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

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

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

4. 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.

6. 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

7. Sudden cardiac death
Does the patient have a skin zipper?

8. 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

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

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

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

12. 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)

13. Pulmonary Disease

14. Asthma!
Shortness of breath
Stridor
Wheezing
Hypoxia

15. 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

16. Asthma!
Animal dander
Dust
Cold air
Stress
Exercise

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

18. 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

19. 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

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

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

23. 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

24. HAPE Physiology

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

26. 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

27. 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)

28. 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

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

30. Good habits! Provider to provider call to: Madigan - 253.968.1390
Harborview
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

31. ?
QUESTIONS?