Cardiac and Pulmonary Conditions on the Mountain IMG Doc Talk Juneuary 21, 2016

Cardiac and Pulmonary Conditions on the Mountain Cardiac Pulmonary -SCD -Asthma -Angina/MI -Angioedema/Anaphylaxis -Palpitations -HAPE

Most are due to arrhythmia SCD in athletes & young adults Most are due to arrhythmia Arrhythmogenic right ventricular cardiomyopathy Mitral valve prolapse Aortic Stenosis

SCD in athletes & young adults The risk of developing VT is related to the length of the QTc interval. -P-wave represents atrial activity -QRS represents ventricular activation -QT interval represents ventricular recovery, or repolarization.

Sudden cardiac death SCD is the leading cause of nontraumtic death in males > 34 recreating at altitude Ischemic heart disease is most common cause History of MI, known CAD, cardiac risk factors

Sudden cardiac death Does the patient have a skin zipper?

Risk factors for heart disease: hypertension (high blood pressure) hyperlipidemia (high cholesterol) diabetes obesity tobacco use sedentary lifestyle poor diet OCP/HRT chronic stress excessive alcohol family history of heart disease gender, age, ethnicity

Angina/MI Chest pain/pressure/discomfort Shortness of breath, pain radiating into neck, L arm Sweatiness, nausea/vomiting, fainting Atypical

Angina/MI What to ask/know: pre-existing heart disease? risk factors? worse with exertion? associated symptoms? ever had this pain before? vital signs

Angina/MI What needs to happen? CPR nitro oxygen 98% aspirin - 325 mg PO (chew) evacuate carefully

Healthy heart at altitude Premature ventricular contractions increase 63% on acute ascent, but return to baseline after 5 days of acclimatization. Increased ectopy due to increased sympathetic activation. Pacemakers and AICDs function at mild-moderate altitude (may be overactive)

Pulmonary Disease

Asthma! Shortness of breath Stridor Wheezing Hypoxia

Asthma! Individuals with well controlled mild asthma do well at moderate and high altitude, likely due to: decreased allergens (dermatophagoides) decrease in airborne pollutant exposure increase in catecholamine levels decreased air density

Asthma! Animal dander Dust Cold air Stress Exercise

Asthma! What needs to happen: Warm moist air Inhaler Prednisone/Dex Epinephrine Evacuate

Asthma! What needs to happen: Prednisone/Dex 10-12 mg PO/IM Epinephrine - maintain airway, CPR as needed - inject 0.01mg/kg (max 0.3mg) of epi 1:1000 IM into lateral thigh or deltoid - repeat every 5 minutes as needed

Asthma treatment Epinephrine 1:1000 treatment 1 ml of solution = 1 mg of epi Therefore: 0.3 ml of solution = 0.3 mg of epi

Asthma treatment - inject 0.01mg/kg (max 0.3mg) of epi 1:1000 IM into lateral thigh

Angioedema/Anaphylaxis Face, mouth, tongue, uvula, throat swelling, hoarseness, difficulty breathing

HAPE Physiology HAPE - noncardiogenic pulmonary edema due to increase in capillary membrane permeability possibly due to pulmonary artery constriction exercise induced capillary leak+altitude ultimately caused by hypoxia genetic component

HAPE Physiology

HAPE Epidemiology HAPE Usually in young, fit adults possibly more common in men about 1.6% of Everest trekkers

HAPE Symptoms HAPE 2-4 days after ascent to altitude (>8000') decreased exercise tolerance/recovery tachycardia/tachypnea worse at night/supine cough, hypoxia not relieved by O2, rales, low grade fever

HAPE Treatment HAPE potentially fatal within hours Gamow bag (1 hour increments) O2 (goal O2 sat >90%) descent (at least 1000 meters) nifedipine (30mg ER BID)

Khumbu cough not specific to Khumbu not infection not related to preexisting conditions anecdotally related to level of exertion perhaps mucociliary dysfunction temp, humidity, nasal obstruction, hypoxia, infection

Vital Signs What do they mean? alot, and not much! pulse - 60-100 BP - 120/80 RR - 12-20 O2 sat - pulse ox pitfalls temp - 37C, 98.6F trends are crucial

Good habits! Provider to provider call to: Madigan - 253.968.1390 Harborview - 206.744.3300 This is ____, I'm an (EMT,WFR) I’ve been providing care for the patient being transported to your ED now. Full name, gender, age and DOB MOI, injuries, vitals, narrative, treatments

? QUESTIONS?