TREATMENT GUIDELINESS FOR AMS, HACO & HAPO

“High altitude illnesses” is a term used to define the pulmonary and cerebral syndromes that
develop in unacclimatized low-landers who ascend to higher altitudes. This term encompasses
Acute mountain sickness, high altitude cerebral oedema and high altitude pulmonary oedema
(1). High altitude has been defined by Indian army to be any height exceeding 2700 metres.
The Lake Louise consensus defined high altitude as any height above 2500 m (2) (3).
Acute mountain sickness and High altitude cerebral oedema share a common
pathophysiology and may considered to be at divergent ends of the same disease, with AMS
being the mild form and HACO the most severe form. The mechanism is increased vascular
permeability and subsequent cerebral oedema, leading to raised intracranial pressure that
leads to the symptoms. The evidence to this proposed mechanism of action comes from MRI
images of patients with HACO in whom a T 2 weighted images revealed hyperintensities in
the splenium and corpus callosum (4).
Clinical features of AMS: AMS is a clinical entity with nonspecific symptoms and very
likely to be presumed by the unwary to be caused by other minor illnesses or ‘hang-over’ (5).
The symptoms are headache, anorexia, nausea, vomiting, fatigue, dizziness, and sleep
disturbance, but not all need to be present. Headache is considered to be the cardinal
symptoms and the Lake Louise Consensus mandates the presence of headache to make a
diagnosis of AMS (3). AMS usually develops within 6 to 10 hrs after ascent to high altitude.
However onset in a few cases has been reported as early as one hour and as late as 36 hours.
Physical examination in AMS is usually normal, however a thorough neurological
examination needs to be undertaken with special emphasis on presence or absence of ataxia.
A tandem walk test should be undertaken and patients unable to complete the tandem walk
without falling off the line need to be evaluated for HACO. Any respiratory signs should
prompt a clinician to look for features of HAPO.
Indeed in individuals who have recently ascended to altitudes greater than 2500, presence of
headache in the absence of any other cause should prompt the diagnosis of AMS.
A Lake Louise score has been proposed for diagnosing and stratifying the severity of illness.
It has been reproduced in table 1.
Treatment of AMS: A Lake Louise score needs to be calculated in all cases of AMS. A
score of 03 – 05 is mild AMS whereas scores of ≥ 06 are moderate to severe AMS.
Suggested treatment for mild AMS

1. Rest
2. NSAID’s/Paracetamol for headache
3. Domperidone/Perinorm for nausea/vomiting

Moderate to severe AMS (LL score ≥ 06 )

1. Symptomatic therapy as for mild AMS

2. Tab Acetazolamide 250 mg BD
3. Oxygen @ 1-2 Lpm

Most cases of AMS are self-limiting and symptomatic treatment with rest, oxygen inhalation
at 1 -2 L/min and tab paracetamol/NSAID should suffice. Tab acetazolamide 250 mg BD has
been proven to help in cases of AMS.
No further ascent should be permitted until all the symptoms of AMS have resolved (6).
Patients of AMS should be monitored for development of confusion, ataxia for any focal
neurological deficit, in which case they should be labelled and treated as case of HACO.
Clinical features of HACO: HACO is diagnosed in cases that fulfil criteria for AMS and
have any neurological deficit (altered sensorium and/or ataxia). Cases of HACO may at times
present without previous history of AMS when it develops very rapidly at higher altitudes.
Focal neurological deficit may also be present. Reversible cranial nerve deficits in form of
facial nerve paresis are common. Fundus evaluation may reveal blurring of disc margins and
may sometimes reveal papilledema.
MRI if available may reveal T2 hyperintensities in splenium and corpus callosum, though it is
not required for diagnosis. It remains a clinical diagnosis and should be actively sought out in
all cases diagnosed as AMS.
Treatment of HACO: HACO is a life threatening condition and requires emergent
management.

1. The treatment of choice is rapid descent. Even a descent of 1000 m could be life-
saving.
2. The patient should be started on oxygen inhalation 6 L/min.
3. Inj Dexamethasone 08 mg iv stat followed by 04 mg every 06 hrs.
4. Compression bags are also useful and can be used in case immediate evacuation is
not possible. A pressure of 2.5 psi of oxygen should simulate a descent of roughly
2000 m (1)

High altitude pulmonary oedema (HAPO): High altitude pulmonary oedema occurs as a
consequence of pulmonary artery hypertension and requires appropriate management. HAPO
occurs in the setting of a recent gain in altitude. Individuals who are well acclimatized to HA
e.g. 03 months stay may still develop HAPO in case of sudden unusual exertion. Patients may
or may not give history of preceding AMS. HAPO is a sub-acute condition with initial
symptoms being relatively nonspecific such as dry cough and minimal breathlessness on
exertion. The symptoms progress over the next 24 hr and may go on to develop breathlessness
at rest and haemoptysis.
Clinical examination usually reveals tachypnoea, tachycardia and central cyanosis. Portable
SpO2 monitors are quite useful to monitor the oxygenation status of the individual and are
recommended at the point-of-care.
Chest auscultation reveals mid to late inspiratory crackles in the lung bases. The lung finding
are mostly bilateral, and may just as commonly be appreciated unilaterally. Wheeze may
occasionally be present.
Diagnosis is clinical and should be the first differential in any patient who presents with
respiratory symptoms, decreased exercise capacity, decreased SPO2 and bilateral or unilateral
mid to late inspiratory crepitations. Up to 14 % of cases of HAPO have concomitant HACO
and this must be excluded in every case.
Though various attempts have been made to classify the severity of HAPO, they have not
been prospectively studied, nor has treatment been stratified according to severity.
Treatment of HAPO:
The following treatment is recommended.

1. Absolute rest
2. Oxygen inhalation 4 – 6 L/min by face mask
3. Nifedipine 10 mg Sublingual followed by sustained release tab 30 mg 12 hrly.
4. In case of persisting hypoxia consider evacuation. Hyperbaric chambers/HAPO bags
may prove beneficial in buying time prior to evacuation.

The various pharmacological agents and their uses have been tabulated in the table 2 for easy
reference.

Role of Gingko biloba: Gingko biloba is a popular supplement used for prevention AMS. It
role was also supported by a few small trials and a lot of anecdotal evidence. A randomized
control trial was conducted where gingko biloba was compared against acetazolamide and
placebo. In this trial that studied 614 healthy trekkers, Gingko biloba fared as well as or as
worse as the placebo and performed worse than acetazolamide (7). In view of this study the
use of Gingko biloba supplements for prevention of AMS should be discouraged.
Table 1. Lake Louise Consensus Score for AMS

Symptoms     Score  Definition  

AMS  self  assessment  Questionnaire:  

0   None  at  all  

1   Mild  headache  
1.  Headache  
2   Moderate  headache  

3   Severe  headache  

0   Good  appetite  

2.   1   Poor  appetite  
Gastrointestin 2   Moderate  nausea  or  vomiting  
al  symptoms  
Severe,   incapacitating   nausea   or  
3  
vomiting.  

0   Not  tired  or  weary.  

3.  Fatigue   1   Mild  fatigue/weakness.  
and/or  
weakness   2   Moderate  fatigue/weakness.  

3   Severe  fatigue/weakness,  incapacitating.  

0   Not  dizzy.  
4.  Dizziness  /   1   Mild  dizziness.  
light-­‐
headedness   2   Moderate  dizziness.  
3   Severe  dizziness,  incapacitating.  

0   Slept  as  well  as  usual.  

5.  Difficulty  in   1   Did  not  sleep  as  well  as  usual.  

sleeping   2   Woke  up  many  times,  poor  night's  sleep.  

3   Could  not  sleep  at  all.  

Table 2: Medications used in High Altitude illness

ILLNESS MEDICATION PREVENTION TREATMENT

AMS Mild ACETAZOLAMIDE(ORAL) 125 mg BD/250 Brufen/paracetam

mg SR OD ol
AMS Mod- Anti-emetics
Severe 125BID/ 250mg 250MG BID
SR OD
HACO DEXAMTHASONE(ORAL,IM,IV 2MG Q6H OR 8-10MG INTIAL
) 4MG BID DOSE THEN
4MG Q6H
HAPO NIFEDIPINE ORAL 20-30 MG 10 MG INTIAL
EXTENDED DOSE SL THEN
RELEASE BID 20-30MG
EXTENDED
RELEASE BID

References:

1. Hackett P, Roach R. High-Altitude Illness. NEJM. 2001; 345:(2);107- 114

2. Gallagher S.A.,Hackett P.H. High-altitude illness. Emerg. Med. Clin. North Am.
2004;22:329–355.
3. Roach RC, Bärtsch P, Oelz O, Hackett PH, Lake Louise AMS Scoring Consensus
Committee. The Lake Louise acute mountain sickness scoring system. In: Sutton JR,
Houston CS, Coates G, eds. Hypoxia and molecular medicine. Burlington, Vt.:
Charles S. Houston, 1993:272-4.
4. Hackett PH, Yarnell PR, Hill R, et al. High-altitude cerebral edema evaluated with
magnetic resonance imaging: clinical correlation and pathophysiology. JAMA.
1998;280:1920 –1925.
5. Schoene RB. Illnesses at high altitude. Chest. 2008 vol. 134 (2) pp. 402-16.
6. Basnyat B, Murdoch DR. High-altitude illness. Lancet. 2003 vol. 361 (9373) pp.
1967-1974.
7. Gertsch JH, Basnyat B, Johnson EW, Onopa J, Holck PS. 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. 2004 vol. 328 (7443) pp. 797