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Case Reports: Altitude Related Illnesses: Mt. Everest North Side 2007

Case Reports: Altitude Related Illnesses: Mt. Everest North Side 2007. Case Number 1. 35 year old healthy male trekking vacation to Advanced Base Camp, and Lhakpa Ri/North Col, Everest medications: none allergies: none. Shegar, Tibet (4350m): 2 days.

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Case Reports: Altitude Related Illnesses: Mt. Everest North Side 2007

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  1. Case Reports: Altitude Related Illnesses:Mt. Everest North Side 2007

  2. Case Number 1 • 35 year old healthy male • trekking vacation to Advanced Base Camp, and Lhakpa Ri/North Col, Everest • medications: none • allergies: none

  3. Shegar, Tibet (4350m): 2 days

  4. Base Camp Mt. Everest, North Side (5300m): 4 days

  5. ABC (6440m) (3 days travel)

  6. Case Number 1 (con’t) • CC: exhausted, pale, insomnia, and vomiting • unable to sleep throughout the night • vomiting 2 times, nauseated, loss of appetite • not drinking, and urinating little

  7. Case Number 1 (con’t) • T=36.5 RR=20 (unlaboured) HR=105 BP=140/60 O2sats=56-61% • Pale • Chest clear • No ataxia, but walks slowly • Normal mental status • No peripheral edema, decreased urine output

  8. Diagnosis? • HAPE • HACE • Dehydration • AMS • C & D • All of the above

  9. Lake Louise Score • Based on: • symptoms: headache, gastrointestinal upset, fatigue, sleep hygeine • signs: mental status, ataxia, and peripheral edema • score out of 23, but based on serial examinations

  10. Why do we become ill at altitude? • High Altitude: 1500 - 3500m (5000-11500 ft) • Very High Altitude: 3500 - 5500 m (11500 - 18000 ft) • Extreme Altitude: 5500m and above (> 18000 ft)

  11. Physiology at Altitude

  12. Pathophysiology of Acute Mountain Sickness (AMS) Theories: • Impaired Hypoxic Ventilatory Response (HVR) leading to further hypoxia • Hypoxia --> oxygen free radicals --> BBB leakage + cerebral vasodilatation --> cerebral edema • Sodium and water retention when exercising correlates with AMS • Unknown 1. Mason, N.P., The Physiology of High altitude: An Introduction to the Cardio-Respiratory Changes Occurring on Ascent to Altitude, Current Anaesthesia and Critical Care, 2000, 11: 34-41. 2. Ward et al., High Altitude Medicine and Physiology, 3rd Ed., Arnold Publishing, 2000. Pp. 46-49, 83-90, 114-115 3. Law and Bukwirwa, The Physiology of Oxygen Delivery: Issue 10 (1999) Article 3: pp 1-2: http://www.nda.ox.ac.uk/wfsa/html/u10/u1003

  13. Treatment • Increase HVR: acetazolamide: 125mg po OD-BID (alkalinizes urine, acidifies blood, mild metabolic acidosis, subsequent hyperventilation, increased oxygenation) • Decrease cerebral edema: dexamethasone: 8mg IM/po x 1, then 4mg IM/po QID • Stop further ascent • Descend if not better in 24 hoursDescend urgently if signs of HAPE or HACE P W Barry and A J Pollard, Altitude Illness, BMJ 2003;326;915-919

  14. Case Report: Treatment

  15. Case No. 2 37 y/o Columbian arriving to advanced base camp short of breath and hearing gurgles in his chest

  16. Further Questions? DDx? • not on diamox, but on aspirin • phx: HAPE when in Aconcagua (6000m) 2 years ago, and HAPE at base camp a week ago (!!!) • ascent from Kathmandu (900m) to base camp (5800m) in 3 days by jeep • DDx: HAPE, pneumonia, chf, (ARDS), (barotrauma)

  17. Case No. 2 (con’t) On Examination: T=36.5, HR=110, RR=30, O2 sats=54-58%, BP=130/80 Chest: crackles at bases

  18. High Altitude Pulmonary Edema (HAPE) similar to non-cardiogenic pulmonary edema:

  19. HAPE Pathophysiology • decreased intrinsic nitrous oxide release (vasodilator) • hypoxic pulmonary vasoconstriction: exaggerated, heterogeneous, pulmonary venules • Normal left ventricle function, but increased pulmonary artery systolic pressure • Increased hydrostatic pressure (not inflammation) resulting in leaking across endothelial barrier, across basement membrane • decreased alveolar fluid clearance by respiratory endothelium (correlated with decreased number of endothelial sodium channel proteins) Schoene, High Alt Med & Bio Vol. 5, No. 2, 2004, pp. 125-135

  20. HAPE Treatment • vasodilator: nifedipine (sildenafil?) • Oxygen • descent or pressure bag (if unable to descend) • alveolar clearance: (salmetrol, antioxidants) • for the case: dexamethasone, acetazolamide Schoene, High Alt Med & Bio Vol. 5, No. 2, 2004, pp. 125-135

  21. Evacuation: manpower

  22. Case No. 4: Logistics Interim Camp: 5800m

  23. Case No. 4 • You are at base camp (5400m) for rest • Half of the expedition team is hiking up to ABC, and calls you from IC via radio • Korean Climber has been found in a tent without support, c/o RLQ pain • Expeditioner, who is also a MD, suspects appendicitis....

  24. Are you ready? • Preparation for remote care medicine

  25. Preparation: Who: Your Team

  26. Preparation Who else? Your team

  27. Preparation Who else? Other teams

  28. Preparation Medical Inventory

  29. Medical Kit What? How much? Where?

  30. Communications

  31. Location: North Col (7000m) Medical Management?

  32. Closest “medical care?” ABC: the view from North Col

  33. Beyond North Col: 7000m Medical Management? Possible?

  34. Summit: 8848m Medical management?

  35. Evacuation? how? where? when?

  36. Evacuation Distance? Time? Ability?

  37. Questions? Leukonychia/Everest Nails

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