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Flickr by Rupert Taylor Price CC by 2.

JamesHunterWinegarner,MD
WildernessandAustereMedicineFellow

Elevationsabove1500m
Moderate15002500m(4,9508,202)
High25004250m(8,20213,953)
VeryHigh42505500m(13,953

18,044)
DeadZone
Extreme55009000m(18,04429527)
Leon-Velarde F, Maggiorini M, Reeves J, et al., Consensus statement on chronic and subacute high
altitude disease. HighAltitude Medicine & Biology. 2005. 6(2), 147157.

Mt Washington, NH
Altitude 6288ft

Flickr by Paul-W CC by 2.0

Mt Baker, WA
Altitude 10786 ft

Flickr by jcurtis4082 CC by 2.0

Mt Rainier, WA
Altitude 14417 ft

Flickr by OneEighteen CC by 2.0

Annapurna I, Nepal
Altitude: 26,545 ft

Flickr by twiga269 FEMEN CC by 2.0

Ascenttoaltitude>2500m(8200ft)
HeadachePLUSatleastoneofthe

following:

Fatigueorweakness
Insomnia
Anorexia,nauseaand/orvomiting
Dizzinessorlightheadedness

Mayoccur<2hoursafterreachinghigh

altitude

AMS
HACE
HAPE

Haltfurtherascentandrest
Analgesicsandantiemetics
Acetazolamide(Diamox)250mgPOBID
Dexamethasone(Decadron)4mg

PO/IM/IVq6hforsevereAMS
Bewareofrebound
>1doseneeded=descend

Descendforworseningsymptoms

AMS
HACE
HAPE

Slow,gradedascent
Acetazolamide125mgPOBID,started24

hoursbeforeascent
Pediatricdose:2.5mg/kgBID

Dexamethasone2mgPOq6hor4mgBID,

startedthedayofascent
Limitof10days
Shouldnotbeusedinchildren

?Motrin600mgPOTID6hrbeforeascent

AMS
HACE
HAPE

AMS
Flickr by Andrew-Hyde CC by 2.0

HACE
HAPE

AMSiscommon
Associatedwithrapidascent
Preventwithslow,gradedascent
ProphylaxissignificantlyreducesAMS
DONTascendwithAMS!
MayresultinHACE

AMS
HACE
HAPE

Wikimedia commons/CC-BY-SA-3.0

AMS

HACE
HAPE

Recentascenttoaltitude
Typically>3000m(9843ft)
Onereportataltitudeof2100m(6890ft)
AMSplusoneofthefollowing:
Ataxia
Alteredmentalstatus
Focalneurologicdeficit
ProgressionfromAMStoHACE
Usually13days,onecasein<12hr
AMS
HACE
HAPE

AMSsymptoms
Headache,nausea,vomiting,fatigue,
anorexia,insomnia
Visualchangesandpapilledema
Hallucinations
Cranialnervepalsy
Hemiparesis/Hemiplegia
Focalneurologicsigns
AMS
Seizures(rare)
HACE
HAPE

Increased T2 signal in splenium


AMS
Image from Hackett PH, Yarnell PR, Hill R, et al: High-altitude cerebral edema evaluated
with magnetic resonance imaging: Clinical correlation and pathophysiology, JAMA 280:1920,
1998.

HACE
HAPE

Immediatedescentwithassistance
Oxygen2to4L/min
Dexamethasone8mgPO/IV/IMfollowed

by4mgq6h
Ifunabletodescend portablehyperbaric

chamberin1hourincrementsfor46
treatments
AMS

HACE
HAPE

Slow,gradedascent
Acetazolamide125mgPOBID,started24

hoursbeforeascent
Pediatricdose:2.5mg/kgBID

Dexamethasone2mgPOq6hor4mg

BID,startedthedayofascent
Notrecommendedforpediatrics
AMS

HACE
HAPE

AMS

HACE
Images from Deitez, T. High-altitude-medicine.com, http://www.high-altitude-medicine.com/hyperbaric.html
Last modified 26-Apr-2001

HAPE

Atleasttwosymptoms:

Dyspneaatrest
Cough
Weaknessordecreasedexercisetolerance
Chesttightnessorcongestion
PLUS

Atleasttwosigns:

Cracklesorwheezinginatleastonelungfield
Centralcyanosis
Tachycardia
Tachypnea

AMS
HACE

HAPE

AMS
HACE
Images from: Maggiorini M et al. Circulation. 2001;103:2078-2083
Copyright American Heart Association, Inc. All rights reserved.

HAPE

Normal

HAPE

Image from: Fagenholz PJ, Gutman JA, Murray AF, Noble VE, Thomas SH, Harris N. Chest Ultrasonography for
the Diagnosis and Monitoring of High-Altitude Pulmonary Edema. Chest. 2007;131(4):1013-1018.
doi:10.1378/chest.06-1864

AMS
HACE

HAPE

Immediatedescentofatleast1000M
Minimizeexertion,keepwarm
Oxygen,4to6L/min
*ConsiderDexamethasone8mgPO/IV/IM

followedby4mgq6h*ifthereisconcomitant
HACE*
Ifunabletodescend portablehyperbaric
chamberin1hourincrementsfor46
AMS
treatments.
HACE
HAPE

Nifedipine(Procardia)SR30mgPOBID

OR
Tadalafil(Cialis)10mgPOBID
OR
Sildenafil(Viagra)50mgPOQ8H
CONSIDER
Albuterol(Proventil)MDI2puffsQ46H
Nofurosemide(Lasix)orAcetazolamide

AMS
HACE

HAPE

Slow,gradedascent
Nifedipine SR30mgqD
Sildenafil50mgq8h
Tadalafil 10mgBID
Salmeterol 125mcgBID
AMS
HACE

HAPE

HACEandHAPEarepotentiallylethal

formsofaltitudeillness
Preventionisbest slow,gradedascent
Descentismandatory
Oxygen+portablehyperbaricchamberif
immediatedescentimpossible
AMS

HACE
HAPE

QUESTIONS?

Fagenholz PJ,Gutman JA,MurrayAF,NobleVE,ThomasSH,HarrisN.ChestUltrasonography


fortheDiagnosisandMonitoringofHighAltitudePulmonaryEdema.Chest.
2007;131(4):10131018.doi:10.1378/chest.061864
HackettPH,RoachRC.HighAltitudeMedicineandPhysiology.Auerbach:Wilderness
Medicine.2011;Chapter1,Mosby,PhiladelphiaPA
LeonVelarde F,Maggiorini M,ReevesJ,etal.,Consensusstatementonchronicandsubacute
highaltitudedisease.HighAltitude Medicine&Biology.2005;6(2),147157.
LuksAM,McIntoshSE,GrissomCK,etal:WildernessMedicalSocietyconsensusguidelinesfor
thepreventionandtreatmentofacutealtitudeillness,WildernessEnvironMed21:146,2010.
MaggioriniMetal.Highaltitudepulmonaryedemaisinitiallycausedbyanincreasein
capillarypressure.Circulation.2001;103:20782083

1year@Madigan,Tacoma,WA
OneslotforFamilyMedicine
Operationaljobprep
TeachAWLSandDiMMs courses
WorkatCrystalMountainSkiResort
PullshiftsinERandFamilyMedClinic
Allowsflexibilityandresearchoptions

Internationallyrecognized(WMS,UIAA,IKAR,

ISMM)
TwiceayearWildernessFellows(Juneand
August)
2wk classroomandhandsondidactics
40+hrsoffreeCME
Requires:
Level1Avalanchecourse
Guidedascentofglaciatedmountain

1540%ofColoradoskiers.
40%ofMountMcKinleyclimbers.
70%inMountRainierclimbers.
70100%ofpeopleflowndirectlyto14,000
feet.
Sleepingaltitudeiscriticalfactorwith>20%
incidenceabove9,000feet.

Big Three:

AMS
HACE
HAPE

Rapidascent.
Maximumelevationachieved.
Sleepingaltitude.
HistoryofpreviousAMS.**
Residenceatlowaltitude(<3,000ft.).
Heavyexertion.
Latitude(increaseddistancefromequator).
Big Three:

AMS
HACE
HAPE

0.51%ofpeopleathighaltitude.
3.4%ofpeoplewithAMS.
Occursin1320%ofpatientswith

HAPE.
OneseriesfromCOshowed11of13
patientswithHACEalsohadHAPE.
PureHACEwithoutconcomitant
HAPEisuncommon.
Big Three:
AMS

HACE
HAPE

Mostcommonataltitudes>3,000meters.
0.01%ofvisitorstoRockyMountains.
2%ofMountDenaliclimbers.
15%ofIndiansoldiersairliftedto5,500
meters.
Typicallyoccurs24daysafterarrivingat
highaltitude.
60%recurrencewithreturnto4,559meters.

Big Three:
AMS
HACE

HAPE