Document pour les gardes Guide la garde concernant les patients hospitalisés en neurologie  

Document pour les gardes Guide la garde concernant les patients hospitalisés en neurologie
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Guide la garde concernant les patients
hospitalisés en neurologie
Aide pratique v 1.0
Service de Neurologie Avril 2021
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avril 21

Page 2
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La neurologie peut faire peur…
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La neurologie peut faire peur…
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Ce qui attendu de vous…
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Faire la visite des patients hospitalisés en neurologie:
- Gérer le flux des soins continus avec l’aide du neurologue de garde et patient
« sortant » identifié en fin de journée par l’équipe de jour
- Poursuite bilan selon dossier
- Régler complications/problèmes nouveaux (souvent « internistique ») durant la
visite
- Faire les entrées selon discussion avec le cadre de gare
- De l’esprit d’initiative et de l’autonomie TOUT en connaissant vos limite
Réagir aux complications ou aggravations neurologiques des
patients déjà hospitalisés avec l’aide du neurologue de garde
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Ce que l’on vous assure…
Une disponibilité pour répondre à vous question en cas de
besoin
Un encadrement et un teaching neurologique lors de la visite du
week-end
Une exposition à des cas intéressants.
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Fonctionnent général
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Les patients de neurologie sont hospitalisés au J1
- 6 lits de soins continus (« Stroke Unit »)
- 16 lits standard
Le neurologue de piquet (un(e) médecin carde ou un(e) chef(fe) de
clinique) est disponible en tout temps au 3 44 55
- Si malheureusement pour des raison technique la déviation ne passe pas, la
réception a le nom et le numéro privé de la personne de garde
- Le neurologue de piquet (le même du vendredi soir au lundi matin) vient le matin des
jours fériés pour faire la visite des soins continus avec vous et est disponible pour voir
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les autres patients qui le nécessitent.
- Le neurologue de piquet est surtout impliqué dans les évaluations des situations
neurologiques urgentes à Sion, la filière cantonale AVC et tout les autres centre du
HVS (y.c SZO), donc parfois très très occupé…
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Fonctionnent général
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Les entrées passent dans la plupart des cas par les urgences où
les patients sont vus ou discuter par le neurologue de garde
avant de monter
Parfois les entrées sont transférées directement depuis:
- d’autres sites du HVS (Martigny, Sierre, SZO): patients vus aux urgences des ces
centres transférés directement pour ne pas surcharger les urgences de Sion
- d’autres hôpitaux:
- CHUV: patients vu aux urgences de Sion, transférés au CHUV pour une thrombectomie
puis renvoyé à Sion patients valaisans rapatriés
- Patients valaisans consultant à Rennaz
- d’autres services à Sion comme les soins intensifs notamment
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Page 8
Pathologies rencontrées
SUVA)
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- AVC
Une majorité des patients hospitalisés souffrent d’AVC
Le parcours habituel de ces patients est:
- Evaluation aux urgences (+/- lyse, +/- transfert au CHUV pour thrombectomie)
- Hospitalisation en stroke unit pour 48-72h
- Surveillance clinique (NIHSS)
- Surveillance rythmique cardiaque pour détection rythme emboligène
- Bilan et mise en place prévention aigue
- Suite hospitalisation en chambre simple pour suite bilan
- RAD ou transfert en rééducation (GER-CHVR, Clinique Bernoise ou CRR-
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Page 9
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Pathologies rencontrées - AVC
Il y a 4 grandes situations d’AVC:
- AVC ischémiques ayant reçu une thrombolyse iv
- AVC ischémiques ayant bénéficié d’une traitement endovasculaire en centre
universitaire
- AVC ischémiques sans lyse ni thrombectomie
- AVC hémorragique
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Page 10
Pathologies rencontrées
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- AVC
AVC ischémiques ayant reçu une thrombolyse iv
- PAS d’antiagrégant ni anticoagulant (y.c prophylactique) durant les 24 premières
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heures
- bottes anti-thrombotique
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- Cible TA:
- En général, mettre en pose tt anti-HTA habituel hormis diurétiques (pour éviter décomp.
cardiaque) et laisser ½ dose de béta-bloquant (pour éviter rebond)
- Utiliser labétol iv selon protocole pour atteindre ces cibles
- Eviter chute trop rapide, surtout si sténose vasculaire pré- ou intra- cérébrales
- Si hypoTA: lit à 0 degré et remplissage NaCl 0.9% 500 cc / 30 min.
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Page 11
Pathologies rencontrées
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- AVC
AVC ischémiques ayant ayant bénéficié d’une traitement
endovasculaire en centre universitaire
- PAS d’antiagrégant ni anticoagulant (y.c prophylactique) durant les 24 premières
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heures
- bottes anti-thrombotique
- CAVE si stent carotidien ou intracrânien antiagrégation rapide nécessaire selon
note de transfert du centre qui a fait la thrombectomie!
- TA et mobilisation idem qu’AVC avec lyse iv.
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Pathologies rencontrées
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- AVC
AVC ischémiques sans lyse ni thrombectomie
- Antiagrégant ou anticoagulant (plus rarement) selon situation discuté dans la note des
urgences ou a discuté avec neurologue de piquet
- En règle générale toujours anticoagulation prophylactique selon fonction rénal (sauf si AC
thérapeutique en place…)
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- Cible TA:
- Cible TA si anticogulation thérapeutique en place:
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- En général, mettre en pose tt anti-HTA habituel hormis diurétiques (pour éviter décomp. cardiaque) et
laisser ½ dose de béta-bloquant (pour éviter rebond)
- Utiliser labétol iv selon protocole pour atteindre ces cibles
- Eviter chute trop rapide, surtout si sténose vasculaire pré- ou intra- cérébrales
- Si hypoTA: lit à o degré et remplissage NaCl 0.9% 500 cc / 30 min.
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Pathologies rencontrées
prophylactique) durant les 48 premières
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- AVC
AVC hémorragique
- PAS d’antiagrégant ni anticoagulante (y.c
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heures
- bottes anti-thrombotique
- Si stable à 48h ½ dose de prophylaxie (p.ex Clexane 20mg)
- Si toujours stable à 72h prophylaxie anti-thrombique standard selon fonction rénale
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- Cible TA:
- Utiliser labétotol iv selon protocole pour atteindre ces cibles
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Pathologies rencontrées
Les infirmier(e)s du J1 ont une grande expérience du patient neurologique… Si on vous
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- AVC
AVC résumé comment réagir
- Attitude définie lors de l’évaluation aux urgences et lors de la visite
- Maintenir cible TA selon situation avec protocole labétolol et/ou remplissage
- Maintenir cible glycémie selon protocole
-
A cas d’aggravation clinique
-
appelle c’est qu’il y a
qqch
(augmentation du NIHSS
2 points)
- En règle général : 2 possibilités soit transformation hémorragique soit nouvel
ischémie
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Prise en charge de l’hémorragie intracrânienne symptomatique après
TIV
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Aggravation NIHSS ≥2 :
- arrêter Actilyse et téléphone immédiat au neurologue (34455)
- Prise de sang immédiate : TP, PTT, plaquettes, fibrinogène
CT et CTA en urgence
Si une hémorragie explique l’aggravation clinique :
- Immédiatement 2U PFC et 1 concentré de plaquettes
- Acide tranexamique : 1g IVD lent sur 10 min. puis perfusion 1g/8h
- Puis maintenir le fibrinogène >1 g/L (norme : 1.6-3.8) et plaquettes >150’000 /mm3
- Consultation neurochirurgicale et hématologique en urgence
Craniotomie pour hématome avec effet de masse: possible si crase et fibrinogène OK et
selon situation clinique
Effectuer un 2° CT pour suivre la taille de l’hémorragie
Bottes anti-thrombotiques, HBPM sc prophylactique ½ dose à 24h, puis dose habituelle à
48h
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Prise en charge de l’aggravation clinique SANS transformation
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hémorragique
Si le CT réalisé après l’aggravation ne montre pas de
transformation hémorragique:
- Il peut s’agir d’un syndrome de menace lacunaire (microangiopathie qui fluctue
avec AVC ON-OFF)
- Il peut s’agir d’un nouvel embole
- Souvent peu de sanction car soit déjà non candidat à la lyse avant ou si vient
d’être lysé, ne pourra pas recevoir une nouvelle dose
- Quoi qu’il en soit
- remettre le patient au lit strict à 0 degré
- s’assurer de la bonne perfusion et cibles tensionnelles du patient
- et si doute discuter la situation avec le neurologue de garde
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Etat de mal épileptique
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Occasionnellement des patients avec un état de mal épileptique ou
une « menace d’état de mal » sera hospitalisé
- La phase très aigu a déjà été discuté aux urgences
- Le patient devrait déjà avoir reçu une dose de benzodiazépine et une autre molécule
- Si le patient a des troubles de la conscience il est en général aux soins intensifs
En cas de récidive de crise et explication claires aux crises:
- Il faut majorer le traitement de fond avec Levetiracetam 30mg/kg, acide valproique 20
mg/kg ou lacosamide 400mg iv selon ce qui a déjà été donné et des comorbidités
- Si les crises se répètent ou si nouvel état de mal clonazépam 1mg + majoration
traitement de fond
- Il est impératif de comprendre pourquoi le patient crise et de s’assurer de l’absence
de cause traitable (métabolique, infectieuse, etc…). Cela devrait être fait avant
l’admission
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Maladie neuro-musculaire avec atteinte respiratoire
Parfois des cas de Guillain-Barré ou Myasthénie seront surveillés au
soins-continus
- La saturation en O2 ou les paramètres de gazométrie sont de très mauvais
marqueurs d’insuffisance respiratoire d’origine neuromusculaire!
- Le meilleur indicateur d’admission aux soins intensif sont une capacité vitale forcée <
20ml/kg, une pression inspiratoire à 30 kPa ou une pression expiratoire à 40 kPa. (a.k.a
« Règle des 20-30-40 »)
- Les infirmier(e) du J1 font ces mesure selon ordre médicale
- Si spiro non disponible, les critères cliniques qui doivent inquiéter et faire considérer un
transfert aux soins intensifs:
- Un patient qui ne peut pas finir ces phrase
- Un patient qui ne peut plus tenir la tête
- Un patient qui ne peut pas compter jusqu’à 20 en une expiration après un inspirium
complet ( = single breath count test)
- Un rythme cardiaque et/ou un profil de TA instable peut être un signe important de
dysautonomie et peut justifier un transfert au SI.
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Ressources (
Tous les recommandations/directives concernant la prise des
AVC se trouvent:
SITE SION (P:) > Neurologie > - Unité cérébrovasculaire (UCV) >
- 02 Urgences et protocole thrombolyse (pour ce qui est de la lyse et ces
complications)
- 03 Unité cérébrovasculaire (pour ce qui est de la gestion des patients admis dans
l’unité cérébrovasculaire)
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