

• Tuberculosis is an airborne disease caused by mycobacterium tuberculosis. Tb can be latent or active.
• The latent infection is contained by the immune system. Latent TB is usually asymptomatic and treated with a variety of regimens.
• Active TB can take many forms, including active pulmonary disease. These patients require aggressive treatment and respiratory precautions.
• TB is passed from person to person via airborne droplets produced from coughing, sneezing and speaking.

Pathophysiology:

The principal mode of spread is through the inhalation of infected aerosolized droplets. The body’s ability to effectively limit or eliminate the infective inoculum is determined by the immune status of the individual, genetic factors, and whether it is a primary or secondary exposure to the organism. The first contact of the Mycobacterium organism with a host leads to manifestations known as primary tuberculosis. This primary TB is usually localized to the middle portion of the lungs. Latent tuberculosis is capable of being reactivated after immunosuppression in the host. A small proportion of people would develop an active disease following first exposure. Such cases are referred to as primary progressive tuberculosis. Primary progressive tuberculosis is seen in children, malnourished people, people with immunosuppression, and individuals on long-term steroid use.

Most people who develop tuberculosis do so after a long period of latency (usually several years after initial primary infection). This is known as secondary tuberculosis. Secondary tuberculosis usually occurs because of reactivation of latent tuberculosis infection. The lesions of secondary tuberculosis are in the lung apices. A smaller proportion of people who develop secondary tuberculosis do so after getting infected a second time (re-infection).

Factors that increase risk:

• Immunocompromise (i.e. AIDS)
• Immigration
• Inadequate infection control (especially communal settings like prisons, nursing homes, etc)

Clinical Presentation:

I know anyone who works in the triage area knows the number one symptom I am going to say that makes us instantly jump to suspicion of TB…. Yup, you guessed it, Hemoptysis. I don’t care what is going on with the patient, if they say they are coughing up blood, its usually instant isolation until proved otherwise.

Now while hemoptysis is one of the symptoms, these patients may also have:

• Chronic cough (2-3 weeks)
• Night sweats, chills, fevers
• Weight loss, anorexia
• Fatigue

Collaborative Management:

With these patients we clearly need some routine lab work. But we all know that one of the definitive tests to check for TB is the Chest X-Ray.

If so ordered, sputum for acid-fast bacilli can also help to diagnose TB.

If TB is confirmed… it’s airborne precautions.

They will probably be started on an aggressive medication regimen to include:

• Isoniazid
• Rifampin
• Pyrazinamide
• Ethambutol

Evaluation | Patient Monitoring | Education:

Evaluation for the ED would center around the airway. Are they maintaining an O2 sat and are in no respiratory distress.

Within that medication list, there is one on there that requires some extra education. With Rifampin, there are some effects which are common, but may seem a bit scary. It can cause temporary discoloration (yellow, reddish-orange, or brown color) of your skin, teeth, saliva, urine, stool, sweat, and tears). This might be something we want to tell the patient.

As well, these medications are not just your standard 7-10 day run. These patients will be on them for months. They will need to have proper follow up and monitoring with a PCP.

Linchpins: (Key Points)

• Airborne Iso
• Long Term Meds
• Chest X-ray