野外與登山醫學-2014 WMS Practice Guidelines 2 高海拔疾病預防及治療 2

1. 高山病及高海拔腦水腫預防 http://blog.xuite.net/ymmcc/twblog/540135871
2. 高山病及高海拔腦水腫治療 http://blog.xuite.net/ymmcc/twblog/540164931
3. 高海拔肺水腫預防 http://blog.xuite.net/ymmcc/twblog/540171169
4. 高海拔肺水腫治療 http://blog.xuite.net/ymmcc/twblog/540177927
5. 同時罹患HACE及HAPE的治療 http://blog.xuite.net/ymmcc/twblog/540188730

2014 Wilderness Medical Society Practice Guidelines 高海拔疾病預防及治療 ，這是第二節，AMS及HACE 的治療

TREATMENT Potential therapeutic options for AMS and HACE include the following.

1. 下降是針對 AMS 及 HACE 最好的治療方式，下降應該下降到症狀改善，或無法繼續下降為止，通常症狀在下降 300-1000 公尺海拔之後會緩解，但因人而異，患者不要單獨下降，尤其是被診斷 HACE 的人
Descent

When feasible, descent remains the single best treatment for AMS and HACE. However, it is not necessary in all circumstances (discussed further below). Individuals should descend until symptoms resolve, unless impossible because of terrain. Symptoms typically resolve after descent of 300 to 1000 m, but the required descent will vary between persons. Individuals should not descend alone, particularly in cases of HACE. Recommendation Grade: 1A.

2. 氧氣，經由鼻導管給予氧氣，維持血中氧氣飽和度 90％ 以上，可作為下降的替代選擇，給氧氣通常在別無選擇之下才給，例如無法下降，偏遠地區的氧氣供應通常有限，要謹慎評估使用時機
Supplemental oxygen

Oxygen delivered by nasal cannula at flow rates suffi- cient to raise SpO2 to 大於 90% provides a suitable alternative to descent. Use is not required in all circumstances and is generally reserved for severe cases when descent is not feasible. Unlike at hospitals or large clinics, the supply of oxygen may be limited at remote high altitude clinics or on expeditions, necessitating careful use of this therapy. Recommendation Grade: 1C.

3. 加壓艙。需要由照護人員持續監測，對幽閉空間恐懼的人和嘔吐的人難以使用，從加壓艙出來的時候症狀可能在發，不要因使用加壓艙耽誤下降時機

Portable hyperbaric chambers

These devices are effective for treating severe altitude illness34,35 but require constant tending by care providers and are difficult to use with claustrophobic or vomiting patients. Symptoms may recur when individuals are removed from the chamber.36 Use of a portable hyperbaric chamber should not delay descent in situations in which descent is feasible. Recommendation Grade: 1B.

4. 丹木斯 ，一篇研究使用早晚 250 mg 的劑量來治療 AMS，是否更低劑量有相同效果則不知，兒童AMS患者目前沒人做研究，但據之前聽過的事件，應該有用，小兒劑量每次.5mg/kg/dose, 每12小時吃一次。
Acetazolamide

Only 1 study has examined acetazolamide for treatment of AMS. The dose studied was 250 mg twice daily and whether a lower dose might suffice is unknown.37 Recommendation Grade: 1B. No studies have assessed treatment of AMS in pediatric patients, but anecdotal reports suggest it has utility in this regard. The pediatric treatment dose is 2.5 mg/kg/dose twice daily up to a maximum of 250 mg/dose. Recommendation Grade: 1C.

5. 類固醇 dexamethasone  對於治療AMS 很有效，但無法加速高度適應，當停藥之後沒有再發作AMS才可以繼續上升，治療 HACE 初次給 8mg, 之後每 6 小時給 4 mg. 直到症狀改善。小兒劑量 0.15mg/kg/dose. 六小時給一次。

Dexamethasone

Dexamethasone is very effective in the treatment of AMS.38–40 The medication does not facilitate acclimatization, and further ascent should be delayed until the patient is asymptomatic while off the medication. Recommendation Grade 1B. Extensive clinical experience supports the use of dexamethasone in patients with HACE. It is administered as an 8-mg dose (IM, IV, or PO) followed by 4 mg every 6 hours until symptoms resolve. The pediatric dose is 0.15 mg/kg/dose every 6 hours.19 Recommendation Grade: 1C.

總結

1. 鑑別其他與AMS 和 HACE 相似的狀況，例如 脫水、虛脫、低血糖、失溫、低血鈉

2. 出現任何程度的高海拔疾病即應停止上升，根據周遭環境及症狀嚴重度，需考慮下降

3. 發生 AMS 的人可停留在原高度，使用 普拿疼或NSAID 治療頭痛，針對腸胃症狀使用止吐藥物

4. 丹木斯可藉由通氣及利尿作用加速高度適應治療AMS，但針對預防性使用的效果可能比治療性使用好。雖然丹木斯對於治療輕微AMS不錯，有經驗的醫師會發現類固醇對於中度到嚴重的疾病，療效更可靠。而中度到嚴重的AMS/HACE通常需要下降。

5. AMS患者在症狀消失之後可繼續攀登，如果仍有症狀不建議回到先前發作症狀的海拔

6. 在AMS症狀緩解後，服用丹木斯並上升是可以的
7. 快速上升到高海拔產生AMS的症狀，HACE 與嚴重 AMS 區別是出現神經症狀：ataxia運動失調、confusion神智迷糊、altered mental status 神智改變。HACE 可與 HAPE 同時發生，發生 HACE 的患者如果在有醫院或特殊診所的環境，應開始接受氧氣及類固醇治療。偏遠地區無法取得醫療資源，懷疑罹患HACE患者需立即下降，AMS症狀經過丹木斯或類固醇治療無效，也應下降。

8. 無法下降時，可考慮給氧或加壓艙。罹患HACE的人應使用類固醇

9. 直到停用類固醇後也不再出現症狀，才可考慮上升

Suggested approach to AMS/HACE treatment

Care should be taken to exclude disorders whose symptoms and signs may resemble those seen in AMS and HACE, such as dehydration, exhaustion, hypoglycemia, hypothermia, or hyponatremia.8 Persons with altitude illness of any severity should stop ascending and may need to consider descent depending on the clinical circumstances and severity of illness (Table 3).8 Patients with AMS can remain at their current altitude and use nonopiate analgesics for headache and antiemetics for gastrointestinal symptom relief; that may be all that is required. Acetazolamide will help treat AMS by facilitating acclimatization through increased ventilation and diuresis, but these physiologic effects may work better for prevention than for treatment. Although acetazolamide is good for treating mild illness, experienced clinicians have found dexamethasone a more reliably effective treatment for moderate-to-severe disease, which often requires descent as well. Individuals with AMS may resume their ascent once symptoms resolve, but further ascent or reascent to a previously attained altitude should never be undertaken in the face of ongoing symptoms. After resolution of AMS, reascent with acetazolamide is prudent. HACE is differentiated from severe AMS by neurological signs such as ataxia, confusion, or altered mental status in the setting of acute ascent to high altitude and may follow AMS or occur concurrently with HAPE. Individuals developing HACE in populated areas with access to hospitals or specialized clinics should be started on supplemental oxygen and dexamethasone. In remote areas away from medical resources, descent should be initiated in any suspected HACE victim or if symptoms of AMS are not responding to conservative measures or treatment with acetazolamide or dexamethasone. If descent is not feasible owing to logistical issues, supplemental oxygen or a portable hyperbaric chamber should be considered. Persons with HACE should also be started on dexamethasone. No further ascent should be attempted until the victim is asymptomatic and no longer taking dexamethasone.