AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Background

Altitude illness refers to a group of syndromes that result from hypoxia. Acute mountain sickness (AMS) and high-altitude cerebral edema (HACE) are manifestations of the brain pathophysiology, while high-altitude pulmonary edema (HAPE) is that of the lung. Everyone traveling to altitude is at risk, regardless of age, level of physical fitness, prior medical history, or previous altitude experience.

The high-altitude environment generally refers to elevations over 1500 m (4900 ft). Moderate altitude, 2000-3500 m (6600-11,500 ft) includes the elevation of many US ski resorts. Although arterial oxygen saturation is well maintained at these altitudes, low PO₂ results in mild tissue hypoxia, and altitude illness is common. Very high altitude refers to elevations of 3500-5500 m (18,000 ft). Arterial oxygen saturation is not maintained in this range, and extreme hypoxemia can occur during sleep, with exercise, or illness. HACE and HAPE are most common at these altitudes. Extreme altitude is over 5500 m; above this altitude, successful long-term acclimatization is not possible and in fact deterioration ensues. Individuals must progressively acclimatize to intermediate altitudes to reach extreme altitude.

Pathophysiology

Acclimatization

Hypoxia is the primary physiological insult on ascent to high altitude. The fraction of oxygen in the atmosphere remains constant (0.21) at all altitudes, but the partial pressure of oxygen decreases along with barometric pressure on ascent to altitude. The inspired partial pressure of oxygen (PiO₂) is lower still because of water vapor pressure in the airways. At the altitude of La Paz, Bolivia (4000 m; 13,200 ft), PiO₂ is 86.4 mm Hg, which is equivalent to breathing 12% oxygen at sea level.

The response to hypoxia depends on both the magnitude and the rate of onset of hypoxia. The process of adjusting to hypoxia, termed acclimatization, is a series of compensatory changes in multiple organ systems over differing time courses from minutes to weeks. While the fundamental process occurs in the metabolic machinery of the cell, acute physiologic responses are essential in allowing the cells time to adjust.

The most important immediate response of the body to hypoxia is an increase in minute ventilation, triggered by oxygen sensing cells in the carotid body. Increased ventilation produces a higher alveolar PO_2.  Concurrently, a lowered alveolar PCO₂ produces a respiratory alkalosis, acting as a brake on the respiratory center of the brain and limiting the increase in ventilation. Renal compensation, through excretion of bicarbonate ion, gradually brings the blood pH back toward normal and allows further increase in ventilation. This process, termed ventilatory acclimatization, requires approximately 4 days at a given altitude and is greatly enhanced by acetazolamide. Patients with inadequate carotid body response (genetic or acquired, eg, after surgery or radiation) or pulmonary or renal disease may have an insufficient ventilatory response and thus not adapt well to high altitude.

In addition to ventilatory changes, circulatory changes occur that increase the delivery of oxygen to the tissues. Ascent to high altitude initially results in increased sympathetic activity, leading to increased resting heart rate and cardiac output and mildly increased blood pressure. Within minutes of exposure, the pulmonary circulation reacts to hypoxia with vasoconstriction. This may improve ventilation/perfusion matching and gas exchange, but the resulting pulmonary hypertension can lead to a number of pathological syndromes at high altitude, including HAPE and altitude-related right heart failure (see, Altitude Illness - Pulmonary Syndromes). Cerebral blood flow increases immediately on ascent to high altitude, returning toward normal over about a week. The magnitude of the increase varies but averages 24% at 3810 m and more at higher altitude. Whether the headache of AMS is related to this flow increase is not known.

Hemoglobin concentration increases after ascent to high altitude, increasing the oxygen-carrying capacity of the blood. Initially, it increases due to hemoconcentration from a reduction in plasma volume secondary to altitude diuresis and fluid shifts. Subsequently, over days to weeks, erythropoietin stimulates increased red cell production. In addition, the marked alkalosis of extreme altitude causes a leftward shift of the oxyhemoglobin dissociation curve, facilitating loading of the hemoglobin with oxygen in the pulmonary capillary.

Sleep architecture is altered at high altitude, with frequent arousals and nearly universal subjective reports of disturbed sleep. This generally improves after several nights at a constant altitude, though periodic breathing (Cheyne-Stokes respiration) remains common above 2700 m.

Pathophysiology of AMS/HACE

The exact pathophysiology of AMS/HACE is unknown. The current hypothesis is that hypoxia elicits neurohumoral and hemodynamic responses in the brain that ultimately result in capillary leakage from microvascular beds and edema. Whether mild AMS or headache alone is actually due to brain edema remains an open question.

Recent studies using ultrasonographic assessment of optic nerve sheath diameter (ONSD), which has been shown to correlate with intracranial pressure, has demonstrated increased ONSD swelling in both AMS and HAPE cases.¹ Magnetic resonance imaging (MRI) studies demonstrate that the brain swells on ascent to altitude in both those with and those without AMS, presumably from vasodilation. True edema, however, was only detected in severe AMS and HACE. Factors that might contribute to a hydrostatic brain edema are multiple and include cerebral vasodilation, elevated cerebral capillary pressure, impaired cerebral autoregulation, as well as alterations in the permeability of the blood-brain barrier through cytokine activation.

Susceptibility to AMS demonstrates great individual variability because of genetic differences. Individual susceptibility is reproducible; a past history of AMS is the best predictor.

Frequency

United States

The incidence of AMS varies depending on the rate of ascent and the maximum altitude reached. In moderate altitude (2000-3500 m) ski resorts, the incidence ranges from 10-40%. Rapid ascent to approximately 4000 m has been associated with incidences of 60-70%.

International

Travelers flying to a high altitude destination such as Lhasa, Tibet (3810 m; 12,500 ft) or La Paz, Bolivia (4000 m; 13,200 ft) can expect an AMS incidence of 25-35%. In those who hike above 4000 m (and so ascend at a moderate pace), 25-50% will suffer from AMS. HACE is estimated to occur in about 1% or less of persons traveling above 4000 m and in 1-3% of those with AMS.

Mortality/Morbidity

The natural history of AMS varies with altitude, ascent rate, and other factors. In general, the illness is self-limiting and symptoms improve slowly, with complete resolution in 1-3 days. However, with continued ascent, AMS is very likely to worsen and is more likely to progress to HACE.

HACE may progress to stupor and coma over hours to days if untreated. Once coma has developed, death is more likely despite aggressive treatment; death is due to brain herniation. The usual course is rapid, complete recovery if treatment is started promptly. Slower recovery results when treatment is delayed. In rare cases, patients with either severe or prolonged HACE may have persistent neurologic deficits. Ataxia commonly persists for days to weeks and is often the last finding to resolve.

Race

No race predilection exists.

Sex

No significant difference based on gender exists. The incidence of AMS is not markedly affected by menstrual cycle phase and does not differ in pregnant women versus nonpregnant women.

Age

Age has a small effect in adults; younger adults are slightly more susceptible.

Children have similar occurrence rates of altitude cerebral syndromes to those of adults.

CLINICAL

Section 3 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

History

AMS is a syndrome of nonspecific symptoms with a broad spectrum of severity. AMS occurs in nonacclimatized persons in the first 48 h after ascent to altitudes above 2500 m, especially after rapid ascent (1 d or less). Symptoms usually begin a few hours after arrival at the new altitude but may arise as much as a day later, often after the first night's sleep. Headache is the principal symptom, typically frontal and throbbing. Gastrointestinal symptoms (anorexia, nausea, or vomiting), and constitutional symptoms (weakness, lightheadedness, or lassitude) are common. AMS is similar to an alcohol hangover, or to a nonspecific viral infection, but without fever or myalgias.

Fluid retention is characteristic of AMS, and persons with AMS often report reduced urination, in contrast to the spontaneous diuresis observed with successful acclimatization. As AMS progresses, the headache worsens, and vomiting, oliguria, and increased lassitude develop. Ataxia and altered level of consciousness herald the onset of clinical HACE.

Using the Lake Louise consensus criteria, the diagnosis of AMS requires headache plus at least one of the following symptoms: gastrointestinal (anorexia, nausea, vomiting), constitutional (lightheadedness, dizziness, weakness, fatigue), or insomnia. Most conditions similar to AMS can be excluded by history and physical examination. Onset of symptoms more than 3 days after ascent, lack of headache, or failure to improve with descent, oxygen, or dexamethasone suggests another diagnosis. Dehydration is commonly confused with AMS, as it can cause headache, weakness, nausea, and decreased urine output.

The most common history in HACE is a person ascending further despite symptoms of AMS; however, rarely, it may develop in the absence of AMS after a very rapid ascent or at extreme altitude in an apparently acclimatized person. Also, HACE commonly occurs in conjunction with HAPE.

Physical

• Acute mountain sickness
• • Patients may appear ill but otherwise have no characteristic physical findings.
  • Neurologic examination (especially mental status and gait) is normal.
  • Heart rate and blood pressure are variable and nondiagnostic.
  • Pulmonary crackles may be present in some patients, but oxygen saturation will be normal or, at most, slightly lower than acclimatized persons at the same elevation.
  • Fever is absent.
  • Funduscopic examination may reveal retinal hemorrhages, but these are not specific to AMS.
  • Peripheral and facial edema may be present, particularly in women.
• High-altitude cerebral edema
• • In a patient with symptoms of AMS who develops gait ataxia (ie, unable to walk heel-to-toe in a straight line) or mental status changes, HACE is the diagnosis until proven otherwise. Immediate treatment and descent is indicated.
  • Regardless of AMS symptoms, a combination of ataxia and mental status changes suggests HACE.
  • Usually, the neurologic examination findings are otherwise normal.
  • In rare cases, focal neurologic signs (eg, cranial nerve III palsy, cranial nerve VI palsy) appear in end-stage HACE, although they are more suggestive of other causes of focal deficits at altitude (eg, stroke, transient ischemic attack [TIA], migraine, brain neoplasm).

Causes

• Rapid ascent to altitudes greater than 2500 m can cause AMS.
• The risk of HACE or AMS increases with altitude.
• Special attention should be paid to the elevation at which the person sleeps. Daytime climbs to higher elevations, with return to a lower sleeping altitude are preferred.
• Continued ascent despite symptoms of AMS is a major risk factor for developing HACE. At altitudes over 5000 m, ascents of as little as 200 m for individuals with moderate AMS have precipitated HACE.
• HACE frequently is seen secondary to HAPE, presumably because of rapidly worsening hypoxia, which is equivalent to continued ascent.

DIFFERENTIALS

Section 4 of 12  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Other Problems to be Considered

Acute psychosis
Alcohol hangover
Dehydration
Ingestion of drugs, alcohol, or toxins
Seizure disorder

WORKUP

Section 5 of 12  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Imaging Studies

• Head CT
• • CT is useful in patients with focal neurologic findings or in atypical cases of suspected HACE.
  • CT can help confirm the diagnosis of stroke, subdural hematoma, subarachnoid hemorrhage, or occult cerebral neoplasm that becomes symptomatic at altitude. Note that no specific changes due to HACE are seen on CT scan. The study is used to exclude other conditions.
• Head MRI
• • Head MRI is useful in demonstrating changes specific to HACE, which is indicated by an increased T2 signal in the white matter of the splenium of the corpus callosum.
  • MRI may be helpful in confirming HACE and in evaluating causes of focal neurologic deficits.

Other Tests

• Pulse oximetry is not helpful in diagnosing or managing AMS and HACE because values do not correlate with severity of illness.

TREATMENT

Section 6 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Prehospital Care

Management of AMS follows 3 axioms: (1) no further ascent until symptoms resolve, (2) descend to a lower altitude if no improvement occurs with medical therapy, and (3) at the first sign of HACE, descend immediately. Predicting the eventual severity from the initial clinical presentation is not possible, and patients must be watched closely for progression of illness. A small percentage (<10%) of persons with AMS will go on to develop HACE, especially with continued ascent in the presence of AMS symptoms.

Descent to an altitude below that where symptoms started is always effective treatment but may not be practical or possible given the topography, weather, the patient's ultimate trekking or climbing goals, or group resources. Accordingly, a descent of 500-1000 m is usually sufficient.

Acetazolamide accelerates acclimatization and thus quickens resolution of the illness, but this may still require 12-24 hours; it is of limited value in HACE because of its relatively slow action. Acetazolamide can be taken episodically without fear of rebound symptoms when it is discontinued. Dexamethasone swiftly reverses symptoms (2-4 h) but does not improve acclimatization. It is the drug of choice for treating HACE and should be given early. Both agents may be used to treat AMS if the victim does not descend. Oxygen is extremely effective, but availability is often limited.

Portable hyperbaric chambers made of coated fabric (eg, Gamow bag, CERTEC, PAC) are now widely available among adventure travel groups on expeditions and in high-altitude clinics. These are all lightweight, coated fabric bags about 2 m long and 0.7 m in diameter. The patient is placed completely within the bag, which is sealed shut and inflated with a manually operated pump, pressurizing the inside to 105-220 mm Hg above ambient atmospheric pressure. Depending on the elevation of use, a physiologic (simulated) descent of up to 2000 m may be achieved within minutes. Continuous pumping is necessary to flush CO₂ out of the system, unless a chemical scrubber system is used. Patients are typically treated in 1-hour increments and then are reevaluated.

Importantly, in HACE cases, these chambers should only be used as a means of acute/temporizing care (eg, to improve a patient's ability to more safely participate in their evacuation in technical terrain). They should never be considered as a replacement for actual descent.

Coca leaf tea is widely recommended in South America, on the Internet, and in the popular press as a cure for altitude illness; however, no studies support this claim. Coca leaf tea may act as a mild stimulant and improve well-being at altitude, which may be its primary effect. Garlic likewise has been advocated for prophylaxis and treatment of altitude illness. Animal studies show efficacy in preventing hypoxic pulmonary hypertension, but studies in humans are lacking and its use cannot be recommended at this time. Additional medications not shown to have any benefit include calcium channel blockers, naproxen, phenytoin, and antacids. Alcohol and other respiratory depressants should be avoided in someone with AMS due to the risk of exaggerated hypoxemia.

Emergency Department Care

All of the symptoms of AMS improve dramatically with descent, and, by the time a patient reaches the emergency department, further treatment is rarely indicated.

Oxygen 4 L/min or to keep SaO₂ above 90% should be used in patients who continue to be acutely ill with either severe AMS or HACE after descent.

Dexamethasone should be continued in symptomatic patients with HACE.

Consultations

Ataxia due to HACE commonly persists for days to weeks after descent, but persistent mental status changes or the presence of focal neurologic deficits should prompt a complete neurologic evaluation. Brain tumors that suddenly become symptomatic at altitude, Guillain-Barré syndrome, herpes encephalitis, and cortical blindness have all been misdiagnosed as HACE.

MEDICATION

Section 7 of 12  

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• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Treatment of HACE is indicated immediately upon diagnosis. AMS may be treated at the discretion of the patient and physician. Mild analgesics (eg, aspirin, acetaminophen, ibuprofen) are indicated for symptomatic treatment of headache. Routine prophylaxis of AMS with acetazolamide can be considered in those without contraindications; see Deterrence/Prevention section for further details.

Drug Category: Carbonic anhydrase inhibitors

These agents are thought to improve acclimatization by increasing renal bicarbonate excretion at high altitude. They act as a respiratory stimulant at high altitude.

Drug Category: Corticosteroids

These agents are used for their potent anti-inflammatory activity in vasogenic brain edema.

Drug Category: Antiemetics

These agents are useful in the treatment of symptomatic nausea caused by AMS.

Drug Name	Promethazine (Phenergan)
Description	Used for the symptomatic treatment of nausea in AMS.
Adult Dose	25 mg PO/PR tid and 25 mg hs 25 mg IV/IM; repeat prn in 2 h; switch to PO as soon as possible
Pediatric Dose	<2 years: Contraindicated >2 years: 0.25-1 mg/kg PO/IM/PR q4-6h prn nausea
Contraindications	Documented hypersensitivity; children younger than 2 y (incidences of death due to respiratory depression); caution in older children
Interactions	May have additive effects when used concurrently with other CNS depressants or anticonvulsants; coadministration with epinephrine may cause hypotension
Pregnancy	C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions	Caution in cardiovascular disease, impaired liver function, seizures, sleep apnea, and asthma

Drug Category: Sedative hypnotics

These agents are useful for the nearly-universal sleep difficulties at high altitude.

Drug Name	Zolpidem (Ambien)
Description	Structurally dissimilar to benzodiazepine but similar in activity with the exception of having reduced effects on skeletal muscle and seizure threshold. Does not depress ventilation at high altitude.
Adult Dose	10 mg PO qhs
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; lactation
Interactions	Increases toxicity of alcohol and CNS depressants
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Monitor elderly for impaired cognitive or motor performance

Drug Category: Analgesics

These agents are indicated for the treatment of mild to moderate pain and headache.

Drug Name	Acetaminophen (Tylenol, Aspirin Free Anacin)
Description	DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking PO anticoagulants.
Adult Dose	325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric Dose	<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d >12 years: 325-650 mg PO q4h; not to exceed 5 doses/d
Contraindications	Documented hypersensitivity; known G-6-PD deficiency
Interactions	Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Pregnancy	B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions	Hepatotoxicity possible in persons with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative doses exceeding recommended maximum dose

FOLLOW-UP

Section 8 of 12  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Further Inpatient Care

• Hospitalization is not indicated for AMS.
• Hospitalization is usually indicated for patients with HACE, depending on severity. Patients with focal neurologic deficits or persistent mental status changes should be admitted. After descent, care is supportive.

Further Outpatient Care

• After descent, further outpatient care is not usually indicated for patients with AMS.
• Patients with mild HACE should have follow-up appointments in 24 hours to check for clearance of symptoms.
• Patients with concurrent HAPE should be immediately reported to the International HAPE Registry.

In/Out Patient Meds

• Residual headache or nausea in patients with AMS should be treated symptomatically.
• Continue dexamethasone for 1-2 days after descent in patients with uncomplicated HACE or until the mental status clears in patients with severe HACE who require hospitalization.

Deterrence/Prevention

• Recommendations on staged ascents are by and large adequate for the average person, but some persons will still become ill despite a slow, staged ascent. Persons traveling to high altitude should allow adequate time for acclimatization and pay careful attention to symptoms. Helpful guidelines to avoid altitude illness include the following:
• • Avoid abrupt ascent to sleeping elevations over 3000 m (10,000 ft).
  • Spend 1-2 nights at an intermediate elevation (2500-3000 m) before further ascent.
  • Above 3000 m, sleeping elevations should not increase by more than 300-400 m per night.
  • When topography or village locations dictate more rapid ascent, or after every 1000 m gained, spend a second night at the same elevation.
  • Day hikes to higher elevations, with return to lower sleeping elevations help to improve acclimatization.
  • Avoid overexertion.
  • Avoid alcohol consumption in the first 2 days at a new, higher elevation; in addition to concerns about respiratory depression and exaggerated sleep hypoxemia, an AMS headache the next morning is all too easily dismissed as a hangover.
• Many travelers wonder how long acclimatization lasts after a sojourn to high altitude. Some value in preventing AMS may persist for a week or more.
• Acetazolamide effectively prevents AMS; it accelerates acclimatization by inducing a bicarbonate diuresis, stimulating ventilation and improving sleep-breathing patterns. It does not mask symptoms of AMS. Acetazolamide prophylaxis is indicated for persons with an unavoidable rapid ascent, such as flying in to a high city (eg, Lhasa, Tibet; La Paz, Bolivia), or with a past history of recurrent AMS. Since it is also useful for treatment, acetazolamide should be in the high altitude traveler's medical kit, along with written instructions. A recent survey concluded that most trekkers carrying acetazolamide did not know how to use it properly.
• Dexamethasone also effectively prevents AMS but does not improve acclimatization. Because of the concern of rebound symptoms and the side effect profile, this medication cannot be routinely recommended for prophylaxis.
• In the past, ginkgo biloba had been suggested for AMS prophylaxis. Importantly, a number of recent well-designed studies have found it to be ineffective at preventing AMS. The studies that also included acetazolamide found that acetazolamide alone was effective and that combining ginkgo and acetazolamide did not provide any increased effectiveness.^{2, 3} Ginkgo cannot be recommended for AMS.

Complications

• Symptoms of HACE, particularly ataxia, commonly persist for days to weeks after descent.
• In rare cases, patients may have long-term neurologic deficits after severe or prolonged HACE.

Prognosis

• The prognosis is excellent for AMS and for survivors of HACE; reascent with caution is acceptable after patients have completely recovered (ie, are fully asymptomatic). It is common for climbers to develop AMS, descend slightly, and 1 or 2 days later (after resolution of their symptoms) continue their ascent.

Patient Education

• Educate patients on staged ascents (see Deterrence/Prevention) and on the golden rules of altitude illness.
• The golden rules of altitude illness
• • If you feel unwell at altitude, it is altitude illness unless proven otherwise.
  • If you have symptoms of altitude illness, go no higher.
  • If your symptoms are worsening, fail to improve with treatment, or if HACE or HAPE are present, descend immediately.
• For excellent patient education resources, visit eMedicine's Environmental Exposures and Injuries. Also, see eMedicine's patient education article Mountain Sickness.

MISCELLANEOUS

Section 9 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Medical/Legal Pitfalls

• Missed HACE diagnosis
• Suddenly symptomatic brain tumors misdiagnosed as HACE
• Guillain-Barré syndrome misdiagnosed as HACE
• Herpes encephalitis misdiagnosed as HACE
• Cortical blindness and other conditions reminiscent of transient ischemic attack misdiagnosed as HACE

Special Concerns

• Other altitude-related conditions
• • Syncope within the first 24 h at high altitude is a well-recognized entity and is termed high altitude syncope. This form of neurocardiogenic syncope does not imply an underlying condition; a complete evaluation is generally unnecessary unless a second episode occurs.
  • The occurrence of focal neurologic deficits has been noted in supposedly healthy individuals at high altitude. These are not part of the altitude illness spectrum and require further evaluation. The etiology of transient focal neurologic deficits is unknown but may include atherosclerotic vascular disease, arterial vasospasm, focal edema, hypocapneic vasoconstriction, or migraine (with or without headache). Patients with previously undiagnosed arteriovenous malformation (AVM), cerebral aneurysm, and brain tumors have all become symptomatic on ascent to high altitude, and both ischemic and hemorrhagic stroke have also been reported. Additionally, transient global amnesia and delirium have been reported at altitude (see Basynat, 2004, for a review).⁴
  • While a tendency toward venous thrombosis has long been associated with high altitude exposure (this association clearly confounded by concurrent dehydration, inactivity, injury, and other DVT risk factors), a recent case of aortic thrombus resulting in loss of limb has been reported in the literature⁵. This case was not confounded by other known risk factors (environmental or genetic).
  • A recent report detailed a series of cases of marked, acute anxiety apparently exacerbated by acute altitude exposure.⁶ Note that marked, new anxiety at altitude should be a diagnosis of exclusion.
  • High-altitude retinal hemorrhage (HARH) is common and usually asymptomatic. The incidence of HARH varies from 4% at 4243 m to more than 50% in one study at 5360 m. For those who develop visual changes, nonemergent evacuation to lower altitude seems wise; however, no reports indicate that such visual changes are progressive in persons who remain at altitude. HARH resolves completely within a few weeks after descent.
  • Peripheral edema is common at high altitude, especially in women. It is not necessarily associated with altitude illness, but anyone with edema must be evaluated for AMS. Edema will resolve with decent. Diuretics work well; however, one must be cautious to avoid dehydration.
• Effects of high altitude on exercise
• • High-altitude hypoxia dramatically impacts aerobic exercise but not anaerobic performance. Maximum oxygen consumption (VO₂ max) drops approximately 10% for every 1000 m of altitude, starting at 1500 m. As a result, a person exercising at altitude to the same degree as at sea level will be operating at a higher percentage of (new) VO₂ max will become more easily fatigued and will reach anaerobic threshold earlier.
  • In addition, because of the large increase in exercise ventilation, breathlessness becomes a limiting factor. The result is that persons exercising at high altitude must exercise less intensely to avoid exhaustion and rest more frequently. Endurance time (minutes to exhaustion at 75% of altitude-specific VO₂ max) does improve, as much as 40% after 12 days.

ACKNOWLEDGMENTS

Section 10 of 12  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Thomas E Dietz, MD, to the development and writing of this article.

MULTIMEDIA

Section 11 of 12  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Media file 1:  High-altitude cerebral edema (HACE). Image courtesy of Dr Peter Hackett.
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Media type:  MRI

Media file 2:  A very ataxic man with high-altitude cerebral edema (HACE) at 4250 m being assisted toward the Gamow bag.
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Media type:  Photo

Media file 3:  Ultrasonography - Optic nerve sheath diameter measurement. Top of field is cornea, bottom of field reveals retina, then optic nerve in lowest field. Images courtesy of Dr Peter Fagenholz et al.
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Media type:  Ultrasound

Media file 4:  Horse evacuation of nonambulatory altitude illness. Patient in the Khumbu, Nepal. Image courtesy of Dr Peter Fagenholz.
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Media type:  Image

REFERENCES

Section 12 of 12

• Authors and Editors
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• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

1. Fagenholz PJ, Gutman JA, Murray AF, Noble VE, Camargo CA Jr, Harris NS. Evidence for increased intracranial pressure in high altitude pulmonary edema. High Alt Med Biol. Winter 2007;8(4):331-6. [Medline].
2. Chow T, Browne V, Heileson HL, et al. Ginkgo biloba and acetazolamide prophylaxis for acute mountain sickness: a randomized, placebo-controlled trial. Arch Intern Med. Feb 14 2005;165(3):296-301. [Medline].
3. Gertsch JH, Basnyat B, Johnson EW, et al. Randomised, double blind, placebo controlled comparison of ginkgo biloba and acetazolamide for prevention of acute mountain sickness among Himalayan trekkers: the prevention of high altitude illness trial (PHAIT). BMJ. Apr 3 2004;328(7443):797. [Medline].
4. Basnyat B, Wu T, Gertsch JH. Neurological conditions at altitude that fall outside the usual definition of altitude sickness. High Alt Med Biol. 2004;5(2):171-9. [Medline].
5. Fagenholz PJ, Gutman JA, Murray AF, Noble VE, Wu A, Zeimer G, et al. Arterial thrombosis at high altitude resulting in loss of limb. High Alt Med Biol. Winter 2007;8(4):340-7. [Medline].
6. Fagenholz PJ, Murray AF, Gutman JA, Findley JK, Harris NS. New-onset anxiety disorders at high altitude. Wilderness Environ Med. Winter 2007;18(4):312-6. [Medline].
7. Barry PW, Pollard AJ. Altitude illness. BMJ. Apr 26 2003;326(7395):915-9. [Medline].
8. Bartsch P, Bailey DM, Berger MM, et al. Acute mountain sickness: controversies and advances. High Alt Med Biol. 2004;5(2):110-24. [Medline].
9. Bartsch P, Roach RC. Acute mountain sickness and high-altitude cerebral edema. In: Hornbein T, Schoene R, eds. High Altitude: An Exploration of Human Adaptation. New York, NY: Marcel Dekker; 2001:731-775.
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Article Last Updated: Apr 16, 2008