altitude illness usafp winegarner

7/25/2019 Altitude Illness USAFP Winegarner

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James Hunter Winegarner, MD

Wilderness and

Austere

Medicine

Fellow

Flickr by Rupert Taylor Price CC by 2.0



Elevations above 1500 m

Moderate 1500

‐2500

m

(4,950

‐8,202’)

High 2500‐4250 m (8,202‐13,953’)

Very High

4250

‐5500

m

(13,953

‐

18,044’)

“Dead

Zone”Extreme 5500‐9000 m (18,044‐29527’)

Leon-Velarde F, Maggiorini M, Reeves J, et al., Consensus statement on chronic and subacute high

altitude disease. HighAltitude Medicine & Biology. 2005. 6(2), 147–157.



Mt Washington, NH

Altitude 6288ft

Flickr by Paul-W CC by 2.0



Mt Baker, WA

Altitude 10786 ft

Flickr by jcurtis4082 CC by 2.0



Mt Rainier, WA

Altitude 14417 ft

Flickr by OneEighteen CC by 2.0



Annapurna I, Nepal

Altitude: 26,545 ft

Flickr by twiga269ॐ FEMEN CC by 2.0



• Ascent to altitude > 2500 m (8200 ft)

• Headache PLUS

at

least

one

of

the

following:• Fatigue or weakness

• Insomnia• Anorexia, nausea and/or vomiting

• Dizziness or lightheadedness

• May occur

<2

hours

after

reaching

high

altitude AMSHACE

HAPE



• Halt further ascent and rest

• Analgesics and

antiemetics

• Acetazolamide (Diamox) 250 mg PO BID

• Dexamethasone (Decadron)

4 mg

PO/IM/IV q6h for severe AMS

• Beware of rebound

• >1 dose

needed

= descend

• Descend for worsening symptoms AMSHACE

HAPE



• Slow, graded ascent

• Acetazolamide 125

mg

PO

BID,

started

24

hours before ascent

• Pediatric dose: 2.5 mg/kg BID

• Dexamethasone 2 mg

PO

q6h

or

4 mg

BID,

started the day of ascent

• Limit of 10 days

• Should not

be

used

in

children

• ?Motrin 600mg PO TID 6hr before ascent AMSHACE

HAPE



AMSHACE

HAPE

Flickr by Andrew-Hyde CC by 2.0



• AMS is common

• Associated with

rapid

ascent

• Prevent with slow, graded ascent

• Prophylaxis significantly

reduces

AMS

• DON’T ascend with AMS!

• May result in HACE AMS

HACE

HAPE



AMS

HACEHAPE

Wikimedia commons/CC-BY-SA-3.0



• Recent ascent to altitude

• Typically

>3000

m

(9843ft)• One report at altitude of 2100 m (6890 ft)

• AMS plus one of the following:

• Ataxia• Altered mental status

• Focal neurologic deficit

• Progression from

AMS

to

HACE

• Usually 1‐3 days, one case in <12hr AMS

HACEHAPE



• AMS symptoms

• Headache,

nausea,

vomiting,

fatigue,

anorexia, insomnia

• Visual changes and papilledema

• Hallucinations• Cranial nerve palsy

• Hemiparesis

/

Hemiplegia• Focal neurologic signs

• Seizures (rare) AMS

HACEHAPE



AMS

HACEHAPE

Image from Hackett PH, Yarnell PR, Hill R, et al: High-altitude cerebral edema evaluated

with magnetic resonance imaging: Clinical correlation and pathophysiology, JAMA 280:1920,1998.

Increased T2 signal in splenium



• Immediate descent with assistance

• Oxygen 2 to

4 L/min

• Dexamethasone 8 mg PO/IV/IM followed

by 4 mg

q6h

• If unable to descend‐ portable hyperbaric

chamber in 1‐hour increments for 4‐6

treatments AMS

HACEHAPE



• Slow, graded ascent

• Acetazolamide 125

mg

PO

BID,

started

24

hours before ascent

• Pediatric dose: 2.5 mg/kg BID

• Dexamethasone 2 mg PO q6h or 4 mg

BID, started the day of ascent

• Not recommended

for

pediatrics

AMS

HACEHAPE



AMS

HACEHAPEImages from Deitez, T. High-altitude-medicine.com, http://www.high-altitude-medicine.com/hyperbaric.html

Last modified 26-Apr-2001



• At least two symptoms:• Dyspnea at rest

• Cough

• Weakness or decreased exercise tolerance

• Chest tightness or congestion

PLUS

• At least two signs:• Crackles or wheezing in at least one lung field

• Central cyanosis

• Tachycardia

• Tachypnea

AMS

HACE

HAPE



Images from: Maggiorini M et al. Circulation. 2001;103:2078-2083

Copyright © American Heart Association, Inc. All rights reserved.

AMS

HACE

HAPE



Normal HAPE

AMS

HACE

HAPE

Image from: Fagenholz PJ, Gutman JA, Murray AF, Noble VE, Thomas SH, Harris N. “Chest Ultrasonography forthe Diagnosis and Monitoring of High-Altitude Pulmonary Edema.” Chest. 2007;131(4):1013-1018.doi:10.1378/chest.06-1864



• Immediate descent of at least 1000M

• Minimize exertion,

keep

warm

• Oxygen, 4 to 6 L/min

• *Consider Dexamethasone 8 mg PO/IV/IM

followed by

4 mg

q6h

*if

there

is

concomitant

HACE*

• If

unable

to

descend‐

portable

hyperbaric

chamber in 1‐hour increments for 4‐6

treatments. AMS

HACE

HAPE



• Nifedipine (Procardia) SR 30 mg PO BID

OR

• Tadalafil (Cialis) 10 mg PO BID

OR

• Sildenafil (Viagra)

50

mg

PO

Q8H

CONSIDER

• Albuterol (Proventil) MDI 2 puffs Q4‐6H

• No furosemide (Lasix) or Acetazolamide AMS

HACE

HAPE



• Slow, graded

ascent

• Nifedipine SR 30 mg qD

• Sildenafil 50

mg

q8h

• Tadalafil 10 mg BID

• Salmeterol 125 mcg

BID

AMS

HACE

HAPE



• HACE and

HAPE

are

potentially

lethal

forms of altitude illness

• Prevention is best – slow, graded ascent

• Descent is mandatory

• Oxygen + portable hyperbaric chamber if

immediate descent

impossible

AMS

HACE

HAPE



QUESTIONS?



• Fagenholz PJ, Gutman JA, Murray AF, Noble VE, Thomas SH, Harris N. “Chest Ultrasonography

for the Diagnosis and Monitoring of High‐Altitude Pulmonary Edema.” Chest. 2007;131(4):1013‐1018. doi:10.1378/chest.06‐1864

• Hackett PH,

Roach

RC.

High

‐Altitude

Medicine

and

Physiology.

Auerbach:

Wilderness

Medicine. 2011; Chapter 1, Mosby, Philadelphia PA

• Leon‐Velarde F, Maggiorini M, Reeves J, et al., “Consensus statement on chronic and subacutehigh altitude disease.” HighAltitude Medicine & Biology. 2005; 6(2), 147–157.

• Luks AM, McIntosh SE, Grissom CK, et al: Wilderness Medical Society consensus guidelines for the prevention and treatment of acute altitude illness, Wilderness Environ Med 21:146, 2010.

• Maggiorini M et al. ”High‐altitude pulmonary edema is initially caused by an increase in

capillary pressure.” Circulation. 2001;103:2078‐2083



• 1 year @ Madigan, Tacoma, WA

• One

slot

for

Family

Medicine

• Operational job prep

• Teach

AWLS

and

DiMMs courses• Work at Crystal Mountain Ski Resort

• Pull shifts in ER and Family Med Clinic

• Allows flexibility and research options



Internationally recognized (WMS, UIAA, IKAR,

ISMM) Twice a year Wilderness Fellows (June and

August)

2 wk classroom

and

hands

‐on

didactics

40+hrs of free CME

Requires:

Level 1 Avalanche course

Guided ascent of glaciated mountain



• 15‐40% of Colorado skiers.

• 40% of Mount McKinley climbers.

• 70% in Mount Rainier climbers.• 70‐100% of people flown directly to 14,000

feet.• Sleeping altitude is critical factor with >20%

incidence above 9,000 feet.

Big Three:

AMSHACE

HAPE



• Rapid ascent.

• Maximum

elevation

achieved.• Sleeping altitude.

• History of previous AMS. **

• Residence at

low

altitude

(<

3,000

ft.).

• Heavy exertion.

• Latitude (increased

distance

from

equator).

Big Three:

AMSHACE

HAPE



• 0.5‐1% of people at high altitude.

• 3.4%

of

people

with

AMS.• Occurs in 13‐20% of patients with

HAPE.

• One series

from

CO

showed

11

of

13

patients with HACE also had HAPE.

• Pure

HACE

without

concomitant

HAPE is uncommon.Big Three:

AMS

HACEHAPE



• Most common at altitudes > 3,000 meters.

• 0.01% of visitors to Rocky Mountains.

• 2% of Mount Denali climbers.• 15% of Indian soldiers air lifted to 5,500

meters.• Typically occurs 2‐4 days after arriving at high altitude.

• 60% recurrence

with

return

to

4,559

meters.

Big Three:

AMS

HACE

HAPE

altitude illness usafp winegarner

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