The neuroradiology service of the CHU Gui de Chauliac, in Montpellier, has organized to ensure closely coordinated management, in record time, of ischemic strokes. In addition to a peak technical tray, the whole patient circuit has been redesigned, not to say, revolutionized.
Decide a therapy and start the treatment in nine minutes, shows in hand, after the arrival of a patient in the emergency room. Rather than thirty minutes usually on average. This is the challenge that the emergency department of the head and neck pole (UTEC), at the Gui de Chauliac hospital, knows today. A challenge all the greater as the stroke – 150,000 cases per year in France, including 36 per day throughout Occitania – is the leading cause of dependence and the third cause of mortality in France. “Roughly speaking, when a patient crosses the service door with a suspicion of stroke, we are capable of in this time, to condition it and prepare it for brain imagery, to start a fibrinolysis* in the fifteen minutes and to launch the vascular intervention in the thirty minutes”summarizes Professor Vincent Costalat, head of the neuroradiology department, and the interventional and clinical neuro-radiology medical team.
This article was published in N ° 52 of Actusoins Magazine (April 2024).
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Ischemic stroke: Exit sequential
This record time is obtained here because everything is done in parallel. “The patient does not wait, it’s the big difference”specifies this doctor at the origin of the “revolution” which took place here, in the patient’s circuit and the transmission of information to caregivers. “Previously, we did everything in sequential. »» Step after step: patient identification, boxing, label verification, first consultation to confirm suspicion then neurological examination to establish reality and finally imagery, if it is not busy “Lots of time can flow, or each minute spent, it’s nearly 2 million lost neurons”recalls the professor.
The multidisciplinary care circuit, now makes work together, at the same time, no less than fourteen speakers-doctors, radio manipulators, nurses, nursing assistants, firefighters. The teams are trained. “When the patient arrives at the hospital, the doors of our emergencies are open, everyone is ready”Note Marie-Laure Vabre, “head and neck” emergency environment. A priority: medical imaging, pre -alerted. “The diagnosis is the major element, the scanner must, installed very close to the entrance, is free at the arrival of the patient who goes there, direct!” »» The nurse, with the help of the caregiver, undressing him, conditions him, poses the peripheral venous path; The emergencyist auscults him immediately.
Ischemic stroke: accelerate management
“Such management is played out at three entities, emergency workers, neurologists and neuro radiologists”describes the caregiver who forms a real pair with the radio manipulator health framework. “We share our info, we open possibilities because we discuss. »» Caregivers are all «Ultra Briefs» On this assumption of strokes “Very ritualized”. “We are trying to make what the medical teams dream of: to go very quickly. »» Without ever losing sight of the patient’s ultra secure course.
An optimized course thanks to the work carried out on connections with the pre -hospital (firefighters, SAMU, regulation of calls in the center 15…). One of the missions set by health executives. “It’s not just about improving internally”suitable. All service emergency artists know the cogs of the pre -hospital. Art is, for the one who wins in the center 15, to disconnect from the context of the call – a festive atmosphere in the background, a slightly strong TV, children who have fun, etc. “He must remain very objective, retain keywords”. Delive the Fast score in order to establish the degree of severity and send immediately, the good means to recover the patient. Bring it back to the UTEC as quickly as possible.
All green lights
“At home, we do not redo the balance sheet. We already know that he is most likely in favor of a stroke “indicates Marie-Laure Vabre. “Our job is to have the information that a vector is triggered with a patient. »» During its transport, a call went to the UTEC five minutes before the vehicle arrived. The alert message is already sent, via GSM, by the Strokner (the nurse dedicated to the stroke) to a dozen people- the emergency artist, the radio manipulator, the radiologist, the neuro-radiologist, the anesthesiologist … All the lights are green. “The team has prepared the typical balance sheet, enough to infuse the patient, the kit is close. »»
The intervention for ischemic strokes – the dissolution of the clot by thrombolysis, or, in serious cases, its evacuation by thrombectomy – is decided for two (neuro radiologist and neurovascular doctor). The nurse directly administers, the scanner, the necessary treatment, with the prescribed thrombolytics. Then, the patient goes to the room in operation: an interventional biplane interventional neuroradiology room capable of taking charge of the bass strokes by mini-invasive way, and under real-time radio control. The Montpellier University Hospital, a thrombectomies pioneer since 2009, a European and global referent in the management of brain vascular pathologies, has set up this advanced technique, in 2019. “She has upset the prognosis of serious strokes, allowing patients to regain their autonomy in a large number of cases”says Professor Costalat. The procedure to unclog the brain arteries and reperfuse the brain is faster.
Intervention techniques: thrombectomy
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Mechanical thrombectomy. Thrombectomy, carried out in interventional neuroradiology, consists in recaliting an occluse cerebral artery to the acute phase of an ischemic stroke, using a mechanical device introduced by femoral route. This technique has experienced an exponential development at the Montpellier University Hospital, from 60 cases to more than 500 in ten years (+12 % per year), a hundred of which are perpignan.
- Thrombolysis consists in injecting a thrombolytic to dissolve the clot. This process can be insufficient when the thrombus is too large.
Mesh
“The magic hour, where we are out of the hour and where there are no sequelae, will depend on the type of stroke, the size of the thrombus and the time that we take to remove the clot”Recalls Olivier Martin, radio health manager radio. The ideal scenario. The delivery time is crucial. “Montpellier gets good results because we have created relays to cover the region”observes Vincent Costalat. For ten years, a mesh has indeed developed in Nîmes – a doctor from Montpellier has provided permanence during the week – and Perpignan who has thrombecotomies. “It allows one of the best access rates to mechanical thrombectomy. »» However, there is, according to this head of service, big progress to be made in the network in France, and in the workflow which brings an eligible patient, to benefit from it.
“Fast for Stroke”, Netflix -style pedagogy
A very didactic short film, around thirty minutes was made in Montpellier to raise awareness of the teams. The first part shows all the care errors, loss of time. Then we rewind and we redo everything, as it would be necessary, by showing the role, at each stage, IDE, manipulators, etc. The scenario, imagined by Professor Costalat, says everything. Hospital and pre -hospital staff play their own role there … It is used in particular to train firefighters and paramedics. A second film, from the same vein was made to alert to aneurysm.
https://masterandfellow.com/workflow
*For ischemic strokes. Hemorrhagic strokes do not go through the same sector: the urgency, if the bleeding is important, will be to drain the hematoma which can initiate the vital prognosis. In this case, the solution will be found in the operating room.
Myri lahidels
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