UPDATE IN HIGH ALTITUDE MEDICINE

Scott McKee MD MPHRocky Mountain GIM: Banff 2012

UPDATE IN HIGH ALTITUDE MEDICINE

Scott McKee MD MPHRocky Mountain – ACP Banff 2012

Practice guidelines

New technologies

Drug therapy

Lots of free gear from outdoor product retailers, but none since 1997

DISCLOSURES:

Lots of free gear from outdoor product retailers – but none since 1997!

You will be called upon to diagnose and treat in the field…

You will be called upon to diagnose and treat in the hospital, and in the ICU…

You will be called to give advice to potential patients of all levels of health and fitness, including those with pre-existing conditions…

Demographics:

-Climbers/skiers-Tourists to mountain resorts-Miners/Operations-Soldiers-Performance Athletes-Pilots/balloonists Comorbidities:

-CVD: all varieties-COPD/CF/OSA-Anemias-VTE/anticoagulation-Migraine/CVD/epilepsy-Pregnancy/pediatrics-Diabetes-Transplant patients & immunosuppression-Retinal/corneal surgeries-Drug therapy & interactions

Research Funding:

-Aviation/Aerospace-Military-Wilderness Medicine-Tourism Bureaus-Sports Medicine

REVIEW ARTICLE

Wilderness Medical Society Consensus Guidelines for the Prevention and Treatment of Acute Altitude IllnessAndrew M. Luks, MD; Scott E. McIntosh, MD, MPH; Colin K. Grissom, MD; Paul S. Auerbach, MD, MS; George W. Rodway, PhD, APRN; Robert B. Schoene, MD; Ken Zafren, MD; Peter H. Hackett, MD

WILDERNESS & ENVIRONMENTAL MEDICINE, 21, 146–155 (2010)

To provide guidance to clinicians about best practices, the Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the prevention and treatment of acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high altitude pulmonary edema (HAPE). These guidelines present the main prophylactic and therapeutic modalities for each disorder and provide recommendations for their roles in disease management. The guidelines also provide suggested approaches to the prevention and management of each disorder that incorporate these recommendations.

www.wms.org

Into thin air: extreme ultrasound on Mt Everest. Otto C, Hamilton DR, Levine BD, Hare C, Sargsyan AE, Altshuler P, Dulchavsky SA.

Department of Emergency Medicine, University of Ottawa, Ottawa, Canada.

Wilderness Environ Med. 2009 Fall;20(3):283-9.

Crit Care Med. 2010 Sep;38(9):1818-23.

Frequent subclinical high-altitude pulmonary edema detected by chest sonography as ultrasound lung comets in recreational climbers.Institute of Clinical Physiology, CNR, Pisa, Italy. lorenza@ifc.cnr.it

CONCLUSIONS: In recreational climbers, chest sonography revealed a high prevalence of clinically silent interstitial pulmonary edema mirrored by decreased O(2) saturation, whereas no statistically significant relationship with pulmonary artery systolic pressure was observed during ascent.

Stroke at High Altitude Diagnosed in the Field Using Portable Ultrasound

Wilderness & Environmental MedicineVolume 22, Issue 1 , Pages 54-57, March 2011

-PDE 5 inhibitors: small studies, wide usage, considerable anecdotal support, for HAPE prevention and treatment.

-Ibuprofen: 2 randomized controlled trials : ASCENT (ibu vs placebo) 2012 and HEAT (ibu vs acetazolamide) 2010. Seems to be equivalent for AMS prevention…

HIGH ALTITUDE MEDICINE & BIOLOGYVolume 11, Number 1, 2010

Caffeine at High Altitude: Java at Base Camp

Peter H. Hackett MD

“In summary, contrary to conventional wisdom, caffeine use at high altitude seems to be not only safe but likely beneficial…”

“Importantly, habitual caffeine users should not discontinue caffeine because of travel to altitude; the symptoms of withdrawal are very similar to acute mountain sickness and can be misdiagnosed as AMS.”

Altitude Research Center at University of Colorado Denver School of Medicinewww.uchsc.edu/arc/

Wilderness Medical Societywww.wms.org

International Society for Mountain Medicinewww.ismmed.org

International Hypoxia Symposiawww.hypoxia.net

Himalayan Rescue Associationwww.himalayanrescue.org

American College of Emergency Physicians - Wilderness Medicine Sectionwww.acep.org/acepmembership.aspx?id=30284

Wilderness Medicine - Stanford University School of Medicinehttp://emed.stanford.edu/fellowships/wilderness.html

Everest ERwww.everester.org 

Keystone Symposiawww.keystonesymposia.org

18th International Hypoxia Symposium26 February to 2 March 2013Chateau Lake Louise (www.hypoxia.net)

Wednesday-Recent Developments Involving Hypoxia Inducible Factor in Clinical Medicine

-The Exercising Hypoxic Brain: N Prabakhar, L Shimoda, G Semenza

ThursdayGenomics, Population Genetics and Metabolism: P Robbins, J Prchal, D McClain

New Advances in Hemoglobin Biology: Peter Wagner, Mark Gladwin

FridayCerebral Blood Flow In Hypoxia: From Early Human Experiments to Systems Biology

Debate: Is Live-High Train-Low (LHTL) Effective for Improving Sea Level Athletic Performance?—LHTL is NOT Effective for Sea Level Performance Enhancement—Carsten Lundby— LHTL IS Effective for Sea Level Performance Enhancement —Ben Levine

•Evening Everest Long Ago—Tom Hornbein

SaturdayNitrite, Nitrate, and Oxygen Delivery in Hypoxia

Also Steve Herrero and Bernadette McDonald

“In summary, contrary to conventional wisdom, caffeine useat high altitude seems to be not only safe but likely beneficial…”

Importantly, habitual caffeine users should not discontinue caffeine because of travel to altitude; the symptoms of withdrawal are very similar to acute mountain sickness and can be misdiagnosed as AMS.

Acute mountain sickness (AMS) High-altitude cerebral edema (HACE) High-altitude pulmonary edema (HAPE)

-High-altitude headache -Peripheral edema -High-altitude pharyngitis and bronchitis -High-altitude syncope-Digestion, cachexia, and metabolism-Cerebrovascular syndromes-Mood disturbance and psychosis-Periodic breathing-Ultraviolet keratitis (snow blindness)-High-altitude retinopathy-Hypothermia and frostbite-High-altitude cognitive impairment

-Drug metabolism and pharmacokinetics

-Chronic mountain sickness (Monge's disease)

-High-altitude pulmonary hypertension, with or without right heart failure

-Reentry pulmonary edema

-Problems of pregnancy: preeclampsia, hypertension, and low-birth-weight infants

-Telemedicine for Mountaineering

-Scientific Evidence of Forest Therapy

-Acute mountain sickness (AMS)

-High-altitude cerebral edema (HACE)

-High-altitude pulmonary edema (HAPE)

WHERE THEY GO: WHAT THEY HAVE:

-Above 8,000 feet a.s.l.:

-US Rockies esp ski resorts

-Alaska-Yukon-Andes-Himalayas-Alps-Volcanos

Coronary Disease Hypertension Cardiomyopathies Congenital heart disease Lung disease: COPD/asthma, OSA,

CF Pregnancy Obesity Neuro: migraine/TIA/tumors/epilepsy CKD Transplants Diabetes Radial keratotomy Anemia and CO poisoning VTEs andAnticoagulation Immunosuppression and delayed

wound healing