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HIGH ALTITUDE SICKNESS

CLINICAL SYNDROMES
Acute Mountain sickness
High Altitude Pulmonary Edema
Chronic Pulmonary hypertension
High Altitude Cerebral edema
Coronary / cerebrovascular insufficiency
Acute Mountain Sickness
Severity of symptoms as per altitude
Headache, insomnia, disturbed sleep
Nausea, vomiting, giddiness
Palpitations
Fatigue, breathlessness
Disinterest in work, lack of concentration,
depression, muscular weakness, drowsinesss
hangover
Prevention
Acclimatization
Proper fluid intake
Avoid smoking, alcohol, late dinner
AMS SYMPTOMATIC TREATMENT

Headache
Acetaminophen / ASA
Avoid narcotics (decrease HVR)

Nausea
Prochlorperazine (stemetil) 10mg PO /IM
AMS SPECIFIC TREATMENT
Acetazolamide
Prophylactic and curative
Carbonic anhydrase inhibitor
Causes bicarbonate diuresis and metabolic acidosis
Increased ventilation and arterial oxygenation
Dose 250 mg po tid
Dexamethasone
Reduces cerebral edema
Useful if acetazolamide not tolerated
Dose 8mg im/po followed by 4mg im/po q6h
High Altitude Pulmonary Oedema
Risk factors
Rapid Ascent above 3000 m
Physical exertion
H/O AMS or HAPO

Clinical features
Usually < 3 days; rarely up to 10 days
Dyspnoea, cough, palpitation, nausea vomiting,
chest discomfort, blood stained sputum
Cyanosis, tachycardia, hypertension, pulmonary
rales
MANAGEMENT OF HAPO
Evacuation to lower altitude
Oxygen
Recompression in chamber 1 atm X 16hrs
All cases of HAPO/ HACO in portable one man
recompression bag; 150 mm Hg (reduce
altitude by 6000); reduce to 50mm Hg every 5
min; recompress 150mm Hg(ensures air
circulation)
Bring patient out of bag 2 hourly for 15-20 min -
monitoring/ nursing
Diuretics
HAPE - TREATMENT
Stop Ascent!!!
Descend at least 2000 ft unless close clinical monitoring possible

If monitoring possible
Mild Cases
Bed Rest (1-2 days)
Moderate Cases
Bed Rest
Oxygen
HAPE TREATMENT ( CONT )

Severe Cases

Descent (1500 to 3000 feet, may reattempt


ascent
in 2-3 days)
Oxygen 4-6 l / min
Hyperbaric chamber
pharmacological therapy
HAPE PHARMACOLOGICAL TREATMENT
Goals
1. Lower pulmonary artery pressure
2. Lower pulmonary blood volume
3. Lower pulmonary vascular resistance

Nifedipine :10mg sl then 30mg SR bid


Sildenafil : 25-50 mg
Nitric oxide : inhalation of 40 ppm of NO
produces decrease in syst pulm arterial pressure
in those prone to HAPE
Lasix : 40-80 mg orally or IV
Beta agonist inhaler (salmetrol)
HAPE - HYPREBARICTREATMENT

Portable Hyperbaric Chambers


Lightweight (14.9 lb)
Manually pressurized
Generate 103mm Hg (2 psi) above ambient pressure
Simulates descent of 4000-5000 feet at moderate altitudes
Simulates descent of 9000 feet at top of Mt. Everest
After short course of treatment patient often able to descend on
their own
HAPO Bag
High Altitude Cerebral Edema
HIGH ALTITUDE CEREBRAL EDEMA (HACE/ HACO)

Least common but most lethal altitude illness


Usually occurs above 12,000 feet
Symptoms usually develop over 1-3 days
reported range 12 hours to 9 days

Represents end stage of AMS


HIGH ALTITUDE CEREBRAL EDEMA

Diagnostic criteria
presence of change in mental status
and /or ataxia in a person with AMS
Or
presence of both i.e change in mental status
and ataxia in a person without AMS
HIGH ALTITUDE CEREBRAL EDEMA : CLINICAL FEATURES

Global encephalopathy
Ataxia
Altered mentation
Seizures
Occasional CN palsies (due to increased ICP)
Papilledema
Retinal hemorrhage
Coma
Death due to brain herniation
HIGH ALTITUDE CEREBRAL EDEMA
Pathophysiology
Hypoxia induces neurohumoral and hemodynamic responses resulting in
1. over perfusion of microvascular beds
2. elevated hydrostatic pressure,
3. capillary leakage
4. edema
MRI FINDINGS .

Edema of splenium of
corpus callosum
HIGH ALTITUDE CEREBRAL EDEMA

Treatment
Descend 2000 feet and keep descending until symptoms resolved
Supplemental O2 (4-6 l /minute)
Dexamethasone 8mg iv then 4mg q6h iv
Hyperbaric chambers
Chronic Pulmonary Hypertension

> 3600 m for 6 months or more


Etiology unsure
Reverses with return to low altitude

Coronary/ cerebrovascular insufficiency


Stress of hypoxia/ cold
Atherosclerosis
ACCLIMATIZATION SCHEDULE

Stage 1 (2700 3600m) [9000-12000] 6days


Days 1-2 : Rest, short walks, no climb
Days 3-4 : Slow pace walk 1.5-3 km, no steep climb
Days 5-6 : 5 km walk, climb 300m
STAGE 2 (3600- 4500 M) [12000-15000]
4 DAYS

Days 1-2 : slow walk 1.5-3 km, no steep climb


Day 3 : slow walk, climb 300m
Day 4 : 300m climb with equipment

Stage 3 (> 4500m) [>15000] 4days


Same as Stage 2