Doc, these mountains are kicking my ass

[Rob_0811]

If I may, here's one for you mountain goats. I'm far from an expert, I'm not even in med school yet. This will probably be easy for you all, but here goes.

You are on a training mission in the Canadian Rockies (or whatever mountain range you want)
It is approx 2000 hrs on your third day of an op that started with an insertion at 7500 feet in elevation. Since then, your unit has been operating at altitudes ranging between 8000 and 12,000 feet. You notice one of your soldiers is having an unusually hard time getting it done. He has to frequently stop to rest and his breathing is very labored. In fact, he tells you he can only breathe correctly if he is standing or sitting up straight. You can hear a strange wheezing when he breathes. Just then he spits on the ground and you see pink foam.

Diagnosis, treatment?

[ussfpa]

High Altitude Pulmonary Edema:
venous pulmonary hyperextension caused by low oxygen levels. This increased pressure causes alveolar capillary "leakage" resulting in an accumulation of fluid in the lungs. More common with short acclimation times and strenuous excercise states at altutude.
Tx:
New research is suggesting pretreatment with an inhaled Beta-Agonist (such as albuterol) for prevention with some success. Immediate descent is the obvious option for treatment of choice. Oxygen therapy alone can be successful in resolving cases of HAPE but extended periods (72hours? if I remember correctly) may be required.
Other more advanced pharmacologic options are available, but not realistic in this scenario.

Primum non Nocere

[Rob_0811]

That was quick.

Evidently mine are too easy.

Semper Fidelis,

Rob

[ussfpa]

Originally posted by Rob_0811
That was quick.

Evidently mine are too easy.

Semper Fidelis,

Rob
I get paid to know this stuff :D
Honestly, would you want it any other way???

Primum non Nocere

[RIT_MEDIC]

Sir:

First, is HAPE common in training? And secondly are there ways to prevent it other than taking time to acclimate to the surroundings and the previously stated Albuterol?

Thanks,

James D

[ussfpa]

Originally posted by RIT_MEDIC
Sir:

First, is HAPE common in training? And secondly are there ways to prevent it other than taking time to acclimate to the surroundings and the previously stated Albuterol?

Thanks,

James D
Not really common, BECAUSE we plan for it with acclimatization. In the early phases of Afghanistan there were a number of cases though, cause the guys from 10th MTN trained in the cold yes, but not the altitudes which they were initially expected to work in.
As far as the albuterol, serevent, or other Beta-agonists, this is still in the "hypothesis" stage with promising results.
Otherwise, meds that reduce pulmonary arterial pressures (lung pre-load pressure if you will) i.e. nifedipene, phentolamine and I am sure others should assist during ascent as long as you monitor for gross hypotension.

Primum non Nocere

[XGEP]

ussfpa got it, only reason I know about this stuff is because I'm an outdoor ed. major hoping to get into mountaineering.

Now don't get me started on HACE and dexamethazone and everything cause I'll put everyone to sleep.

[DFC5343]

BULLSHIT...too many beers the night before.

[RIT_MEDIC]

Thank you Sir.

James D

[Chris Mac]

A drug they are using now for the prevention of AMS, HAPE. and HACE is Acetazolamide or also known as Diamox. I was told alot of 18D's were giving it to their team before heading up into the mountains in Afghanistan.

The dosage is 250mg Tablets BID for 3 days before ascent.

However, in your scenario, since symptoms have already presented themselves, your main course of action would be DESCEND. If possible that is. Otherwise Procardia, or Decadron (dexamethasone as XGEP stated) would be some of the drugs you would consider to combat cerebral edema and dilate his coronary and pulmonary vasculature. Oh, and never forget O2.

We were also taught that portable hyperbaric chambers could be used if transport or evac couldn't happen, but I doubt one of those would just be floating around.

Take care

[ussfpa]

Originally posted by Chris Mac

However, in your scenario, since symptoms have already presented themselves, your main course of action would be DESCEND. If possible that is. Otherwise Procardia, or Decadron (dexamethasone as XGEP stated) would be some of the drugs you would consider to combat cerebral edema and dilate his coronary and pulmonary vasculature. Oh, and never forget O2.
Thanks for validating my initial post that already said descent was the treatment of choice. I appreciate that, really.
The scenario did not involve HACE, your bringing HACE into the picture confuses what was asked.
O2, while a good rule of thumb has shown no great efficacy for improvement of HAPE symptoms unless, as posted earlier, it is going to be constantly available for up to 72 hours. Most teams, trekkers, etc will not have such access. Though it does lower pulmonary arterial pressures, descent will still do more.
Your profile says you are in school...please learn more, and post less when it doesn't pertain.

Primum non Nocere

[SWAT Doc]

USSFPA,

Sir, found some pertinent "Golden Rules" for AMS.
I. Any illness at altitude is altitude illness until proven otherwise.
II. Never ascend with symptoms of AMS.
III. If you are getting worse, go down at once.
IV. Never leave someone with AMS alone.

Since the waters have been muddied by a cross-over discussion of HAPE and "portable" hyperbaric chambers...
I'm curious, do you have personal or anecdotal experience with the Gamow bag?

[ussfpa]

Originally posted by SWAT Doc
USSFPA,

Sir, found some pertinent "Golden Rules" for AMS.
I. Any illness at altitude is altitude illness until proven otherwise.
II. Never ascend with symptoms of AMS.
III. If you are getting worse, go down at once.
IV. Never leave someone with AMS alone.

Since the waters have been muddied by a cross-over discussion of HAPE and "portable" hyperbaric chambers...
I'm curious, do you have personal or anecdotal experience with the Gamow bag?
These are excellent rules for mountaineering medicine. I have not personally used a Gamow bag, BUT, a previous BN SGN of mine (Chris Adams D.O.) was a BIG mountain rescue / ski patrol Guru (even did 2 expeditions to Everest as the Medical Man -but never summited :() HE relayed useing the Gamow bag with tremendous success and swore by it.

As long as we are on HAPE:
How about someone coming up with the three levels of HAPE and some signs and symptoms of each. Generalities are fine. Since there is fluid in the lung tissue, infiltrates are anticipated on RAD studies, but that resource will not be avail so lets leave them out of the descriptions.

Primum non Nocere

[rubberneck]

I get paid to know this stuff

I hope that if the day ever comes where I or my family needs help that the first responder knows as much as you do. You, KJ, Suffer and Sneaky are all a credit to your profession and the nation. Apologies to all other medically trained soldiers that post here if I didn't include you. Its nice to know our troops have the best care available.

[Axe]

Originally posted by rubberneck
Apologies to all other medically trained soldiers that post here if I didn't include you.

And Trauma surgeons, and Paramedics, and cops as well. Ditto.

[SWAT Doc]

USSFPA,

Since I am not savvy to the differential between pulmonary edema and HAPE I will submit what I know about the three stages of PE.

In stage one, there is an increase of fluid transferred into the interstitial lungs but because you also have an increase in the lymphatic system as a compensatory mechanism, you don't get a real increase in interstitial volume.

In stage two, you overcome the ability of the lymphatic system to compensate and fluid begins to build in the interstitial space around the bronchioles.

And finally, in stage three, as more fluid accumulates, the increase in pressure causes the fluid to go into the interstitial space around the alveoli and also screws with the alveolar membrane cohesion. First it surrounds the capillary membranes and then it overcomes the alveoli. This causes pulmonary edema which inhibits gas exchange.

It is my gut feeling that this process occurs whether the problem is metabolic, cardiac, altitude, etc. - induced.

I'll appreciate the feedback if I'm not tracking this appropriately.

[ussfpa]

Originally posted by SWAT Doc
USSFPA,

Since I am not savvy to the differential between pulmonary edema and HAPE I will submit what I know about the three stages of PE.

And finally, in stage three, as more fluid accumulates, the increase in pressure causes the fluid to go into the interstitial space around the alveoli and also screws with the alveolar membrane cohesion. First it surrounds the capillary membranes and then it overcomes the alveoli. This causes pulmonary edema which inhibits gas exchange.

I'll appreciate the feedback if I'm not tracking this appropriately.
Start here at phase III. So the guy has absolute HAPE (or other Pulmonary Edema compromise) now...

there are 3 Severity classifications, simply put, Mild, Moderate, and Severe...what would be some of the general signs and symptoms of each?

Axe & Rubberneck...thanks guys...

Primum non Nocere

[ussfpa]

Originally posted by ussfpa
Start here at phase III. So the guy has absolute HAPE (or other Pulmonary Edema compromise) now...

there are 3 Severity classifications, simply put, Mild, Moderate, and Severe...what would be some of the general signs and symptoms of each?

Primum non Nocere
Wow, lookey there...I am quoting myself!

Mild: Difficulty breathing with excertion, dry cough, increased fatigue on ascent, dusky nailbeds

Moderate: the above PLUS, increased fatigue on level ground, raspy cough, headache, lack of appetite, increased heartrate (90-110), blueish nailbeds, increased respiratory rate (up to 30 breaths per minute), may have difficulty walking (balance)

Severe: difficulty breathing at rest, productive cough, postional breathing (stooped or tripodded), extreme weakness and fatigue, altered mental status, bloody froth sputum, audible fluid on respiration, heart rate 120+, resp rate 30+, visable blueing of mouth and nails.

OK...hope this has been beneficial to someone. More next week!

Primum non Nocere

[Bandaid]

I appreciated it..... I just didn't know enough about it to comment.
Thank You

[SWAT Doc]

USSFPA,

I left the office last night before I could reply to the question. "Too slow private...push!"

I did find the other device besides the Gamow, it's called a CERTEC (sp?).

[ussfpa]

Originally posted by Bandaid
I appreciated it..... I just didn't know enough about it to comment.
Thank You
Maybe YOU can do next weeks on field expedient treatments of peritonsillar or apical abcesses there Saca Muelas?!? :p
I had planned on doing something for factured teeth in the near future anway...want to grab those and run with them???

SWATDude...no personal info on your other system there Buddy, practical or otherwise. Sorry

Primum non Nocere

[Sneaky SF Dude]

Originally posted by ussfpa
Maybe YOU can do next weeks on field expedient treatments of peritonsillar or apical abcesses there Saca Muelas?!? :p
I had planned on doing something for factured teeth in the near future anway...want to grab those and run with them???


What an absolutely outstanding idea! Hey saca muelas, what's the most teeth you ever pulled in a day?

[Bandaid]

Hmmm......

In one day, probably between 75-100 (maybe more) in the rural mountains of the Dominican Republic... using school writing desks for an operatory and a caving headlamp for light!!!
I would sit three patients in chairs, give all anesthesia, then go down the line one after the other extracting teeth with their heads rested back onto my knee ... then NEXT


As to presenting, I will be glad to do it. Do you want one on fractured teeth or something else like head/neck abscesses and subsequent complications particularly the life threatening variety?
Or maybe jaw fractures, general toothaches, bleeding, "trench mouth", etc......
Just let me know. I don't want to waste anyone's time discussing something that you never actually see in your daily work.

[Sneaky SF Dude]

Originally posted by Bandaid
Hmmm......

In one day, probably between 75-100 (maybe more) in the rural mountains of the Dominican Republic... using school writing desks for an operatory and a caving headlamp for light!!!
I would sit three patients in chairs, give all anesthesia, then go down the line one after the other extracting teeth with their heads rested back onto my knee ... then NEXT


As to presenting, I will be glad to do it. Do you want one on fractured teeth or something else like head/neck abscesses and subsequent complications particularly the life threatening variety?
Or maybe jaw fractures, general toothaches, bleeding, "trench mouth", etc......
Just let me know. I don't want to waste anyone's time discussing something that you never actually see in your daily work.

Why not present S/S and let them (us) figure it out?

450

[Bandaid]

that's 450 for you? On the living or dead?

You know it doesn't count if you only snap off the top half right? LOL hahaha So your the guy the locals were talking about that came though town and charged $5 per tooth to break it off at the gumline leaving the root and performing all that with NO anesthesia.:D

We saca muelas actually sew up the holes we leave too!:cool:

[Bandaid]

Appreciate the presentation advice. Will do. Thanks

[Sneaky SF Dude]

I had help. Team assembly line. One taking history, one or two doing anthesia, two pulling and two doing post procedure and maintain order.

Had one guy that had one of those petrified teeth. One long one, the only one in his head. He said the gobermint wouldn't give him false teeth because he still had one left. The Group Dentist ok'ed it, so I pulled it. That thing was IN THERE! I thing we ended up using a little C4 while I stood on his chest and pulled with both hands. LOL.

[Bandaid]

You must be referring to the process of ankylosis. This is where the inflammatory process either due to trauma (ex. only one tooth to chew with so heavy forces on it) or infection causes the periodontal ligament to be dissolved and replaced with a direct bone to root connection. Makes for a fun extraction doesn't it.

Like the idea of C4.... did he look like this afterwords? :D

[Sneaky SF Dude]

I didn't ACTUALLY USE C4, it was a joke. LOL

[Bandaid]

I knew that.....

Just thought this gunshot case pic would give you a good chuckle for demonstration of a " what if.....":D

[18C/GS 0602]

I know this thread has been dead a little while, but I have been out of email access. In October I spent a month working with the Himalayan Rescue Association (HRA) in the Everest base camp region studying High Altitude Medicine. Because there are only 5 doctors in the Khumbu region I was left having to take care of several people with AMS (acute mountain sickness), HAPE, and HACE because I was the only one with any medical training within a days hike. This is a great thread; I just wanted to add a few things.

1. The dose of Diamox (250 mg BID) that was stated on this thread is actually the treatment dose for AMS/HACE. It is also recommended as a last line treatment for HAPE if you can not descend or if there is no O2/nifedipine/GAMOW bag available. There is some controversy in the literature about the correct prophylactic dose to prevent AMS and HACE(which was the reason I was up there in the first place), but the HRA feels confident that 125 mg twice a day is the best dose. This is based on their clinical experience and has not been proven in the literature yet. However the literature does show that Diamox at various doses can reduce the incidence of AMS by about 40%. The prophylactic dose should be started the night before ascent and anyone with a sulfer allergy should not take Diamox.
2. HAPE can initially present without any signs of AMS before hand. Typically one does not initially present with HACE- they first develop AMS which then progresses into HACE.
3. I had to GAMOW bag (portable pressure chamber) a person with HAPE and HACE, and it improved the way he felt, but he really responded to supplemental O2. His initial O2 sat before I put him in the bag was 56%, and he stayed at that level in the bag with cyanotic lips for an hour until we got some O2. With O2 his sat immediately went up to 93% and his lips returned to normal color. Not to mention the fact he felt a lot better with the O2 on. It is amazing how much just O2 can help with all forms of altitude illness.

[rheanna]

Originally posted by DFC5343
BULLSHIT...too many beers the night before.

Man....I guess this means I can drink only AFTER I ski.