altitude illness usafp winegarner
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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
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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.
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Mt Washington, NH
Altitude 6288ft
Flickr by Paul-W CC by 2.0
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Mt Baker, WA
Altitude 10786 ft
Flickr by jcurtis4082 CC by 2.0
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Mt Rainier, WA
Altitude 14417 ft
Flickr by OneEighteen CC by 2.0
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Annapurna I, Nepal
Altitude: 26,545 ft
Flickr by twiga269ॐ FEMEN CC by 2.0
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• 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
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• 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
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• 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
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AMSHACE
HAPE
Flickr by Andrew-Hyde CC by 2.0
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• 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
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AMS
HACEHAPE
Wikimedia commons/CC-BY-SA-3.0
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• 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
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• 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
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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
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• 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
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• 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
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AMS
HACEHAPEImages from Deitez, T. High-altitude-medicine.com, http://www.high-altitude-medicine.com/hyperbaric.html
Last modified 26-Apr-2001
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• 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
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Images from: Maggiorini M et al. Circulation. 2001;103:2078-2083
Copyright © American Heart Association, Inc. All rights reserved.
AMS
HACE
HAPE
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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
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• 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
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• 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
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• Slow, graded
ascent
• Nifedipine SR 30 mg qD
• Sildenafil 50
mg
q8h
• Tadalafil 10 mg BID
• Salmeterol 125 mcg
BID
AMS
HACE
HAPE
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• 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
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QUESTIONS?
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• 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
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• 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
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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
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• 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
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• 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
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• 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
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• 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
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