Hyperbaric Oxygen for Emergency Room Personnel Daphne W. Denham, MD FACS FACCWS Healing with Hyperbarics of North Dakota
• What Is It? • How Does It Work? Hyperbaric • Who Can Benefit? – FDA approved Indications Oxygen • Extras – Non-FDA approved
• I own two hyperbaric clinics – Northbrook, IL November 2015 – Fargo, ND July 2018 I am Biased! • We have multiple different studies • My goal: Standard of Care after Injury
Full Disclosure I got some images off of the internet without prior approval Because these talks are boring… without pictures
What is hyperbaric oxygen? • Breathing 100% oxygen • Increased atmospheric pressure • 1.5 ATA – 3 ATA • Medical grade chambers
What it is not? Soft Chamber = face mask of 100% oxygen http://www.hbomdga.com/hyperbaricvsmildhyperbaricther
What is involved with a treatment? • A patient goes into the chamber • He/she can watch TV/sleep • If you aren’t born with it, it doesn’t go in • No • Paper • Make-up • Bling • Electronics • Etc. Pacemakers, AICDs, implants all need to be approved
HBO is one of the safest procedures/devices Over 1,000 tx given a day in USA Risks: Minimal really • FIRE! • Wear our 100% cotton • Ear drum rupture • Like flying on an airplane • We communicate and stop if necessary • Low blood sugar • Diabetics • Cardiac and pulmonary • Not an issue with athletes • We do a medical clearance Pneumothorax!!
Take a deep breath What bodily process does not need oxygen?
O 2 Diffusion Through Normal Tissue Fluid (Capillary to Cell) Gradient Gradient
What happens when RBCs can’t get to the tissue?
Or RBCs get there too slowly for tissue O 2 demands?
Welcome to the ER
Indications 14 FDA, Many Internationally FDA Approved Internationally Accepted Insurance Covers Insurance Does Not Cover • 1. Air/gas embolism Strokes/cranial trauma/concussion • 2. CO poisoning Poor healing fractures • 3. Gas gangrene Peripheral nerve injury • 4. Crush Injury (compartment syndrome) Viral encephalitis • 5. Decompression sickness Cerebral palsy • 6. Arterial Insufficiency Heart disease • 7. Severe anemia Myocarditis • 8. Intracranial abscess Vertigo • 9. Necrotizing infections Spinal cord injury • 10. Osteomyelitis Ulcerative colitis • 11. Radiation tissue damage Hepatitis • 12. Skin grafts/flaps Psoriasis • 13. Thermal burns (frostbite) Malignant tumors • 14. Sudden hearing loss Multiple sclerosis • Sports Injuries
700-1200% more oxygen
What does it do? Primary Secondary • Decreases edema • Hyper-oxygenates tissues • Decreases reperfusion injury Increase tissue levels of oxygen by 700-1200% • Angiogenesis • Increases circulating stem cells • Increases circulating growth factors
All cells are within the diffusion gradient (range) of a blood vessel
After an injury, cells swell. Vessels occlude. Cell necrosis can occur . Necrotic cell Ischemic cell Damaged blood vessel
With hyperbaric oxygen , tissues have much higher levels of oxygen due to increased diffusion. Necrotic cell Ischemic cell Damaged blood vessel
Hyperbaric Oxygen 64 m 247 m Oxygen gets to ischemic tissue, decreases edema, restores some circulation
What does it do? Primary Secondary • Hyper-oxygenates tissues • Decreases edema • Decreases reperfusion injury Increase tissue levels of oxygen by 700-1200% • Angiogenesis • Increases circulating stem cells • Increases circulating growth factors
Normal Situation Blood Blood Inflow Outflow Filtration = Reabsorption Interstitial Fluid Balance
Trauma or Injury Increased Inflow from Vasodilation Inflow Outflow Filtration > Reabsorption Swelling
Decreased Inflow with Hyperbaric Oxygen ( vasoconstriction ) Inflow Outflow Filtration < Reabsorption 20-30% Reduction in Swelling With improved tissue oxygenation
What does it do? Primary Secondary • Hyperoxygenates tissues • Decreases edema • Decreases reperfusion • Increase tissue levels of injury (inflammation) oxygen by 700-1200% • Angiogenesis • Increases circulating stem cells • Increases circulating growth factors
Prevents Neutrophil Adhesion less swelling/inflammation
What does it do? Primary Secondary • Hyperoxygenates tissues • Decreased edema • Decreases reperfusion injury • Increase tissue levels of oxygen by 700-1200% Angiogenesis Increases circulating stem cells Increases circulating growth factors
Over time, new vessels grow into the tissue, if needed (Important for the older injuries) Stem Cell Necrotic cell Ischemic cell Damaged blood vessel
HBO • Hyperoxygenates tissue • Reduces swelling • Turns off inflammation • Increases stem cells and growth factors • Turns on angiogenesis
Indications 14 FDA, Many Internationally FDA Approved Internationally Accepted Insurance Covers Insurance Does Not Cover • 1. Air/gas embolism Strokes/cranial trauma/concussion • 2. CO poisoning Poor healing fractures • 3. Gas gangrene Peripheral nerve injury • 4. Crush Injury (compartment syndrome) Viral encephalitis • 5. Decompression sickness Cerebral palsy • 6. Arterial Insufficiency Heart disease • 7. Severe anemia Myocarditis • 8. Intracranial abscess Vertigo • 9. Necrotizing infections Spinal cord injury • 10. Osteomyelitis Ulcerative colitis • 11. Radiation tissue damage Hepatitis • 12. Skin grafts/flaps Psoriasis • 13. Thermal burns (frostbite) Malignant tumors • 14. Sudden hearing loss Multiple sclerosis • Sports Injuries
Air or Gas Embolism https://www.cathlabdigest.com/article/Coronary-Artery-Air-Embolism-What-Look-Out-How-Treat-It
CO Poisoning https://orlandohyperbarics.com/carbon-monoxide-poisoning-and-hyperbaric-therapy/
CO Poisoning But even low levels CO and/or repeated CO exposure has been shown to cause long-term neurologic issues Inflammation
Gas Gangrene Clostridium perfringens Anaerobic bacteria Tissue oxygen pressures > 60 mmHg stop alpha toxin production Still need OR debridement and antibiotics
Compartment syndrome
Traumatic Brain Injury Skull---Compartment Syndrome?
TREAT a Concussion In 2019, “REST” Is the best we’ve got? We are taking an aggressive TREAT a Concussion approach Average less 4 tx (acute) No long term consequences Fewer repeat concussion
Indications 14 FDA Air/gas embolism Osteomyelitis CO poisoning Crush Injury (compartment Skin grafts/flaps syndrome) Decompression sickness Radiation tissue damage Arterial Insufficiency Severe anemia Thermal burns (frostbite) Gas gangrene Intracranial abscess Necrotizing infections
Bone (ligaments, tendons) poorly vascularized
Flaps: Ankle replacement
Flaps: Ankle replacement
Delayed Radiation Injury 10,15,20,35,40,55mmHg 50,50,90,120-350 mmHg = 10-20 mm Hg 230 mmHg Baseline at 1.0 ATA During HBO at 2.4 ATA 30,40,55,55,55 mmHg 5,25,35,55,55 mmHg = 10-20 mm Hg After 18 HBO treatments After 24 HBO treatments, oxygen gradients are reduced
Frostbite 10 day follow up
Frostbite: After 1 tx no pain Dying tissue to pink HBO works
Extra So much more HBO can do
Recent Review Article http://www.bestpub.com/images/WCHM_Online/WCHM_Winter_2016.pdf
Concussion • Brain requires high oxygen and glucose levels
Diffuse brain vascular changes
Case 1 • 16 year old lacrosse player took a “shot to the head” • Stopped practice immediately • Within an hour “head was really bothering him, just didn’t feel right.” • Wore his sunglasses to pediatrician the next morning • Headache 7 of 10 • Mental fogginess • AP History test — could not study
Case 1 Treated him Friday midday (less 48 hours) I was out of town over the weekend Treated Monday morning — symptoms resolved, he was able to study Monday afternoon Tuesday morning (didn’t need it really) 4 total treatments
Case 1 Post-injury day 7 had studied for 8 hours Post-injury Day 8 • Took AP History test Test 12:00 pm-4:30 pm “Left the test feeling good” NO HEADACHE PASSED Able to concentrate
2 weeks after injury • Played the entire playoff game • No headache, no return of symptoms • His mom sent me a photo of him drenched with sweat, smiling! (Not this photo) Now 2 years out and no additional concussion
TREAT a Concussion • Over 250 acute • Acute on Chronic – Worse injury • Defined as less than 7 – More treatments days from injury • Chronic • Average < 4 treatments – Some respond quickly • No “new” normal
32 year old Veteran • Multiple suicide attempts • Kept the entire house dark • After 10 treatments More than 40 pills in a single day (recommendation 40) – All shades were up – He was up and fixing his children’s lunches before school.
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