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UPDATE IN HIGH ALTITUDE MEDICINE Scott McKee MD MPH Rocky Mountain GIM: Banff 2012

UPDATE IN HIGH ALTITUDE MEDICINE Scott McKee MD MPH Rocky Mountain – ACP Banff 2012. UPDATE IN HIGH ALTITUDE MEDICINE Scott McKee MD MPH Rocky Mountain GIM: Banff 2012. Practice guidelines. New technologies. Drug therapy. DISCLOSURES. DISCLOSURES:.

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UPDATE IN HIGH ALTITUDE MEDICINE Scott McKee MD MPH Rocky Mountain GIM: Banff 2012

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  1. UPDATE IN HIGH ALTITUDE MEDICINE Scott McKee MD MPH Rocky Mountain – ACP Banff 2012 UPDATE IN HIGH ALTITUDE MEDICINE Scott McKee MD MPH Rocky Mountain GIM: Banff 2012 Practice guidelines New technologies Drugtherapy

  2. DISCLOSURES DISCLOSURES: Lots of free gear from outdoor product retailers – but none since 1997! • Lots of free gear from outdoor product retailers, but none since 1997

  3. Why does this matter to GIMs? You will be called upon to diagnose and treat in the field…

  4. Why do GIMs care? You will be called upon to diagnose and treat in the hospital, and in the ICU…

  5. Why does it matter? You will be called to give advice to potential patients of all levels of health and fitness, including those with pre-existing conditions…

  6. Demographics: -Climbers/skiers -Tourists to mountain resorts -Miners/Operations -Soldiers -Performance Athletes -Pilots/balloonists Research Funding: -Aviation/Aerospace -Military -Wilderness Medicine -Tourism Bureaus -Sports Medicine 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

  7. What’s new? REVIEW ARTICLE Wilderness Medical Society Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness Andrew 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)

  8. -ACCPclassificationscheme-recommendations for individual risk categories-evidence-based guidelines for ascent-summary of prophylactic regimens-summary of treatment options: dosages and devices 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

  9. What’s New? ultrasound 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.

  10. Ultrasound on Everest 2009

  11. What’s new? Ultrasound II 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.

  12. What’snew? Ultrasound III Stroke at High Altitude Diagnosed in the Field Using Portable Ultrasound Wilderness & Environmental MedicineVolume 22, Issue 1 , Pages 54-57, March 2011

  13. R MCA flow

  14. What’s new: Therapeutics -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…

  15. What’s new: therapeutics HIGH ALTITUDE MEDICINE & BIOLOGY Volume 11, Number 1, 2010 Caffeine at High Altitude: Java at Base Camp Peter H. Hackett MD

  16. “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.”

  17. Altitude Illness:Current ResourcesResearch and Guidelines • 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

  18. A local recommendation: 18th International Hypoxia Symposium 26 February to 2 March 2013 Chateau Lake Louise (www.hypoxia.net)

  19. Wednesday • -Recent Developments Involving Hypoxia Inducible Factor in Clinical Medicine • -The Exercising Hypoxic Brain: N Prabakhar, L Shimoda, G Semenza • Thursday • Genomics, Population Genetics and Metabolism: P Robbins, J Prchal, D McClain • New Advances in Hemoglobin Biology: Peter Wagner, Mark Gladwin • Friday • Cerebral 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 • Saturday • Nitrite, Nitrate, and Oxygen Delivery in Hypoxia • Also Steve Herrero and Bernadette McDonald

  20. SLIDE CREDITS-Institute for Altitude Medicine-Google Images-International Hypoxia Symposium-Scott Darsney

  21. HIGH ALTITUDE MEDICINE & BIOLOGYVolume 11, Number 1, 2010 “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.

  22. High Altitude Medicine: an increasingly rich area of reaearch and evidence-based clinical care • Acute mountain sickness (AMS) • High-altitude cerebral edema (HACE) • High-altitude pulmonary edema (HAPE)

  23. High Altitude medicine is an increasingly rich area of research and evidence-based clinical care… -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

  24. Normobaric hypoxic tent“sleep high, train low”

  25. The demographic 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

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