Most of the travelers and adventurer might have known with awareness in trekking or traveling around high altitude areas where people can catch with the symptom of AMS (Acute Mountain Sickness)
Nepal Himalayan Sherpa Adventure offers detail information of High Altitude Sickness and related problems.
Symptoms of High Altitude Sickness:
Rather than one or two, usually a group of symptoms begin to appear as a person gains altitude. These symptoms vary in intensity and in the elevations at which they appear, depending on the individual experiencing them. The predominant characteristic associated with mal adaptation to altitude is headache.
Usually a headache appears in the evening after a long day of ascending. The headache should be relieved by aspirins and should go away by the following morning. The principal symptoms that accompany the onset of altitude sickness are: headache and weakness, sleeplessness, often accompanied by irregular breathing, particularly at night, fluid retention [oedema], particularly about the eyes or fingers, depending on the degree of altitude sickness, dry cough, mild nausea, loss of appetite, ataxia or loss of co-ordination and severe breathlessness at rest.
If the symptoms are a mild annoyance then you should rest until they subside. If the symptoms become more severe or do not disappear after a night's sleep, then you should descend until you feel well.
The basic treatment for severe altitude sickness is immediate descent: altitude sickness can progress rapidly once it becomes serious. The person afflicted should be taken down between 1,000 to 3,000ft. [300 to 450m.], the distance increasing with the extent of the symptoms.
The drug acetazolamide [Diamox] has been used for assisting with acclimatization when travelling to altitude. Some reports indicate that the drug might be useful in treating the early stages of altitude sickness in addition to its use in prevention. It has been shown that people who had headaches, nausea and felt unwell improved considerably within 30 minutes of taking the tablets. The adult dosage is one 250mg. tablet twice a day. The most pronounced and irritating side effect is a tingling sensation which can occur at any site and without warning. The dose can be reduced to 250 mg. per day. It is recommended that the drug is started on the morning of ascent above 10000ft/3000m and to be continued until descent or the person feels acclimatized. If you decide to take acetazolamide, please inform your guide / group leader. It should not be taken by people who are allergic to sulphur drugs.
Severe altitude sickness affects few trekkers, most know when to stop and head back down. All of our treks are based on experience and are planned to gain height gradually, with days allowed for rest and acclimatization. The above brief notes on altitude sickness are to point out what it is and to note the symptoms. Prevention is simple; make a gradual ascent and allow sufficient rest at intermediate altitudes.
AMS (ACUTE MOUNTAIN SICKNESS):
Acute mountain sickness (AMS) is a frequent problem in the Himalayan region.
The altitude of the peaks and trails between them are among the highest on earth.
Many of the passes between valleys are higher than the Matterhorn and Mont Blanc.
Acclimatization to altitude above 3,000 meters (10,000 feet) takes time.
The body undergoes a number of physiological changes some of which are immediate
like increased pulse and respiratory rate.
Others symptom appears more slowly over a period of weeks like the change in acid base balance and production of extra red blood cells. These changes plus the effect of intense sunlight, walking hard and dehydration may cause a number or mild or vague symptoms such as: loss of appetite, fatigue, headache, nausea, dizziness, palpitations, sleeplessness, mild shortness of breath with exercise.
If anyone has these symptoms while ascending above 3000 meters (10,000 feet) and
there is no obvious cause like diarrhea, infection, flu or head cold etc then give them 5 day course of Diamox, one 250 mg tablet morning and night.
Diamox appears to acidify the blood and stimulate the respiratory rate, especially at night when breathing slows during sleep.
Another symptom of Acclimatization is periodic breathing otherwise known as Cheyne-Stokes breathing which is characterized by pronounced cessation of breathing
for up to a minute followed by gasping breaths during sleep.
This is another indication to use Diamox.
Should these mild symptoms return after stopping Diamox then continue it for the rest
of the time at altitude. If symptoms persist or worsen the clients should stay at that altitude for a rest day or descend to a lower altitude for a night or two until the symptoms disappear.
Flying into Lhasa, Lukla, Jomsom or Dolpa may cause AMS. Consider starting your clients on diamox 48 hours before flying in and continue for 3 days after arrival. Should anyone have problems after this continue the Diamox for another 5 days before trying again without the drug.
So what is AMS? Anyone at a high altitude will have a low level of oxygen in the blood. The body responds by acclimatizing or changing its physiology. Should this process be pushed too rapidly then fluid can start to accumulate in the lungs (high altitude pulmonary oedema-HAPE) or brain (high altitude cerebral oedema- HACE). This may be mild and insidious in onset or it may be rapid and cause death in one or two days.
The problem of diagnosing AMS is that many of its symptoms are just those we suffer in the normal course of acclimatizing. Below is a list of symptoms for each case with some guides to differentiation. In AMS any symptom may become severe.
Acclimatization Symptoms AMS
Headache: Usually mild to moderate to severe and not relieved helped by lying down and by
painkillers, often made worse by taking a Panadol or Asprin and lying down.
Nausea: Nausea and vomiting.
Shortness of breath: Usually appears with exercise, persists even at rest. Symptoms may and disappears with rest. Include the lips and tongue turning blue.
Fatigue: May be intensely tired.
Loss of appetite: Loss of appetite.
Dizziness: Dizziness-maybe severe with inability to stand.
Palpitations increased heart rate: Palpitations increased heart rate.
The guide lines here are that if any symptom becomes a severe or persistent or is worse lying down, suspect AMS. There are number of symptoms which are specific to AMS.
Symptoms Specific to AMS:
1) Cough- may produce frothy blood stained sputum. (HAPE)
2) Shortness of breath while resting, better for sitting up. (HAPE)
3) Ataxia, loss of coordination-tripping up, can’t tie shoe laces, clumsy.
Test by asking patient to close their eyes and touch the tip of their nose with
their index finger from arm extended position rapidly several times in succession.
Failure to do this accurately diagnoses ataxia. (HACE)
4) Severe headache-worse for lying down, does not respond to mild analgesics like Panadol
(check for fever to differentiate meningitis). (HACE) 5) Loss of mental abilities- mental arithmetic is a good test for this ask the patient to
subtract 7 from a 100 ie 100-7= 93, 93-7=86, 86-7=79 ets. (HACE) 6) Coma- people suffering from AMS become tired drowsy and may rapidly become
unconscious. (HACE, HAPE)
7) Visual disturbances- blurred or double vision (HACE)
8) Vomiting- may be severe prolonged and associated with headache.
So we have some non-specific symptoms which make us suspect or confirm that the patient has AMS.
To Examine a Person For Suspected AMS:
Take a good history of symptoms, severity, duration, previous occurrence. Then ask about other symptoms. Ask what drugs the person has taken. Ask specifically about the symptoms in the two lists above.
Now examine the person, check their respiratory rate and note if they remain breathless after exercise. Look at the color of lips and tongue (pink OK while dark or blue NOT OK).
Are they coughing and what are they coughing up? Put your ear to the bare chest and listen for "wets sounds", use a normal person for comparison.
See if the person can perform simple manual tasks like tying shoelaces or the ataxia test in the specific symptoms list above (finger to nose test). Ask them to subtract 7 from 100.
Inability to perform these tests is a sign of HACE.
Treatment of AMS:
The best treatment is prevention! Avoid rapid ascents, take acclimatization symptoms
seriously using rest days or Diamox. Consider Diamox if flying into Leh, Lhasa, Lukla or Jomsom. Should you suspect that someone has early symptoms of AMS put them on Diamox and keep them at that altitude or descend until symptoms clear up. Reascent using Diamox for at least five days. Recurrence of the symptoms or worsening is an indication to return the client to lower altitude with a responsible person.
If symptoms are severe and the patient ill DESCEND IMMEDIATELY 300 meters
(1000 feet) of descent or more should be sought. This will usually give rapid improvement.
Drug Therapy:
Not a substitute for descent but use where no descent is possible or the patient is very ill.
Oxygen if available should be given at the rate of 4 to 6 liters per minute till improvement occurs. Lasix (frusemide) 10 mg ampoules, give by intra muscular injection into the buttock
or upper arm. This is aimed at producing urine and drying out the lungs and brain.
Large amounts of clear urine should be passes within four hours.
Check lower belly for a full bladder if this does not occur. May be repeated after
4 hours. It is extremely important to rehydrate the patient 2 to 3 liters minimum if warm rehydration solution for every injection of Lasix. This drug benefits HACE and HAPE.
Dexamethasone 4 mg ampoules, this drug is given for symptoms of HACE injected
into buttock or upper arm every 8 hours.
Nurse the patient sitting up and reassure them. Prepare for descent or evacuation carefully ie torches (flash lights), food and shelter for all concerned. Take sufficient help and accompany the person. Use porters, Yaks or ponies for transporting the patient. Helicopters are usually inappropriate in cases of AMS.
Re-ascent: As a rule of thumb if a person has been carried down they should not
continue with the trek but remain at a lower altitude or return home with a responsible
person.
The difficult decision is when someone has had mild or moderate symptoms.
If they recover rapidly at a lower altitude they may try to re-ascend a day or two later
using Diamox. Recurrence of symptoms is a sign to send them home.
HYPOTHERMIA (EXHAUSTION, EXPOSURE)
Exhaustion and Exposure:
Cold and wet conditions may cool a person down enough to kill them. This can occur
after immersion in cold water on wet and windy days or with people who have fallen
down a crevasse or been recovered with snow for some time.
Prevention is better than cure; windproof clothing, hot drinks and food.
The symptoms are:
Tiredness, shivering, uncooperative behavior, slurred speech, drowsiness, unconsciousness.
Protect from further heat loss with windproof dry clothing, shelter, food and hot drinks.
If the person is unconscious or drowsy, treat with outmost gentleness. Avoid letting the patient walk or be carried unless absolutely necessary as the heart may stop.
Re-warm by hot drinks or rectal fluid. Add heat to the arm pits, neck, head, and groin with hot water bottles or heated stones wrapped in towels. Do not massage the limbs or give alcohol.
Use the rectal low reading thermometer. The normal temperature is 37 degrees Celsius. It may take many hours to fully re-warm the person and they should be evacuated with care after re-warming.
FROST BITE
Caused by freezing of the flesh, usually fingers toes or nose occurs after snow fall or on glaciers and the most susceptible people are the porters. Avoidance is better than cure. In severe conditions keep your group together. For porters use plastic bags inside shoes to keep feet dry. Hand out spare clothing gloves, socks, sand shoes.
Stop and inspect everyone and re-warm any numb parts by massage before frost bite occurs.
Frost bitten extremities are hard white, frozen and painless.
DO NOT MASSAGE once frost bitten. Do not re-warm until the person can be carried or does not need the use of the affected limbs (you can walk off a pass with frost bitten feet but not after they have been re-warmed).
Re-warming:
Re-warm with water at 40 to 45 degrees centigrade. ( you can just put your hand in
water at this temperature). This may take several hours for a frost bitten area such as
foot or hand.
The area will now become black and blistere4d and painful and must be protected with gauze, cotton wool and bandages. Give adequate pain relief and rehydrate.
If there is any sign of broken skin or infection give an antibiotic.
Evacuate for medical treatment.
SURVIVAL IN SEVERE CONDITIONS
Keep the groups together including the porters as soon as the weather looks threatening? Consult with the head guide / Sirdar or Group Leader, about the best course of action with respect to the terrain and weather. In cold wet conditions put on wind shell clothing, gloves and hats, encourage everyone to eat and drink. If people are exhausted, camp but beware of avalanche slopes. Put your porters in the mess/cook tent.
Emergency shelter:
01: Make a pile of rucksacks, gear, and brush etcs.
02) Cover in snow one to two feet deep and pat down firmly.
03) Make an opening an extract the rucksacks leaving an instant igloo.
Personal Medical Kit - We suggest that you bring the following:
Elastoplast
Adhesive tape
4" crepe bandage
Elasticated knee and /or ankle support if you experience strain these joints
Blister dressings, e.g. moleskin, compead, spenco dressings
Nasal Decongestant
Throat lozenges/ glucose sweets
* Wide spectrum antibiotic [Ciproxin recommended]
Anti -diarrhoea - Immodium or Lomotil
* A course of Flagyll [treatment of giardia]
* Codeine Phosphate - constipates, cough suppressant and pain killer
Cold and flu suppressant
Aspirin / Paracetamol.
Re-hydrate powder - useful for adding to your water bottle and for fluid replacing purposes.
Small pair of scissors
any special medicines you require as authorize by your doctor.
