Upload
doanminh
View
217
Download
4
Embed Size (px)
Citation preview
David A. Connett, DO, FACOFP, dist
Nothing to disclose – including pharmaceuticals
Disclosures
Acute Mountain Sickness (AMS)
High Altitude Cerebral Edema (HACE)
High Altitude Pulmonary Edema (HAPE)
Decompression Sickness (DCS)
High Altitude Syndromes
High Altitude-5,000 feet to 11,500 feet (1500-3500 m) • Highest U.S. ski resorts
• Minor impairment of arterial oxygen transport arterialSaO2> 90%
• AMS common with rapid ascent above 8000 feet
Very High Altitude-11,500 feet to 18,000 feet (3500-5500 m) • High peaks in the lower 48, Europe
• Maximum arterial SaO2 < 90%, PAO2<60 torr
• Most common range for serious altitude sickness
Extreme Altitude-over 18,000 feet (above 5500 m) • Denali, Himalaya, Karakoram, Andes
• Marked hypoxemia and hypercapnia
High Altitude
Oxygen Levels at Altitude
Barometric pressure falls with increasing altitude in logarithmic fashion
Partial pressure of oxygen decreases resulting in hypoxia
Altitude changes with distance from equator, hypoxia worse at the poles.
Pressure is lower in winter than in summer.
Temperature decreases with altitude 1000 feet for every 3.56°F
Ultraviolet light increases by 4% every thousand feet
Environment at High Altitude
Pathophysiology Acute Mountain Sickness
Hypoxic Ventilatory Response (HVR)
Pathophysiology Acute Mountain Sickness
Pathophysiology of HAPE
Components of endothelial activation/dysfunction in acute lung injury (ALI). This schematic cartoon illustrates the components of endothelial activation including
1) Endothelial cell-leukocyte interactions,
2) Endothelial cell-platelet-neutrophil interactions, and
3) Structural changes between endothelial cells. RBC, red blood cell; MLCK, myosin light chain kinases; PASMC, pulmonary artery smooth muscle cell.
Pathophysiology of HAPE
Pathophysiology of HAPE
Acute • Ventilation
• Heart rate
• Cerebral blood flow
• Diuresis increased hematocrit
Chronic • Increase in pulmonary ventilation
• Increase and diffusing capacity in the lung
• Red blood cell count due to erythropoietin
• Metabolism (tissue changes over years)
• Increase in the number of mitochondria
• Augmentation of the cytochrome oxidase system
Factors Increased by Acclimatization
Rapid ascent and exposure to the altitude at the summit of Mount Everest 29,028 feet results in loss of consciousness in a few minutes and death shortly thereafter.
Acclimatization occurs over time
Ability to acclimatize varies from individuals
Just a few days at sea level may make one susceptible to AMS or HAPE
Acclimatization to High Altitude
“Climb high. Sleep low.”
High carbohydrate diet
Mild exercise-avoid exertion
Avoid alcohol and sleeping medications
Other Aids to Acclimatization
In the setting of a recent gain in altitude, there is precedence of headache and at least one of the following: • Gastrointestinal (anorexia, nausea or vomiting)
• Fatigue or weakness
• Dizziness or lightheadedness
• Difficulty sleeping
Lake Louis Consensus definitions of High Altitude Acute Mountain Sickness
Rapid ascent to 8200 feet from altitudes below 5000 feet for unacclimatized
Headache • Throbbing, by temporal or occipital worse at night
Fatigue
Dizziness/lightheadedness
Anorexia and nausea
Difficulty sleeping
Acute Mountain Sickness
Mild Headache
Insomnia
Shortness of Breath while Exercising
May continue climbing
More time for acclimatization
Mild Acute Mountain Sickness
Headache may be severe
Some lassitude
Weakness
Loss of appetite
Nausea
Beginning to lose coordination - ataxia
Begin to descend
Moderate Acute Mountain Sickness
Viral illness
Hangover
Exhaustion
Dehydration
Hypothermia
Sedatives/hypnotic medications
Carbon monoxide
Acute Mountain Sickness Differential Diagnosis
Usually self-limited
If untreated may persist for weeks
May precede HACE or HAPE
Responds well to treatment
Acute Mountain Sickness
In the presence of a recent gain in altitude, the presence of the following: • Two of the following symptoms:
• Dyspnea at rest
• Cough
• Chest tightness or congestion
• At least two of the following signs: • Crackles or wheezing and at least one lung field
• Central cyanosis
• Tachypnea
• Tachycardia
Lake Louis Consensus definitions of High Altitude High Altitude Pulmonary Edema (HAPE)
The most common cause of death from high-altitude illness.
Most often after second night at new altitude
Apparent abrupt onset
May occur in the absence of Acute Mountain Sickness
High Altitude Pulmonary Edema
Early symptoms: fatigue, weakness, dyspnea on exertion, dry cough
Progression to tachycardia, tachypnea, and orthopnea and dyspnea at rest – marked shortness of breath even at rest
Pink or blood-tinged sputum is a very late finding
Crackles usually start in right axilla
May also have headache, lassitude, reduced urine output, peripheral edema and ataxia.
HAPE Symptoms and Signs
Severity Percent Symptoms
Mild 65 Headache, anorexia, nausea and malaise
Moderate 30 Unrelieved headache, vomiting, reduced urine output
Severe 5 Altered consciousness, ataxia, rales, cyanosis, dyspepsia at rest, possible papilledema
Distribution of Symptoms and signs in 154 Trekkers Nepal with AMS
Study Group Number at Risk per Year
Sleeping Altitude (feet)
Maximum Altitude Reached (feet)
Average Rate of Assent (days low altitude)
Percent with AMS
Percent with HAPE and/or HACE
Western State Visitors
30 million 6500 ft. 8000 ft. >9800 ft.
11,500 ft. 1-2 18-20 22 27-42
0.01
Mount Everest
6000 18,000 ft. 1-2 (fly in) 10-13(walk)
47 23
1.6 0.05
Mount Denali 800 20,321 feet 3-7 30 2-3
Mount Rainier 6000 14,409 ft. 1-2 67 -
Indian soldiers Unknown 18,000 ft. 1-2 2.3-15.5
Incidents of Altitude Illness in Various Groups
Can be considered “end-stage” or severe acute Mountain sickness. In the setting of a recent gaining altitude there is either: • The presence of a change in mental status and/or ataxia in a person
with Acute Mountain Sickness
• Or the presence of both mental status changes and ataxia any person without Acute Mountain Sickness
Lake Louis Consensus definitions of High Altitude High Altitude Cerebral Edema (HACE)
Progression of cerebral signs and symptoms of Acute Mountain Sickness • Headache, vomiting
Truncal ataxia (other focal neurologic deficits may also occur)
Severe lassitude
Altered consciousness or coma
Weakness or paralysis on one side of the body
Amnesia or hallucinations
Especially common with High Altitude Pulmonary Edema - Shortness of breath, dry cough
High Altitude Cerebral Edema
Late Symptoms • Ataxia (appendicular to
truncal) • Irrationality • Hallucinations • Visual disturbances • Focal neurological deficits • Abnormal reflexes
Early Symptoms • Headache • Anorexia • Nausea • Emesis • Photophobia • Fatigue • Irritability • Decrease socialization
High Altitude Cerebral Edema
High-altitude retinopathy – maintain good fluid intake to reduce hemoconcentration, spontaneously resolves
Peripheral edema – treat with a diuretic in the absence of AMS, HACE or HAPE; condition spontaneously resolves on descent
Venous stasis and thrombotic complications – stay active keep well hydrated and descend if needed
Altitude pharyngitis and bronchitis – suck on hard candy, brie through a facemask and drink plenty of fluids
Ultraviolet keratitis ( snow blindness) – remove contact lenses, patch affected eye, use oral analgesics to decrease pain; prevented by wearing sunglasses
Other Altitude Related Disorders
# 1 AMS symptoms at altitude are AMS until proven otherwise
# 2 Don’t ascend further if you have symptoms
# 3 Descend if very ill or not improving. Descend immediately for ataxia or decreased consciousness
#4 Don’t let anyone with AMS descend alone
Acute Mountain Sickness Management The Golden Rules
Prevention • Acetazolamide (Diamox) 125 mg twice a day (or 500 mg slow release
daily)
• Start 12 hours before assent
• Continue first day at altitude
Sleep • Acetazolamide (Diamox) 62.5-280 mg at dinner time
Prevention Acute Mountain Sickness
The mainstay of treatment of AMS is rest, fluids, and mild analgesics: acetaminophen (Tylenol), aspirin, or ibuprofen. These medications will not cover up worsening symptoms.
The natural progression for AMS is to get better, and often simply resting at the altitude at which you became ill is adequate treatment. Improvement usually occurs in one or two days, but may take as long as three or four days. • Dehydration is a common cause of headache at altitude. Drink one
liter of fluid, and take acetaminophen or aspirin. • If the headache resolves quickly and totally (and you have no other
symptoms of AMS) it is very unlikely to have been due to AMS.
Descent is also an option, and recovery will be quite rapid.
Treating Acute Mountain Sickness
Stop ascent, rest, acclimatize at same altitude
Acetazolamide, 125 to 150 mg twice a day, to speed acclimatization
Symptomatic treatment as necessary with analgesics and anti-medics or
Descend 1500 feet or more
Treatment Mild Acute Mountain Sickness
Low-flow oxygen, if available
Acetazolamide, 125 two 250 mg twice a day with or without Dexamethasone, 4 mg PO,IM, IV q 6hr
Hyperbaric therapy or Immediate descent
Treatment Moderate Acute Mountain Sickness
0.14 atmosphere (102 torr) above ambient pressure
14,000 feet simulates 8000 feet
CO2 buildup minimal if used properly (and maybe helpful)
Instant Descent Inside a Bag
Minimize exertion and keep warm
Oxygen, 4 to 6 L/min until improving it, then 2 to 4 L/min
Dexamethasone, 4 mg PO,IM, IV q 6hr
Treatment HAPE
Graded ascent
Nifedipine for HAPE susceptibles • 20 mg orally every eight hours or 30 mg every 12 hours-starting 24
hours before arrival and continuing for three days
HAPE Prevention
Tadalafil and Sildenafil
Phosphodiesterase-5 (PDE-5) inhibitors that augment the pulmonary vasodilatory effects of nitric oxide by blocking the degradation of cyclic guanosine monophosphate (cGMP), the intracellular mediator of nitric oxide. Nitric oxide is a potent pulmonary vasodilator and reduces hypoxic pulmonary vasoconstriction (HPV) and pulmonary hypertension in HAPE.
Both Tadalafil and sildenafil have been shown to be effective as prophylaxis for HAPE, but neither has been studied as treatment.
Nevertheless, based upon their mechanism of action, both Tadalafil and sildenafil may be effective adjunct treatments for established HAPE when neither oxygen nor descent is available options. These drugs may have advantages over nifedipine because they lower PA pressure with less risk of lowering systemic blood pressure. The appropriate dose for treatment is unknown but might be similar to that used for prophylaxis (Tadalafil 10 mg by mouth every 12 hours; sildenafil 50 mg by mouth every eight hours).
HAPE Prevention
Dexamethasone 8 mg every 12 hours (also helps to prevent Acute Mountain Sickness)
Tadalafil 10 mg every 12 hours (no benefit for Acute Mountain Sickness)
Salmeterol 125 µg every 12 hours (some benefit for Acute Mountain Sickness)
All regimes start 24 hours prior to assent and continue at altitude
HAPE Prevention
Dexamethasone • Indicated with contraindication to Acetazolamide
• Also used in conjunction with acetazolamide for rapid ascent above 10,000 feet (rescue)
• Dosage 4 mg every six hours
Other Drugs to Prevent Acute Mountain Sickness
Immediate descent or evacuation
Oxygen, 2 to 4 L/min
Dexamethasone, 4 mg PO,IM, IV q 6hr
Hyperbaric therapy
Treatment HACE
Rapid ascent to altitudes over 10,000 feet
Past history of recurrent Acute Mountain Sickness
Treatment of Acute Mountain Sickness
Periodic breathing or poor sleep
Indications for Acetazolamide
Contraindications • Uncompensated left heart failure • Pulmonary hypertension • Sickle cell anemia • Moderate-severe COPD • Seizure disorders
Cautions • History of left heart failure • Cardiac arrhythmias • Cerebral vascular disease • Sleep apnea • Sickle Trait
High Altitude Medical Contraindications/Cautions
Distribution of DCS
Decompression sickness (DCS) results from the formation of nitrogen bubbles in the tissues or circulation as a result of inadequate elimination of nitrogen after a dive.
The formation of nitrogen bubbles may occur following a dive and ascending to high altitudes in a short period of time to include a pressurized commercial aircraft.
Bubbles that form are trapped in the joints called the “bends.”
Bubbles that are formed in circulation may become trapped in the brain or spinal cord resulting in serious neurological compromise or death.
DCS may also occur in very high altitudes with aircraft or spacecraft without a dive to precipitate the response.
Decompression Sickness
Pulmonary DCS
Skin Bends
Inner Ear Decompression Sickness
Limb Bends
Central Nervous System (CNS) DCS
Cerebral Decompression Sickness
Decompression Sickness
Dalton’s Law - in a mixture of non-reacting gases, the total pressure exerted is equal to the sum of the partial pressures of the individual gases.
Henry’s Law - the amount of dissolved gas is proportional to its partial pressure in the gas phase. In diving more gas is dissolved in solution when at pressure.
Gas Laws - Dalton and Henry
Decompression Sickness
Boyles Law - Air Embolism vs Bends
Gas (air) entry into the circulation from ruptured pulmonary veins or patent foramen ovale
Air bubbles travel in the arterial blood supply and the tissues
Air bubbles become lodged in tissues blocking blood flow
Air Embolism
Occurs within 2-3 minutes
Cardiac arrest or arrhythmias
Neurological focal paralysis, sensory disturbance, seizures, altered mental status
Air Embolism
Physiological Atmospheric Divisions
Pathophysiology of Bubbles in DCS
Dive Table “Pushing Your Tables”
Altitude Decompression Risk Assessment
Altitude Decompression Risk Assessment
Classification DCS
Risks at Altitude
1. Can happen over 18k ft, especially repeated ascents
2. Is a substantial risk over 30k ft.
3. Is a much greater risk after diving.
4. Risk is related to altitude and rate of ascent.
5. In gliders, is a risk in wave flights.
6. In pressurized aircraft, is likely in depressurization accidents.
7. Can results in permanent injury.
1. Must seek a bariatric physician ASAP
2. 100% oxygen rebreathing
Two principal factors control the risk of a diver suffering DCS:
1.The rate and duration of gas absorption under pressure – the deeper or longer the dive the more gas is absorbed into body tissue in higher concentrations than normal (Henry's Law);
2.The rate and duration of outgassing on depressurization – the faster the ascent and the shorter the interval between dives the less time there is for absorbed gas to be offloaded safely through the lungs, causing these gases to come out of solution and form "micro bubbles" in the blood.
Even when the change in pressure causes no immediate symptoms, rapid pressure change can cause permanent bone injury called dysbaric osteonecrosis (DON). DON can develop from a single exposure to rapid decompression.
Principle Factors for DCS
Symptoms Frequency and Onset
“Skin Bends”
Spinal Cord Bends – Infarction of Cord
Bends Prevention
DCS Management
DCS Management US Navy Table 6
DCS Management
Important Safety Tip
Questions