ACUTE MOUNTAIN SICKNESS

Acute mountain sickness is an illness that can affect mountain climbers, hikers, skiers, or travelers at high altitude (typically above 8,000 feet or 2,400 meters).

Causes
Acute mountain sickness is brought on by the combination of reduced air pressure and lower oxygen concentration that occur at high altitudes. Symptoms can range from mild to life-threatening, and can affect the nervous system, lungs, muscles, and heart. In most cases the symptoms are mild. In severe cases fluid collects in the lungs (pulmonary edema) causing extreme shortness of breath. This further reduces how much oxygen enters the bloodstream and reaches vital organs and tissue. Brain swelling may also occur (cerebral edema). This can cause confusion, coma, and, if untreated, death. The chance of getting acute mountain sickness increases the faster a person climbs to a high altitude. How severe the symptoms are also depends on this factor, as well as how hard the person pushes (exerts) himself or herself. People who normally live at or near sea level are more prone to acute mountain sickness. Approximately 20% of people will develop mild symptoms at altitudes between 6,300 to 9,700 feet, but pulmonary and cerebral edema are extremely rare at these heights. However, above 14,000 feet, a majority of people will experience at least mild symptoms. Some people who stay at this height can develop pulmonary or cerebral edema.

Symptoms
Symptoms generally associated with mild to moderate altitude illness include:

Difficulty sleeping Dizziness or light-headedness Fatigue Headache Loss of appetite Nausea or vomiting Rapid pulse (heart rate) Shortness of breath with exertion

Symptoms generally associated with more severe altitude illness include:

Bluish discoloration of the skin (cyanosis)

Chest tightness or congestion Confusion Cough Coughing up blood Decreased consciousness or withdrawal from social interaction Gray or pale complexion Inability to walk in a straight line, or to walk at all Shortness of breath at rest

Exams and Tests

Listening to the chest with a stethoscope (auscultation) reveals sounds called crackles (rales) in the lung, which can mean pulmonary edema. A chest x-ray may be performed.

Treatment
The main form of treatment for all forms of mountain sickness is to climb down (descend) to a lower altitude as rapidly and safely as possible. Extra oxygen should be given, if available. People with severe mountain sickness may be admitted to a hospital. Acetazolamide (Diamox) is a drug used to stimulate breathing and reduce mild symptoms of mountain sickness. This drug can cause increased urination. When taking this medication, make sure you drink plenty of fluids and do not drink alcohol. Pulmonary edema, the build-up of fluid in the lungs, is treated with oxygen, the high blood pressure medicine nifedipine or phosphodiesterase inhibitors (sildenafil), and, in severe cases, a breathing machine (respirator). The steroid drug dexamethasone (Decadron) may help reduce swelling in the brain (cerebral edema). Portable hyperbaric chambers have been developed to allow hikers to simulate their conditions at lower altitudes without moving from their location on the mountain. These new devices are very important if bad weather or other factors make climbing down the mountain impossible.

Outlook (Prognosis)
Most cases are mild, and symptoms improve promptly with a return to lower altitude. Severe cases may result in death due to respiratory distress or brain swelling (cerebral edema).

In remote locations, emergency evacuation may not be possible, or treatment may be delayed. These conditions could adversely affect the outcome.

Possible Complications

Coma High altitude cerebral edema (brain swelling) Pulmonary edema

When to Contact a Medical Professional

Call your health care provider if you have or had symptoms of acute mountain sickness, even if you felt better when you returned to a lower altitude. Call 911 or your local emergency number, or seek emergency medical assistance if severe difficulty breathing develops, or if you notice a lower level of consciousness, coughing up of blood, or other severe symptoms. If unable to contact emergency help, descend immediately, as rapidly as is safely possible.

Prevention
Education of mountain travelers before ascent is the key to prevention. Basic principles include: gradual ascent, stopping for a day or two of rest for each 2,000 feet (600 meters) above 8,000 feet (2,400 meters); sleeping at a lower altitude when possible; and learning how to recognize early symptoms so you can return to lower altitude before symptoms get worse. Mountaineering parties traveling above 9,840 feet (3,000 meters) should carry an oxygen supply sufficient for several days. Acetazolamide (Diamox) helps speed the process of getting used to higher altitudes, and reduces minor symptoms. This drug should be taken starting one day before the ascent and continue one to two days into the excursion. This is recommended for those making a rapid ascent to high altitudes. Those who may be prone to anemia (particularly women) should consult a doctor regarding an iron supplement to correct the condition before traveling at high altitudes. People with anemia have a reduced red blood cell count, and therefore a lower amount of oxygen carried in the blood. Drink enough fluids, avoid alcohol, and eat regularly. Foods should be relatively high in carbohydrates. People with underlying heart or lung diseases should avoid high altitudes.

Alternative Names

High altitude cerebral edema; Altitude anoxia; Altitude sickness; Mountain sickness; High altitude pulmonary edema

References
Auerbach PS, ed. Wilderness Medicine. 4th ed. St. Louis, Mo: Mosby; 2001:12-19. Schoene RB, Swenson ER. High Altitude. In: Mason RJ, Murray JF, Broaddus VC, Nadel JA, eds. Textbook of Respiratory Medicine. 4th ed. Philadelphia, Pa: Saunders Elsevier; 2005: chap 65. Wright A, Brearey S, Imray C. High hopes at high altitudes: pharmacotherapy for acute mountain sickness and high-altitude cerebral and pulmonary oedema. Expert Opin Pharmacother. 2008;9(1):119-127. Yaron M, Honigman B. High-altitude medicine. In: Marx, JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia, Pa : Mosby Elsevier; 2006: chap 142.

Update Date: 1/15/2009

Updated by: Jacob L. Heller, MD, Emergency Medicine, Virginia Mason Medical Center, Seattle, Washington, Clinic. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.