1. Prevention is better than Cure

2. 3 Golden Rules Three golden rules to avoid dying from altitude illness: 1.Learn the early symptoms of altitude illness and recognize when you have them. Remember, there may be only one person in a group with symptoms. 2.Never ascend to sleep at a new altitude with any symptoms of AMS. 3.Descend if your symptoms are getting worse while resting at the same altitude.

3. Sometimes symptoms overlap from one illness to another Identifying the cause of the symptom is not always easy… Causes of stomach pain? Causes of headache?

4. Altitude- what happens up high?

5. The problem of altitude Decrease in pressure Not enough Oxygen Usually noticed above 2500m

6. The body’s solution Our bodies need to adjust – Breathe faster – Heart beats faster – Pee more – Make more red blood cells (later) …. But what happens if our bodies don’t adjust?

7. Altitude Illness AMS HAPE HACE

8. Remember, some people take longer to adjust. We are all different.

9. Who acclimatizes better? Of the following, say which are better at acclimatizing: Young or old Fit or unfit Female or male Skinny or fat Nepali or European From Dharan or Barabise?

10. Risk factors for developing altitude illness Individual susceptibility Ascent profile – 300 m per day – Rest day every 3 days or 1000m Physical activity Fluid intake Avoid alcohol, caffeine & sedatives

11. What is ‘normal’ for up there? Hands/ feet a bit puffy Pee more Breathe a bit faster and deeper Heart beats a bit faster Dreams

12. S HEADACHE and one or more of: – Tiredness – Dizziness – Nausea or if severe vomiting – Poor sleep AMS

13. Any one symptom may indicate the onset of AMS at high altitude Treat as AMS unless proven otherwise The best treatment for AMS is prevention

14. Treatment of AMS Mild: – Rest (don’t go higher) – Paracetamol or NSAIDs ± anti-emetic Moderate or Severe: – Descend, descend, descend! – Acetazolamide (Diamox) – Dexamethasone – Oxygen or PAC if available NB: should not delay descent

15. Duff’s* High Altitude Triangle AMS Hypothermia (Cold) Dehydration (thirsty)Hypoglycaemia (hungry) * Conceived by our great leader JD

16. HACE “Severe AMS” Fluid squashing the brain Rarely occurs without being preceded by AMS Important signs: – Severe headache unresponsive to painkillers – Confusion – Physical clumsiness (ataxia) Presence of any of these signs at altitude: → HACE until proven otherwise

17. HACE - Treatment Descend, descend, descend! Carry, or at least help, the victim down Oxygen, (bottled or hyperbaric bag) Dexamethasone 8mg (IM if possible) – 4mg / 6 hourly thereafter Need medical follow up

18. HAPE Fluid in the wrong place in the lungs Classically: sudden onset after 24-48 hrs at new altitude Often occurs without AMS Severe cases can be complicated by HACE Many symptoms but important ones: – Cough and tiredness – Breathlessness out of proportion to exercise, especially breathlessness at rest – Inability to lie flat – Presence of these at altitude = HAPE Predisposing factors: – genetic; respiratory infection; exercise; cold environment

19. HAPE - Treatment Descend, descend, descend! Carry, or at least help, the patient down down Oxygen, (bottled or hyperbaric bag) Nifedipine / Adalat ® 20mg orally – Ensure patient is warm & well hydrated – 10mg / 8 hourly thereafter Salbutamol / Ventolin ® inhaler, or similar treatment spray – 2 puffs 4 hourly (best by ‘spacer’ ie plastic bottle) Consider assisted breathing Treat for HACE if any doubt as to whether present or not

20. Prevention is better than Cure! Walk slowly with a rest day for every 3-4 days Do not make rapid ascent Drink more fluids (3-4l/day) Do not carry heavy pack Do not smoke/drink alcohol/take sleeping pills Look after each other Recognize the symptoms early Never send someone down alone!

21. Acetazolamide / Diamox ® Can be used for prevention and for treatment Side effects – Can be unpleasant: – Tingling/numbness of any body part! – Try before you go – Dose dependant Sulphonamide / sulphur allergy Start night before ascent Continue until reach maximum height & descending Dose: – Start with 125 mg x 2 / day – 250 mg x 2 / day if this doesn’t work – The lowest dose possible !

22. Sleep at altitude Big problem for many people: – Difficult to get off to sleep – Poor quality of sleep ↓ refreshing deep REM sleep ↑ non-refreshing light sleep – Periodic breathing De-saturation Repeated waking (20 – 30 times per hour?)

23. Sleep at altitude 2 Acetazolamide / Diamox ® at night can be very effective treatment – early in evening (18.00) – 125 mg initially – ↑ to 250 mg if ineffective

24. 3 Golden Rules Three golden rules to avoid dying from altitude illness: 1.Learn the early symptoms of altitude illness and recognize when you have them. Remember, there may be only one person in a group with symptoms. 2.Never ascend to sleep at a new altitude with any symptoms of AMS. 3.Descend if your symptoms are getting worse while resting at the same altitude.

25. Questions? What questions do you have about altitude and AMS?