We will discuss various clinical presentations of concussions and risk factors for prolonged recover

Denham, Daphne W.

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UND Scholarly Commons (University of North Dakota)

Acute Concussion Diagnostics and Treatment:  Case Study ResultsDaphne W Denham, MD FACS FACCWSOne Year Follow Up• What we know about concussions• Our data• What we have learned • FUTURE!Full DisclosureI got some images off of the internet without prior approvalBecause these talks are boring… without picturesMy Background:General Surgery Training 1993-2000Traumatic Brain InjuryIntra-cranial monitorsA pressure sensor is place through the skullto monitor the pressure in the brainWait and watch…RespondHerniation• By about age 2 the skull is closed• Too much swelling of the brain can cause herniation• Death“Standard of care 2017” PROACTIVEpart of the skull is removed to allow room for the brain to swellThink compartment syndromeFDA approved HBOWound Care and Hyperbaric MedicineWARNING:WoundsIn January 2012, ChicagoTeenage girlLeft a party after drinking……36 hours after walking in the snow87 year old with Pyoderma Gangrenosum Less than 1 month--Lesions often open for months to yearsHBOT 2014Cerebral Ischemia HBO TREATmentImprove Oxygen DeliveryEnhance Oxygen ExtractionImprove BBBReduce Brain EdemaImprove MetabolismGlutamate, Glucose, PyruvateInhibit InflammationEnhance Superoxide DismutaseIncrease Deformity of Red Blood CellsBrain InfarctionBrain EdemaBBB breakdownMortalityNeurological DeficitGlutamateCalciumATP depletionDepolarizationMitochondrial DamageOxidative DamageInflammationApoptosisMechanisms of hyperbaric oxygen neuroprotection.  Adapted from Zhang et al., 2005.StrokeConcussionScope of the Problem?Google:  Concussion• More than 3 million/year• “no specific cure”• “rest…allow brain to recover”Weekly / June 22, 2018 / 67(24);682–685But then what?So, if someone has a concussion, how is that treated?June 21, 2018• Dr. Lara DePadilla, Behavioral Scientist, Centers for Disease Control and Prevention• “Well, as I’ve kind of alluded to, there is no one size fits all approach to treating concussion.  Instead, healthcare providers can create a tailored return to activity plan that makes sense with a person’s individual symptoms.  This could include short-term changes to a person’s daily activities, such as wearing sunglasses if they’re having light sensitivity, or maybe allowing for breaks at school if they’re feeling more slowed down than usual.  But as they feel better, they can start to remove these changes and use their symptoms as a guide for how quickly to return to normal activities.”1 in 5 Teens Reports a Concussion“About 20 percent of teens said they have been diagnosed with at least one concussion. And nearly 6 percent said they've been diagnosed with more than one, according to a research letter published Tuesday in the Journal of the American Medical Association.”2018Recovery TimemTBIConsequences• “….social isolation…..harmful effects on their well-being.”640,000 ER visits, 85% mTBI544,000Economic ImpactTREAT a ConcussionIn 2017, “REST”Is the best we’ve got?Currently, no “TREATment.”We have concussion “management.”2018Hyperbaric Oxygen just makes senseConcussionsTREAT with HBOWound of the brainOur ExperienceSince last year’s conference• August 1, 2017 until June 1, 2018• TREAT a Concussion• Still word of mouthAny patient suspected of a concussion Protocol Definitions• Acute---14 days or less• Subacute  everything in between• Chronic 3-6 months with persistent symptomsAcute on Chronic:  acute concussion but patient was still symptomatic from previous concussionRough dataI have not been back through each chart to confirmLast Year • 54 patients• 8 adults --- excluded• 47  patients age 6 -23• 52 concussions• 5 patients had a 2ndconcussion• Gender• 17 females• 30 males• All but 1 patient completely resolved his/her symptoms in our office after hyperbaric oxygen treatment.HBOT 2018•99 patients•4 patients had  2 concussions tx103 concussions (adults removed)•40 females•59 malesGenderPrevious Concussions103 ConcussionsFirst One prior Two prior Three prior Four prior Five prior Six+ prior No data51 21 11 5 0 2 2 1149.5% 20% 10.7% 4.9% 0 2% 2% 11%Mostly first concussionNumber of Treatments Needed1 2 3 4 5 6 7 8 9 1026 28 20 13 6 4 1 3 2 1Average 2.95Photophobia• Has been shown to be a risk factor for increased duration of symptoms• 75 of the 103 concussions (no data on 5)• Average number of treatments 3.1 verses 2.5 if not photophobicFall 2015 startedWhat we have learned in 3 years?Now over 150 acute concussions TREATED1.  We can TREAT concussionsHigh School Senior Football Player• September 2017• Taken off the field on stretcher+LOC• Diagnosed in ER with a concussion• Pediatrician recommended HBO• 2:00 Saturday (less 24 hours) TxWow, I was messed up!“Are you better than what you thought you needed to be?Photo not him2.  Concussed athletes do not appreciate full extent of their injuryThe damaged brain just doesn’t self-report very wellDanger of returning too earlyTREATEDFather emailed me “(Patient) resumed playing after sitting for (2) games and did not have any impairment from the original concussion. School and social activities were back on par after a week. Currently, he is enrolled at (university) as a student-athlete. He is likely to red shirt this season to get his body prepared for the rigors of playing in the Big Ten.”[He did not miss a single day of school.]3.  Can we stop full extent of concussion?What if we start treatment before full progression of concussion?Retrograde amnesiaRisk factor for prolonged recovery• 12 year old male could not remember events 1 hour prior to fall• HBO less 3 hours after injury• 5 treatments • Back in school 1 week after (Monday)• No issues now 3 months outRetrograde amnesia• 12 year old male hockey player, boarded• Appeared to have shoulder injury---off ice, dazed• Coach sent him to locker room• Father got him out of his uniform, drove home• 45 minutes later, took ice pack off his head “What happened?”Concussion mitigated?• 1st HBO five hours after injury• Was back in school by Tuesday, 3 days post-injury• Total of 6 treatments• Worth noting, he had a previous concussion year prior Prevent Concussion Progression30 patients began treatment 1 day or less from injury4.  Can we decrease risk of subsequent concussions?We have had 4 recurrent“1 in 15 players with a concussion may have additional concussions in the same playing season”JAMA November 19, 2003Subsequent ConcussionsTime will tell• One of our “recurrent concussion” patients16 year old, straight A student, couldn’t readPost-concussive syndrome until 15 HBO July 2016Started playing lacrosse May 2017Returned twice less 24 hours after injuryfear of another concussionRecent ACT > 30Celebrate Success?• Concussion experts say:“Normal recovery”“Just relaxation”My favorite:“What Dr. Denham is doing is notokay.”Why is this so hard?“But I can still go, right Mom?”Told by “concussion doctor” that ‘HBO was not helping him and he didn’t need to return’Fargo, North DakotaThank you Gary Tharaldson!• Met January 14, 2018• Less 6 months• Found and built out incredible space• 4 chambers• Room to growVisual Symptoms69-82% of concussed patients• Dr. David Biberdorf will test patients prior to treatment and immediately after HBO.We will haveOBJECTIVE EVIDENCEFuture:• Protocol perfection• MRI pre-season• Eye studies• Can we change the attitude of reporting a concussion• Longer term follow up• Academic performance• Social/emotional• Subsequent concussions• Cost-effectiveCan we afford not to treat?Limbic System• Wikipedia:  system supports a variety of functions including emotion, behavior,motivation, longterm memory, and olfaction.[5] Emotional life is largely housed in the limbic system, and it has a great deal to do with the formation of memoriesVulnerable Areas of the brain with swellingBlack Friday Crowdspeople at the doors get crushedhttps://biofoundations.org/tag/arginine-pyroglutamate/Diffuse brain vascular changesWe CanTREAT a ConcussionAcuteSubacuteAcute on ChronicChronicOxygen + PressureOxygenate tissue—healDecrease swellingTurn off the inflammation

Acute Concussion Diagnostics and Treatment: Case Study Results

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Acute Concussion Diagnostics and Treatment: Case Study Results

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