Altitude-Related Emergencies Chapter 28 Altitude-Related Emergencies 1

Objectives 28.1 Define altitude. 28.2 Describe the principles of altitude physiology. 28.3 List risk factors for the development of altitude illnesses. 28.4 Describe strategies to prevent altitude illness. continued 2

Objectives 28.5 List the signs and symptoms of the following altitude illnesses: acute mountain sickness high-altitude pulmonary edema high-altitude cerebral edema 28.6 Describe how to assess a patient with altitude illness. 28.7 Describe the treatment of a patient with altitude illness. 3

Topics Altitude Physiology Altitude-Related Problems Prevention of Altitude Illness Assessment Management Chapter Summary

Case Presentation At first-aid duty, in the patrol room, a 45 year-old man slowly walks in. He appears unwell, and slightly cyanotic around his lips. You help him to the nearest gurney and assess him. He states he hasn’t felt well since arriving 2 days ago. The resort is located 9,000 feet above sea level. He feels very fatigued and winded. He has no significant medical history, has not suffered recent trauma, and is not on any prescribed medications. Discussion Points: What should you do? What symptoms would you see for altitude sickness?

Altitude Physiology Body’s ability to preserve homeostasis includes the ability to adapt to altitude changes. Rate of ascent determines the probability of developing an altitude illness. Discussion Points: What is the definition of altitude? At what elevation does most altitude illness occur? continued

Altitude Physiology continued Copyright Wilderness Medical Society educational powerpoint series, 2008

Altitude Physiology Copyright Wilderness Medical Society educational powerpoint series, 2008

Altitude Classifications Low altitude (<5,000 ft) Intermediate altitude (5,000 to 8,000 ft) High altitude (8,000 to 12,000 ft) Very high altitude (12,000 to 18,000 ft) Extreme altitude (>18,000 ft) Discussion Point: Explain each altitude classification. continued

Altitude Classifications Copyright David Johe, MD

Altitude Acclimatization Changes that help preserve homeostasis Increased rate and depth of respiration Increased heart rate Increased red blood cell production Construction of pulmonary blood vessels Increased enzyme production Discussion Point: What is the definition of acclimatization? continued

Altitude Acclimatization Copyright Denise Cheney

Altitude-Related Problems Acute mountain sickness High-altitude pulmonary edema High-altitude cerebral edema Discussion Points: What do these acronyms stand for? Review their definitions. AMS HAPE HACE continued

Altitude-Related Problems continued

Altitude-Related Problems Other altitude-related problems Khumbu cough Peripheral edema High-altitude retinal hemorrhage Radial keratotomy eye surgery Solar keratitis Chilblains Sunburn continued

Altitude-Related Problems Copyright Luanne Freer, MD

Altitude-Related Problems Copyright Andy Crawford and Steve Gorton / Dorling Kindersley Media Library

Case Update On examination of the patient, you notice that not only his lips, but also his nail beds are cyanotic, and his breathing is labored, even at rest. The patient appears physically fit, which he confirms by saying, “I run and ride more than 50 miles a week.” He has a heart rate of 116, a blood pressure of 132/80, respirations of 36. The pulse oximeter indicates the patient’s oxygen saturation is 76%. The rest of the physical assessment is negative for any abnormalities or signs of trauma. Discussion Points: What do think is wrong with the patient? What should you do? 18

Prevention of Altitude Illnesses Ascend gradually. Avoid rapid ascent above 10,000 feet. Incorporate layover at an intermediate altitude. Once above 10,000 feet, limit altitude increase to 1,000 feet/day and for every 2,000 feet of elevation gained, take 1-2 extra rest days. continued

Prevention of Altitude Illnesses continued Copyright Jamie Marshall / Dorling Kindersley Media Library

Prevention of Altitude Illnesses As you increase altitude, more rest and less altitude gain per day may be necessary. Avoid heavy physical exertion for the first 24-48 hours at altitude. Discussion Points: Discuss how to keep the rescuer safe and what the student needs to learn to not become a patient as well. continued

Prevention of Altitude Illnesses Stay hydrated. Altitude acclimatization is often accompanied by fluid loss, drink often (3-4 quarts/day). As breathing increases, fluid is lost due to increased exhalation. Urine output should be copious and straw colored. Discussion Points: Discuss how to keep the rescuer safe and what the student needs to learn to not become a patient as well. continued

Prevention of Altitude Illnesses continued Copyright Dorling Kindersley Media Library

Prevention of Altitude Illnesses Avoid alcohol and other depressant drugs. Eat a high carbohydrate diet. If symptoms of altitude illness occur, do not ascend until they resolve. continued

Prevention of Altitude Illnesses Acclimatization occurs at different rates. If traveling in a group, make sure everyone is properly acclimatized before going higher. “Climb high and sleep low.” continued

Prevention of Altitude Illnesses Medications Acetazolamide Dexamethasone Gingko biloba Discussion Point: Discuss the side effects of these medications.

Prevention of Altitude Illnesses Copyright Dorling Kindersley Media Library

Assessment Initiate life saving equipment ABCDs SAMPLE OPQRST Discussion Point: Walk students through how to assess a patient with altitude illness.

Assessment Copyright Studio 404

Assessment Copyright Candace Horgan

Management Descend to lower elevation General management AMS treatment HAPE treatment HACE treatment Khumbu cough treatment Discussion Point: Describe the treatment of a patient with altitude illness.

Management Copyright Dorling Kindersley Media Library

Prevention of Altitude Illnesses continued Copyright Nigel Hicks / Dorling Kindersley Media Library

Case Disposition The patient may have early signs of HAPE, so you place him on high-flow oxygen, keep him comfortable, and mobilize resources to transport him to a hospital approximately 1,500 feet lower. Two days later, the patient’s wife thanks you “for taking such great care of my husband.” She reports he recovered from is symptoms within a day after descent and supplementary oxygen. She further states that her husband was advised to avoid high altitude or to ascend slowly next time. Discussion Point: Could the wife have prevented HAPE? What must the patient do for himself? 34

Chapter Summary Altitude sickness is a common disorder that affects outdoor enthusiasts. It is caused by a decrease in available oxygen concentration and can afflict even those who are extremely healthy. Compensatory mechanisms increase cardiopulmonary function to speed oxygen delivery to the cells. The body must work harder to keep up. Discussion Point: What are the symptoms of altitude sickness? continued

Chapter Summary As an OEC technician, you have a good chance of encountering an altitude-related illness if you live and work in a high-altitude setting, and compounded by guests who arrive from a low altitude and without gradual ascent. Symptoms can manifest quickly in these individuals. Discussion Points: Have you ever had or encountered altitude-related illness? What did you do? continued

Chapter Summary Preventive measures, such as slow ascent and the use of prophylactic (prescribed) medications may provide some protection but are no guarantee of immunity. Thus, it is essential that you recognize the signs and symptoms of acute mountain sickness, HAPE, and HACE as well as other altitude-induced conditions. continued

Chapter Summary Additionally, be prepared to act quickly to treat an altitude-related illness to halt the progression of symptoms and to reduce the chance of a potentially lethal outcome. Altitude illness can become life-threatening. Once symptoms of AMS develop, do not ascend until symptoms completely resolve. Discussion Point: Review signs and symptoms of HAPE, HACE, and how to recognize and treat them quickly. continued

Chapter Summary Suspect HACE in the presence of headache and ataxia when at altitude. Descent with supplemental oxygen will almost always improve symptoms of altitude illness. 39