ALTITUDE MEDICINE Shawn Dowling Sept 2008 Shawn Dowling Sept 2008.

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Transcript of ALTITUDE MEDICINE Shawn Dowling Sept 2008 Shawn Dowling Sept 2008.

  • Slide 1
  • ALTITUDE MEDICINE Shawn Dowling Sept 2008 Shawn Dowling Sept 2008
  • Slide 2
  • Objectives Discuss basic altitude physiology Discuss basic altitude physiology How to recognize altitude disorders How to recognize altitude disorders Management Management Prevention Prevention Discuss basic altitude physiology Discuss basic altitude physiology How to recognize altitude disorders How to recognize altitude disorders Management Management Prevention Prevention Will not discuss: Subacute/Chronic Altitude Illnesses Cold-related illnesses Altitude-exacerbated illnesses
  • Slide 3
  • High Altitude Illnesses Definition Definition Cerebral (AMS HACE spectrum) and pulmonary (HAPE) syndromes which develop in un- or underacclimatized persons after ascent to high altitude Cerebral (AMS HACE spectrum) and pulmonary (HAPE) syndromes which develop in un- or underacclimatized persons after ascent to high altitude Are often PREVENTABLE and can usually be managed if S/Sx are recognized early and Tx are implemented in a timely fashion Are often PREVENTABLE and can usually be managed if S/Sx are recognized early and Tx are implemented in a timely fashion Definition Definition Cerebral (AMS HACE spectrum) and pulmonary (HAPE) syndromes which develop in un- or underacclimatized persons after ascent to high altitude Cerebral (AMS HACE spectrum) and pulmonary (HAPE) syndromes which develop in un- or underacclimatized persons after ascent to high altitude Are often PREVENTABLE and can usually be managed if S/Sx are recognized early and Tx are implemented in a timely fashion Are often PREVENTABLE and can usually be managed if S/Sx are recognized early and Tx are implemented in a timely fashion
  • Slide 4
  • Moderate Altitude 2400-3000m (8,000-10,000ft)- i.e. Lake Louise/Sunshine Valley 2400-3000m (8,000-10,000ft)- i.e. Lake Louise/Sunshine Valley Minor impairment of arterial oxygen transport (S a O 2 >90%), P A O 2 >60 torr Minor impairment of arterial oxygen transport (S a O 2 >90%), P A O 2 >60 torr Usually not clinically important unless significant underlying medical disorder Usually not clinically important unless significant underlying medical disorder AMS common with rapid ascent above 2500 meters AMS common with rapid ascent above 2500 meters 2400-3000m (8,000-10,000ft)- i.e. Lake Louise/Sunshine Valley 2400-3000m (8,000-10,000ft)- i.e. Lake Louise/Sunshine Valley Minor impairment of arterial oxygen transport (S a O 2 >90%), P A O 2 >60 torr Minor impairment of arterial oxygen transport (S a O 2 >90%), P A O 2 >60 torr Usually not clinically important unless significant underlying medical disorder Usually not clinically important unless significant underlying medical disorder AMS common with rapid ascent above 2500 meters AMS common with rapid ascent above 2500 meters
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  • High Altitude 3000-5500m (10,000-18,000ft) 3000-5500m (10,000-18,000ft) i.e. Mount Columbia (12, 365ft highest point in Alberta) i.e. Mount Columbia (12, 365ft highest point in Alberta) Maximum arterial saturation < 90%; P A O 2
  • Lake Louise Criteria for AMS Presence of a HA in an un-acclimatized person who has arrived at an altitude >2000m (usu >2500m) Presence of a HA in an un-acclimatized person who has arrived at an altitude >2000m (usu >2500m) + 1 of + 1 of GI (anorexia, N,V) GI (anorexia, N,V) Fatigue Fatigue Insomnia Insomnia Dizziness/lightheaded Dizziness/lightheaded Sx usually begin between 6-10 hrs but may be as early as 1 hour Sx usually begin between 6-10 hrs but may be as early as 1 hour Presence of a HA in an un-acclimatized person who has arrived at an altitude >2000m (usu >2500m) Presence of a HA in an un-acclimatized person who has arrived at an altitude >2000m (usu >2500m) + 1 of + 1 of GI (anorexia, N,V) GI (anorexia, N,V) Fatigue Fatigue Insomnia Insomnia Dizziness/lightheaded Dizziness/lightheaded Sx usually begin between 6-10 hrs but may be as early as 1 hour Sx usually begin between 6-10 hrs but may be as early as 1 hour
  • Slide 29
  • Pearls Never ascend with symptoms of AMS Never ascend with symptoms of AMS Never leave someone with AMS alone Never leave someone with AMS alone -Letting someone with AMS hike alone is the equilavent of going for a hike in the Kananaskis alone the night of Party at the retreat. Never ascend with symptoms of AMS Never ascend with symptoms of AMS Never leave someone with AMS alone Never leave someone with AMS alone -Letting someone with AMS hike alone is the equilavent of going for a hike in the Kananaskis alone the night of Party at the retreat.
  • Slide 30
  • AMS Pathophysiology
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  • Treatment? Any or Combination Any or Combination Stop, Rest and Continue once Sx resolve Stop, Rest and Continue once Sx resolve Acetazolimide (alone or in combination) Acetazolimide (alone or in combination) Dexamethasone Dexamethasone O2, immediate descent O2, immediate descent Nifedipine Nifedipine + Symptomatic Treatment + Symptomatic Treatment Any or Combination Any or Combination Stop, Rest and Continue once Sx resolve Stop, Rest and Continue once Sx resolve Acetazolimide (alone or in combination) Acetazolimide (alone or in combination) Dexamethasone Dexamethasone O2, immediate descent O2, immediate descent Nifedipine Nifedipine + Symptomatic Treatment + Symptomatic Treatment
  • Slide 32
  • Treatment? Any or Combination Any or Combination 1. Stop, Rest and Continue once Sx resolve 2. Acetazolamide (alone or in combination) 3. Dexamethasone (if severe) 4. O2, rapid/immediate descent 5. Nifedipine 6. + Symptomatic Treatment Any or Combination Any or Combination 1. Stop, Rest and Continue once Sx resolve 2. Acetazolamide (alone or in combination) 3. Dexamethasone (if severe) 4. O2, rapid/immediate descent 5. Nifedipine 6. + Symptomatic Treatment
  • Slide 33
  • Treatment Options of AMS Stop and rest at altitude that Sx 1 st develop +/- Acetazolamide -> May proceed once Sx abate Stop and rest at altitude that Sx 1 st develop +/- Acetazolamide -> May proceed once Sx abate + Tx Sx + Tx Sx Nausea: Prochlorperazine 10mg po/im (stimulates HVR) Nausea: Prochlorperazine 10mg po/im (stimulates HVR) HA: Tylenol/NSAIDs HA: Tylenol/NSAIDs Insomnia: acetazolamide 125mg PO QHS Insomnia: acetazolamide 125mg PO QHS Stop and rest at altitude that Sx 1 st develop +/- Acetazolamide -> May proceed once Sx abate Stop and rest at altitude that Sx 1 st develop +/- Acetazolamide -> May proceed once Sx abate + Tx Sx + Tx Sx Nausea: Prochlorperazine 10mg po/im (stimulates HVR) Nausea: Prochlorperazine 10mg po/im (stimulates HVR) HA: Tylenol/NSAIDs HA: Tylenol/NSAIDs Insomnia: acetazolamide 125mg PO QHS Insomnia: acetazolamide 125mg PO QHS
  • Slide 34
  • Treatment of AMS Mild Symptoms Mild Symptoms Does not need descent if mild Sx and constant supervision Does not need descent if mild Sx and constant supervision Stop ascent until better Stop ascent until better Acetazolamide (250 BID) Acetazolamide (250 BID) Tylenol/ASA for Sx Tylenol/ASA for Sx Anti-emetic PRN Anti-emetic PRN Consider O 2 at 1-2 LPM Consider O 2 at 1-2 LPM Moderate or Unresolving AMS Moderate or Unresolving AMS Descent 500 m Descent 500 m Consider: Consider: O 2 at 1-2 LPM O 2 at 1-2 LPM Hyperbaric therapy Hyperbaric therapy Dexamethasone 4mg PO q6h until able to descend Dexamethasone 4mg PO q6h until able to descend May ascend after symptoms resolve May ascend after symptoms resolve
  • Slide 35
  • If someone is getting worse, go down at once If someone is getting worse, go down at once If Sx of HACE are present DESCEND IMMEDIATELY If Sx of HACE are present DESCEND IMMEDIATELY If someone is getting worse, go down at once If someone is getting worse, go down at once If Sx of HACE are present DESCEND IMMEDIATELY If Sx of HACE are present DESCEND IMMEDIATELY
  • Slide 36
  • Quick word about Acetazolamide Whats the MOA? Whats the MOA?
  • Slide 37
  • Quick word about Acetazolamide Whats the MOA? Whats the MOA? Causes a bicarb diuresis by inhibiting Carbonic Anhydrase at the kidney Causes a bicarb diuresis by inhibiting Carbonic Anhydrase at the kidney This leads to a metabolic acidosis which counteracts the alkalosis from hyperventilation This leads to a metabolic acidosis which counteracts the alkalosis from hyperventilation Allowing an individual to have a better HVR and therefore acclimatize better Allowing an individual to have a better HVR and therefore acclimatize better Which allergy must you ask about? Which allergy must you ask about? Whats the MOA? Whats the MOA? Causes a bicarb diuresis by inhibiting Carbonic Anhydrase at the kidney Causes a bicarb diuresis by inhibiting Carbonic Anhydrase at the kidney This leads to a metabolic acidosis which counteracts the alkalosis from hyperventilation This leads to a metabolic acidosis which counteracts the alkalosis from hyperventilation Allowing an individual to have a better HVR and therefore acclimatize better Allowing an individual to have a better HVR and therefore acclimatize better Which allergy must you ask about? Which allergy must you ask about?
  • Slide 38
  • Pt adamant that the HA is from dehydration Pt adamant that the HA is from dehydration Can give Dx/Tx of 1L of fluid + advil or tylenol if this completely resolves HA, not likely to be AMS Can give Dx/Tx of 1L of fluid + advil or tylenol if this completely resolves HA, not likely to be AMS Pt adamant that the HA is from dehydration Pt adamant that the HA is from dehydration Can give Dx/Tx of 1L of fluid + advil or tylenol if this com