Download - High Altitude Medical Problems
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High Altitude Medical Problems
Resident RoundsGarth Smith R3Feb 25, 2010
thanks to Shawn Dowling, Chris Hall
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Objectives
• Review some physiology and terminology
• Recognition, Treatment, Risk Factors, and Prevention of High Altitude Syndromes
• high altitude decompression of airplanes
• secretly make use of the Gas Laws
• Not covering Illnesses Aggravated by High Altitude, hypothermia, trauma, frostbite, avalanches, lightning
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Case 1
• 24y male trekking with friends
• 20-night trek including a pass @ 5,400m
• During 8th day c/o headache at dinner (4,000m)
• Has poor sleep but awakes feeling well enough to continue
• Continues hiking and by mid-morning has H/A again and has vomited twice (now at 4,150m)
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Case 2
• 20yo male porter
• Camped at 4,930m after crossing a steep, technical pass at 5,120m and awoke with significant exercise intolerance and a cough
• Descended with the group and camped at 3,800m feeling significant improvement
• The following morning had severe dyspnea at rest; was unable to carry his load
• Arrives at a volunteer clinic being carried by his colleagues; resting O2 sat 48% on room air
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Summary
• go up slow, sleep low, take it easy, consider taking meds prophylactically if at risk
• if kinda sick: find a friend, rest, don’t ascend, and consider meds. ascend when no symptoms.
• if sick: find a friend, descend, and use meds.
• if really sick: a friend will find you, they will get you down fast, and they will use meds on you.
• oxygen is good. portable HBOT is wise.
• the mountain will be there tomorrow.
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What mtn am I on?
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How high is high?intermediate1500-2500m
high 2500 - 4200m
very high 4200 - 5500m
extreme >5500m
“dead zone” >7600m
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Who wrote this book?
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Who is this guy?
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What’s the problem• High altitude is a
hypoxic environment!
• hypoxia is bad
• we need oxygen to live
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What is the concentration of oxygen at sea level? 5000m above sea
level?
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both have 21% O2 but I’d get more O2 on the
right if delivered at twice the pressure
Hey...we just used the ideal gas law
same volumesame temp
same concentration but twice the mass
= ? x pressure
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Gas Laws
• Boyle’s Law
• Dalton’s Law
• Henry’s Lawthe solubility of a gas in a liquid at a particular temperature is proportional to the pressure of that gas above the liquid
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Hypoxia
• Partial pressure of oxygen decreases as a function of the barometric pressure
Hey...we just used Dalton’s law!
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What SaO2% or PaO2 makes you worried?
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What’s the problem
• High altitude is a hypoxic environment because of hypoxemiaAltitude (m) Barometric Pressure
(mmHg)PaO2 (mmHg) SaO2% PaCO2 (mmHg)
sea level 760 90-95 96% 40
1500 640 75-81 95% 36
2300 580 69-74 93% 32
4500 445 48-53 86% 25
6000 370 37-45 76% 20
7600 300 32-39 68% 13
8900 252 26-33 58% 10
Hyp
oxem
ia
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If PaO2 is halved when Barometric Pressure is doubled, why isn’t SaO2%
halved?
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75
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Below what Osat would someone rapidly deteriorate and become
unconscious?
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75
60
8900 252 26-33 58% 10
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Why is the pressure lower at altitude?
Pressure = force / area
more mass = more force = more pressure
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What happens when you are exposed to low
PiO2 • increased ventilation
• make more blood
• diuresis
• ↑sympathetic tone
• ↑pulmonary pressure
improve arterial and cellular oxygenation
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Ventilation
• hypoxic ventilatory response (HVR)
• effected by the carotid body - senses ↓paO2
• resp center in medulla ↑RR
• effected by chronic hypoxia, ETOH, resp suppresants (benzos, opiods)
• culminates after 4 -7 d
• central chemoreceptors reset to progressively lower PCO2
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Acclimatization
• The process by which individuals gradually adjust to hypoxia and enhance survival and performance
• Complex adaptation by essentially every system to minimize hypoxia and maintain cellular functions despite decreased PiO2
• Given sufficient time most people can acclimatize to 5500m, beyond that progressive deterioration occurs
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Definition• “high-altitude illness” (HAI) is used to describe
the cerebral and pulmonary syndromes that can develop in unacclimatized persons shortly after ascent to high altitude.
HAPEAMS → HACE
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Pathophysiology
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Name 4 risk factors for the development of HAI
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Risk factors
• fast ascent, high altitude reached, high sleeping altitude
• a history of HAI
• residence at an altitude below 900 m
• physical exertion, cold
• preexisting pulmonary hypertension, low hypoxic ventilatory response and low vital capacity
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Epidemiology
• age has little influence on incidence but persons >50 may have some protection
• physical fitness has no bearing on susceptibility to HAI
• women are equally at risk for AMS/HACE but less susceptible to HAPE
• HAI is reproducible in an individual on repeated exposures; suggesting some unknown genetic risk factors
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I’ll never see that...Study Group # at Risk per
YearSleeping Altitude
% AMS(# affected)
% HAPEor HACE
Western USAVisitors
40 Million 2400-2800 meters
15 (6 million) .01(4000?)
Mt. EverestTrekkers
6,000 3000-5200 meters
35 (2100) 1.0 (60?)
Mt. McKinleyClimbers
1,200 3000-5300 meters
30 (300) 2-3 (25-35)
Mt. RainierClimbers
9,000 3000 meters
67 (6000) ?
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AMS → HACE
• Acute Mountain Sickness (AMS) and High Altitude Cerebral Edema (HACE) are considered a spectrum of the same pathophysiological process
• HACE is the end-stage of AMS.
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what three criteria must be met in all cases of AMS?
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AMS
Lake Louise Consensus Group says
AMS is
1) headache in
2) unacclimatized person
3) at altitude >2500m
4) plus one or more of: GI symptoms, insomnia, dizziness, lassitude, or fatigue
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HACE
• defined as the onset of ataxia, altered consciousness (drowsiness is commonly followed by stupor), or both in someone with acute mountain sickness or high-altitude pulmonary edema.
• In those who also have high-altitude pulmonary edema (HAPE), severe hypoxemia can lead to rapid progression from acute mountain sickness to high-altitude cerebral edema.
• The cause of death is brain herniation.
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AMS → HACE Pathophysiology
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Name 4 classes of medications used in the treatment of AMS → HACE
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Prophylaxis
• ASA 325 Q4 x 3 dose (HA only)
• Acetazolamide 125-250 BID
• slow ascent
• meds not for everyone (risk of unknown sulfa allergy)
• consider if prev history of AMS at low/mod altitude, or forced rapid ascent (flying to high elevation)
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Treatment
Mild Symptoms of AMS
•Does not need descent if mild Sx and constant supervision
•Stop ascent until better
•Acetazolamide (250 BID)
•Tylenol/ASA/NSAID for HA
•Anti-emetic PRN
•Consider O2(1-2L)
•May ascend after Sx resolve
•Avoid things that limit HVR
Moderate or Unresolving AMSDescend 500 m, if not possibleO2 at 1-2 LPMHyperbaric therapyDexamethasone 4mg PO/IV/IM q6h
•Acetazolamide (250 BID)May ascend after symptoms resolve
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Treatment
HACE
•Initiate immediate descent or evacuation
•if descent is not possible, use a portable hyperbaric chamber
•administer oxygen (2 to 4 liters/min)
•administer dexamethasone (8 mg orally, intramuscularly, or intravenously initially, and then 4 mg every 6 hr)
•administer acetazolamide if descent is delayed
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Rebound
• Acetazolamide “cures” AMS, discontinuation does not risk rebound of symptoms, unless you climb higher
• Dexamethasone improves AMS→HACE but does not cure it. discontinuation can induce rebound symptoms and clinical deterioration even at constant altitude
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Gamow Bag
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Portable Hyperbaric Chamber
• pronounced “Gam-Off”, Dr. Igor Gamow
• Lightweight (14.9 lb), costly ($2400US)
• Manually pressurized
• Generate 100mm Hg above ambient pressure
• Simulates descent of 1,500m at moderate altitudes
• After short course of treatment patient often able to descend on their own
• duration - AMS - 2 hrs, HAPE - 4hrs, HACE - 6hrs
• This is primarily a temporizing measure - Not an alternate to descending
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What’s the problem
Altitude (m) Barometric Pressure (mmHg)
PaO2 (mmHg) SaO2% PaCO2 (mmHg)
sea level 760 90-95 96% 40
1500 640 75-81 95% 36
2300 580 69-74 93% 32
4500 445 48-53 86% 25
6000 370 37-45 76% 20
7600 300 32-39 68% 13
8900 252 26-33 58% 10
Hyp
oxem
ia
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Dr. Gamow’s father George was a famous physicist. What did theory did he co-
author
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How does acetazoladmide help with AMS → HACE?
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AMS → HACE Pathophysiology
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How does dexamethasone help with AMS → HACE?
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AMS → HACE Pathophysiology
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Myths
• Coca leaves for Machu Picchu
• Ginko Baloba helps/prevents
• overhydration prevents
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HAPE
• High Altitude Pulmonary Edema (HAPE)
• this is the killer - accounts for most deaths from high-altitude illness
• commonly strikes the second night at a new altitude (sneaky)
• rarely occurs after more than four days at a given altitude
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Diagnosis
• Early diagnosis is critical.
• In the proper setting, decreased performance and a dry cough should raise suspicion
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Diagnosis
≥2 symptoms:
•Dyspnea at rest
•Cough
•Weakness or decreased exercise performance
•Chest tightness or congestion
≥2 signs:Central cyanosisAudible crackles or wheezing in at least one lung fieldTachypneatachycardia
•fever
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HAPE Pathophysiology
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Treatment
• Increasing alveolar and arterial oxygenation is the highest priority
• descent and supplemental O2
• Medication is necessary only when supplemental oxygen is unavailable or descent is impossible
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Medications
Prevention
•Nifedipine ER 30mg PO Q12h
•Salmeterol 1-2p BID
•Acetazolamide 250mg PO BID
•slow ascent, stay warm, avoid ETOH/sleeping pills/narcotics
Temporizing O2, PEEP
•Nifedipine IR 10mg then ER 30mg Q12h
•HBOT
•Salmeterol
•Sildenafil 20mg PO TID
•Acetazolamide
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Case 1
• 24y male trekking with friends
• 20-night trek including a pass @ 5,400m
• During 8th day c/o headache at dinner (4,000m)
• Has poor sleep but awakes feeling well enough to continue
• Continues hiking and by mid-morning has H/A again and has vomited twice (now at 4,150m)
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Case 1
• What is the diagnosis?
• Does this person need to descend?
• What other treatment options are available?
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AMS
• Lake Louise Consensus Group says
• AMS is
1) headache in
2) unacclimatized person
3) at altitude >2500m
4) plus one or more of: GI symptoms, insomnia, dizziness, lassitude, or fatigue
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Mild Symptoms of AMS
• Does not need descent if mild Sx and constant supervision
• Stop ascent until better
• Acetazolamide 250mg PO BID
• Tylenol/ASA/NSAID PRN for HA
• Anti-emetic PRN
• Consider O2 (1-2L/min)
• May ascend after Sx resolve
• Avoid things that limit HVR
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Case 1, part 2
• The patient manages to continue with the group
• Spends the 8th night at 4,600m, occasionally vomits
• On awakening is still unwell but persuaded by his friends to continue
• On arrival at the ‘base camp’ at 4,830m, the patient is too ataxic to continue and seems confused
• His friends are attempting to hire a horse to continue up the pass when you arrive…
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Case 1, part 2
• What is the diagnosis now?
• What would the correct course of action have been on the second morning (4,600m)?
• What adjunctive therapies might help at this point?
• A makeshift clinic is present at the 4,830m camp with a supply of oxygen. Darkness has fallen and the patient is too ataxic to walk.
• How would you approach this problem?
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Case 1, part 2
• HACE
• with unresolving or worsening AMS, should have descended 500m and stopped to acclimatize until symptom free
• now with HACE and descent not possible, he needs O2, dex, acetazolamide and a Gamow bag
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Case 2
• 20yo male porter
• Camped at 4,930m after crossing a steep, technical pass at 5,120m and awoke with significant exercise intolerance and a cough
• Descended with the group and camped at 3,800m feeling significant improvement
• The following morning had severe dyspnea at rest; was unable to carry his load
• Arrives at a volunteer clinic being carried by his colleagues; resting O2 sat 48% on room air
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Case 2
• What is the diagnosis?
• What is the most important treatment?
• What other treatments should also be initiated at this time?
• Helicopter evacuation is impossible and the solar-powered O2 concentrator has been depleted. Evacuation on foot will entail a 35km walk in darkness.
• How would you approach this problem?
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HAPE
≥2 symptoms:
•Dyspnea at rest
•Cough
•Weakness or decreased exercise performance
•Chest tightness or congestion
≥2 signs:Central cyanosisAudible crackles or wheezing in at least one lung fieldTachypneatachycardia
•fever
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Case 2
• He needs to get down ASAP but unadvisable to travel at night...unless ?
• Temporizing measures include O2, PEEP, Nifedipine, HBOT, Salmeterol, Sildenafil, Acetazolamide
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Take Home Points
• high altitude is a hypoxic environment
• any illness at altitude is altitude illness until proven otherwise
• early recognition is key
• never ascend if symptoms of AMS
• if deteriorating, descend immediately
• if unsure, descend. tackle that mountain another day.
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Resources
• Tintinalli. Emergency Medcine.
• Auerbach. Wilderness Medicine.
• Gertsch, J. Randomised, double blind, placebo controlled comparison of ginkgo biloba and acetazolamide for prevention of acute mountain sickness among Himalayan trekkers: the prevention of high altitude illness trial (PHAIT). BMJ. 328;797, 2004
• Hackett, P.H. High-Altitude Illness. NJEM.Vol. 345, No. 2. July 12, 2001
• Sartori, C. Salmeterol for the Prevention of High Altitude Pulmonary Edema. NJEM, Vol. 346, 2002
• Dowling’s Rounds from 2009