Advances in High Altitude Illnesses
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1 Advances in High Altitude Illnesses Judith R. Klein, MD, FACEP Assistant Clinical Professor UCSF-SFGH Emergency Medicine A bit too high 24 year old on trek to Everest Base Camp Headache, vomiting, severe fatigue Arrives at clinic: 14K feet PE: 170/100, P 110, O 2 78%, RR 18 Tired, oriented, clear lungs, steady gait Differential diagnosis Viral syndrome Meningitis Subarachnoid hemorrhage Carbon monoxide poisoning (floor heaters) Migraine/tension headache Acute mountain sickness (AMS) Objectives AMS: physiology, prevention and treatment HACE: how do you distinguish it from AMS and how do you treat it HAPE: the fascinating physiology and how do you approach prevention and treatment 1
2 Acute mountain sickness (AMS) Increase altitude decrease inspired O 2 Sea level: 100% 3000m: 68% 4500m: 57% 6000m: 47% 8848m (Mt Everest): 33%!! AMS: What s happening in the brain? Hypobaric hypoxia--> cerebral blood flow--> hydrostatic pressure in brain-->edema Inflammatory mediators compromise BBB and neuronal cell integrity Acclimatization to altitude Minutes: RR (resp alkalosis) HR Days: Alkaline diuresis Weeks to months: RBC Production More efficient O 2 use Muscle vascularity Normal symptoms at altitude Exertional fatigue Increased urination Nocturnal awakening/ periodic breathing Odd dreams Dependent edema (particularly women) HAFE 2
3 Quiz: AMS risk factors? A. Age B. Dehydration C. Rate of ascent D. Fatigue/exertion E. Alcohol use F. Prior altitude illness G. Physical fitness AMS risk factors B. Dehydration C. Rate of ascent D. Fatigue/exertion E. Alcohol use F. Prior altitude illness (particularly HAPE) Headache Fatigue Nausea/vomiting Dizziness Poor sleep AMS symptoms 3
4 Descent Rest if mild symptoms Oxygen Fluids AMS treatment: AMS treatment: acetazolamide Mechanism: -alkaline diuresis -central resp stimulant -reduces BBB leakage -anti-inflammatory? Efficacy: better for prophylaxis Dosing: 250mg BID Side effects AMS treatment: dexamethasone Mechanism: -enhances BBB integrity -anti inflammatory Efficacy: lots of evidence Dosing: 8mg load then 4mg q6h DOES NOT FACILITATE ACCLIMATIZATION: do not ascend further on dex AMS prevention Ascend <1500 feet/day over 8000 feet Rest day every 3-4 days Climb high; sleep low Fluids/ carb rich foods Avoid: alcohol, sleeping pills 4
5 AMS prevention Diamox*: - 125mg bid 1 day prior Ibuprofen*: -86pt RCT vs placebo: NNT4-600mg tid same day Dexamethasone: -4mg q12; NNT 2-3 -if unable to take diamox or NSAID Gingko? Coca? Sumatriptan? Gabapentin? I think she s hit the bottle.. 32 yo female trekking in Annapurna, Nepal HA, vomiting at 15 K feet Ascends 17K pass Stumbling, unstable gait, agitated, resisting assistance Differential diagnosis Stroke Drug/alcohol intoxication Subarachnoid hemorrhage Meningitis High Altitude Cerebral Edema (HACE) HACE: diagnosis Signs: Confusion and ataxia Time from onset-->death in as little as 6 hours Treatment: -DESCENT -Dexamethasone and oxygen to temporize -Gamow bag 5
6 He s gotta stop smoking.. Differential diagnosis 42 year old Italian mountaineer at 14K feet c/o SOB at rest, cough Similar episode in Alps RR 28, O 2 70%, T nl PE: scattered crackles Pneumonia Pulmonary embolus Pneumothorax Congestive heart failure (CHF) High Altitude Pulmonary Edema (HAPE) What causes HAPE? Diagnosis of HAPE *Sartori, Resp Physiol Neurobiol 2007 Text Early: -cough -reduced exercise performance/doe Later: -shortness of breath at rest (hallmark) -orthopnea -frothy sputum Can present without AMS 6
7 Management of HAPE DESCENT (minimal exertion) If delay: Oxygen/Gamow bag Nifedipine 20mg q6hr OR Phosphodiesterase inhibitors (e.g. Sildenafil mg q8) NO diuretics Prevention of HAPE Gradual ascent If prior history of HAPE: Nifedipine: SR 60mg div BID 1 day prior *First line: 64% 10% HAPE Salmeterol: 125 ug BID *tighten endothelial jxn and decrease PA pressure *74 33% reduction in HAPE *high side effect profile Prevention of HAPE If prior history of HAPE: Tadalafil: 10mg BID 1day prior *single small study: 74 10% *can increase AMS risk Dexamethasone: 8mg bid *small study *reduced AMS risk In a nutshell AMS Ascend slowly, take diamox or ibuprofen Go down, take diamox/dex if you have it HACE Confused and ataxic-->descend HAPE Nifedipine or salmeterol if you ve had it DESCEND, nifedipine/viagra if you have it 7
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