sos a orta a 24/7program foraorticemergencies in« …100-200 type a dissection/y in idf 12 012 km2...
TRANSCRIPT
SOS A ORTASOS A ORTASOS A ORTASOS A ORTASOS A ORTASOS A ORTAA 24/7program forA orticEm ergencies
in« IledeFrance»
SOS A ORTASOS A ORTAA 24/7program forA orticEm ergencies
in« IledeFrance»in« IledeFrance»in« IledeFrance»
P aulACHO U H,M D,P hDP aulACHO U H,M D,P hDP aulACHO U H,M D,P hD
DirectorofT horacicAorticS urgery P rogramEuropeanHospitalGeorgesP om pidou
P aulACHO U H,M D,P hD
DirectorofT horacicAorticS urgery P rogramEuropeanHospitalGeorgesP om pidouEuropeanHospitalGeorgesP om pidou
& P aris-DescartesU niversity,P aris,FranceEuropeanHospitalGeorgesP om pidou
& P aris-DescartesU niversity,P aris,France
Suspected orcon firm ed aorticSuspected orcon firm ed aorticem ergen ciesem ergen ciesem ergen ciesem ergen cies
Acute aortic syndroms Acute aortic syndroms
Complicated or symptomatic aorticaneurysms
Traumatic aortic rupture Traumatic aortic rupture
100-200 type A dissection/y in IDF
12 012 Km2
Mortality 1% / h
12 012 Km2
Pop. 12 millions
200 ruptured AAA /y
Mortality = 48 % ** Meta-analysis of 171 studies since 1955. Brown et al. Br J surg 2002
1500 severe polytrauma patients/ y 1500 severe polytrauma patients/ y
Before SOS Aorta
Cases are scattered around different hospitals
Lower case-volume per hospital …. longer learning
curve …curve …
Multidisciplinary approach is not available in most of Multidisciplinary approach is not available in most of
these hospitals
Before SOS Aorta
No defined contact nor phone number
No dedicated unit
No decisionnal algorythms No decisionnal algorythms
No standardized diagnosis workup or treatment No standardized diagnosis workup or treatment
Loss of time… loss of means …
… loss of lives?
SOS Aorta
01 56 09 25 55: One phone number, dedicated to aorticemergencies, 24/7 (senior physician)
SSPI (Trauma Unit) : One dedicated admission Centre,specialized in dealing with vital emergencies & unstablepatientspatients
On-call senior aortic/CV surgeon, with a dedicated phonenumber 56 09number 56 09
CV-ICU : Dedicated cardiovascular ICU
On-site lifeflights
Multidisciplinary approach cardiovascular surgeon, Multidisciplinary approach cardiovascular surgeon,endovascular surgeon, cardiologists, on-site anesthesist,cardiovascular radiologists…) …
SOS AORTA call 01 56 09 25 55
Pt accepted immediatly & unconditionnally,Pt accepted immediatly & unconditionnally,(unless ethical issues or surgical team unavailable
Surgeon ( 5609)
Admission flow initiated
Surgeon ( 5609)
CV-OR
Emergency CT scan
Pré-admission
Radio follow-up
Arrival of pt Immediate assesment
CV-ORVital emergency
CV-OR
Imaging
Vital emergency« minutes »
Vital emergency« hours »« hours »
Other diagnosisReorientation
Work-up
Diagnosis
Treatment protocoles
SOS Aorte
Prospective registry since Feb 2010
SOS Aorte
• Information campaign to ER mobileunits (SAMU) & ER departmentsunits (SAMU) & ER departments
• Internet for general public &professionnalsprofessionnals
• French television documentary
• « Post-university teaching » sessions
• Oral presentations• Oral presentations
SOS A orte
Nb pts
133
159174
186 180
140
160
180
200
Nb pts
55
84
133
60
80
100
120
140
0
20
40
60
2010 2011 2012 2013 2014 2015 20162010 2011 2012 2013 2014 2015 2016
Impact of SOS Aorta on referral & mortalityImpact of SOS Aorta on referral & mortality
461 patients referred for aortic emergencies over a 6 year-periodperiod
SOS aorte
174 patients 287 patients
20063 yrs
2009 20113 yrs
174 patients 287 patients
Impact of SOS Aorta on referral & mortality
Number pts Before SOS Aorta After SOS Aorta
All aortic emergencies 58±6,6 96±17 p<0,05
Impact of SOS Aorta on referral & mortality
All aortic emergencies 58±6,6 96±17 p<0,05
Type A Dissection 28±3 42±3,6 p<0,05
Type B Dissection 18±3,2 23±5,2 p=0,1
Ruptured aneurysm 10±1,5 21±6,1 p<0,05
Traumatic rupture of the aorta 6±1 9±3,1 p=0,07
Mortality Before SOS Aorta After SOS Aorta
All aortic emergencies 36,4±1,84% 21,6% p<0,01
Type A Dissection 53% 30% p<0,01Type A Dissection 53% 30% p<0,01
Type B Dissection 12% 9% p=0,1
Ruptured aneurysm 50% 23% p<0,05
Traumatic rupture of the aorta 22% 9% p<0,05
Impact of SOS Aorta on referral & mortalityImpact of SOS Aorta on referral & mortality
Before SOS Aorta After SOS Aorta
Mean age 64 y(33-88)
68 y(20-93)(33-88) (20-93)
Hemodynamicinstability
12% 31%instability
Neurologic deficit @presentation
3,1% 6%
Deep hypothermic 45% 62%Deep hypothermiccirculatory arrest
45% 62%
Impact of SOS Aorta on referral & mortality
Geographic distribution of referred cases
Impact of SOS Aorta on referral & mortality
Geographic distribution of referred cases
00Outside IDFOutside IDF
12%
ParisIDF (outside Paris)
28%
11%
0
Paris
Outside IDFOutside IDF
50%37%
IDF (outside Paris)28%
61%
IDF (outside Paris)
BeforeS O S aorta A fterS O S aortaBeforeS O S aorta A fterS O S aorta
SOS A orte
SOS Aorta Registry :2/2/2010 16/08/2016: 900 pts2/2/2010 16/08/2016: 900 pts
• Mean age 66 ans (16-100)• Mean age 66 ans (16-100)
• ♂ 68%
• Unstable 22 %
• Cardiac arrest 5%
(1,8% non recuperated)
• SAPS2 mean 38,3 ± 25,2• SAPS2 mean 38,3 ± 25,2(New Simplified acute physiology score)
SOS A orte
Fin ald iagn osis
Other CVOther CV21%
Non CV12%
Aortic67%
SOS A orte
Fin ald iagn osis
Type Adissection
Type Bdissection
18%dissection
38%
AAAAAA27%
IMH B
PAU1%
DT/TAAA8%
TAR1%
Asc/Arch3%IMH A
2%
IMH B2%
1%
SOS A orte
Geographic distribution
Primary referral (ER Mobile U)Primary referral (ER Mobile U)
Outside IDF2%
Ile de France
Paris51%
Ile de France(Outside
Paris)47%
SOS A orte
Pain
Thoracic44%
Abdominal44%
Abdominal30%
Thoraco-abdominalOtherNo pain abdominal
9%Other
6%
No pain11%
SOS A orte
Neurological deficit
No ND80,3%
Hemiplegia2,8%
Other4,9% 2,8%
Monoplegia3,5%
Paraplegia1,8%Coma
6,6%
4,9%
SOS A orte
Hemodynamics
Stable53%
HTN25%
53%
UnstableUnstable22%
SOS A orte
%
Results
80
100
%
20
40
60
22,9
4.9 7.7 22.442.1
0
20 4.9 7.7 22.4
SOS A ORTA
S urgicaltreatm ent
Surgery duringUrgent surgery
(before nextday)41%
Surgery duringhospitalisation
12%
Delayed41% Delayedsurgery
4%
No surgery
Emergent
No surgery41%
Emergent(under CPR)
2%
Median time to urgent surgery = 54 min
A com plete & m ultid isciplin arym an agem en tm an agem en t
Emergencyservices
CV surgeryCV Rehabilitation
Follow-upAcute management
CV surgery
Aortic
CV Rehabilitation
Blood pressuremanagementCV-ICU
Endovascular team
Cardiovascularradiology
Aorticemergency
management
Vascular Medecine
CV-ICUGenetic counseling
Interventionnalcardiology
INSERMINSERMRESEARCH
UMR 970-PARCC
Nextstep
01 56 09 25 5501 56 09 25 55