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? A. HAPE B. HACE C. Dehydration D. AMS E. C & D F. 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: 1. Impaired Hypoxic Ventilatory Response (HVR) leading to further hypoxia 2. Hypoxia --> oxygen free radicals --> BBB leakage + cerebral vasodilatation --> cerebral edema 3. Sodium and water retention when exercising correlates with AMS 4. 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, 3 rd 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