可提供隊員高海拔反應及預防治療資訊, 請隊員去掛旅遊醫學科門診, 由醫師開立藥物
旅遊醫學門診所有服務都是自費項目，不在健保給付範圍內，旅客需自行負擔掛號、診療費用、藥品費、藥事服務費、接種耗材費用等。
無醫師執照,擅自給予他人"處方"藥物是違法的《藥事法》規定「須由醫師處方之藥品，非經醫師處方，不得調劑供應。
處方藥」是經醫師診斷，確定病因後開立處方箋，才能到藥局拿到藥品使用，藥局沒有醫師處方是不能販賣醫師處方藥（例如高血壓、糖尿病用藥、抗生素等）。
指示藥」可以由醫師、藥師或藥劑生來指導民眾使用，購買時不需要有處方箋（例如普拿疼、胃藥（制酸劑）等）。
成藥」不但不需要醫師處方箋，也不必經過藥師、藥劑生指示，民眾可以自行選購，但使用前須詳細閱讀藥品說明書與用法用量（例如綠油精與萬金油等）。
課前測驗，高山病的部分
1. 隊員如果出現頭痛, 要如何判定是AMS急性高山病? 海拔? 到達高海拔的時間? 症狀?治療方式? 預防方式? 預防用藥有哪些可以用?2. 隊員出現咳嗽及呼吸困難症狀, 如何判定是HAPE高海拔肺水腫? 症狀? 會發燒嗎? 跟肺炎怎麼區分? 治療方式?
3. 隊員出現神智異常或昏迷, 如何診斷是HACE高海拔腦水腫? 症狀? 發燒? 伴隨肺水腫? 治療?
4. AMS與體力不好怎樣區分?
2016-05-25 台大登山社 登山醫學主題
1. 急性高山病 AMS、高海拔腦水腫
2. 高海拔肺水腫
3. 失溫
4. 外傷處置：止血、固定、包紮、搬運
5. 蛇咬、蜂螫、其他動物昆蟲叮咬
6. 口服藥物使用方式、注射藥物使用方式
7. 水泡處理
8. 急性腹痛評估及處置
9. 熱急症：中暑、熱衰竭、熱痙攣
https://www.facebook.com/notes/10152148618727794/
到底要稱呼是登山醫學還是野外醫學呢？野外醫學似乎是比較貼切的稱呼，不過之前在登山社上課，都是用登山醫學當題目，所以習慣了103年 陽明上課的內容
18:30社課part 1
19:50中間休息
20:00社課part 2
21:30 社課結束(會議室須淨空)
課程大綱:
part 1: 開場
1. 高山症、高海拔腦水腫、高海拔肺水腫
2. 熱急症：中暑、熱衰竭、熱痙攣
3. 失溫
4. 溺水
5. 雪盲、凍傷、皮膚龜裂
6. 外傷處置：止血、固定、包紮、搬運
7. 蛇咬、蜂螫、其他動物昆蟲叮咬
8. 口服藥物使用方式、注射藥物使用方式
9. 燙傷
10. 水泡處理
11. 腸胃炎
山難案例參考
1. 王士豪醫師 http://goo.gl/8vqWtl
2. 宜蘭教師走山隊
台大登山社2002/07/16 北二段山難事件 綜合檢討報告書
參考資料：
1. 衛福部疾管署 高海拔疾病
其他文章
寫給登山入門者的登山醫學
2015-03-12 登山醫學授課內容
醫療
人員分配上課內容
0. 總論，藥物的使用方式
1. 高山症 AMS + 高海拔腦水腫
2. 高海拔肺水腫 (靜雯)
3. 熱急症：中暑、熱衰竭、熱痙攣
4. 失溫、凍傷、溺水 (ting yuan)
5. 外傷處理 (筱雯)
足底水泡、雪盲、燙傷 (筱雯)
6. 蛇咬、蜂螫、其他動物昆蟲叮咬
有些疾病的重要性，在於認識疾病，進而能避免發生，例如AMS、雪盲、熱急症
蜂螫、蛇咬、燙傷、溺水、外傷的部分在於處理已經發生的事情
有些情況雖然知道也無法避免，但知道萬一遇到了怎麼辦，比較重要
以前的活動內容
1.每個參與的學員，要負責以下一個主題，並製作講解
融會貫通後，社課時解說給大家聽
2.社課前一個禮拜要繳交PPT給社課負責人，需審個稿
3.社課當天每位社員會被指定(由社課負責人指定)，去記錄某人講解PPT上的錯誤或學長有補充的地方，
社課完需幫其PPT做修改。
4.社課完一個禮拜內(到12/30前)，記錄人要繳交修改之PPT給社課負責人
主題
a.高山症簡介與急性高山症---信儒
b.高海拔腦水腫、高海拔肺水腫---秉仲
c.外傷處置(止血、固定、包紮、搬運)---仲廷、芷
d.蛇咬、蜂螫、其他動物昆蟲叮咬--彥澄
e.雪盲、凍傷、皮膚龜裂--芳羽
f.燙傷、水泡處理---佳琦
g.腸胃炎、失溫及溺水--恭平、賦庭
h.熱急症(中暑、熱衰竭、熱痙攣)---容君
i.運動傷害處理(抽筋、拉傷、肌肉休息)--李依臻
參考資料
高山症主要用藥介紹
止血、包紮、固定、搬運
1.台東縣消防局 救護常識 急救大觀園 脫臼與骨折 溺水 毒蛇咬傷 燒(燙)傷 中暑 電擊 止血法 急救原則 求救方法 初步創傷評估 哈姆立克急救法 民眾版心肺復甦術
2.傷口清洗
3.足底筋膜炎的繃帶纏繞法
4.鎖骨~肩峰關節受傷的繃帶纏繞法
蛇咬
1.蛇咬傷到院前處置和急診治療原則
2.台東縣消防局 救護常識 急救大觀園 脫臼與骨折 溺水 毒蛇咬傷 燒(燙)傷 中暑 電擊 止血法 急救原則 求救方法 初步創傷評估 哈姆立克急救法 民眾版心肺復甦術
3.蛇咬處理
4.蛇咬傷到院前處置和急診治療原則
5.毒蛇咬傷 台北榮總 楊振昌醫師
6.毒蛇咬傷
7.默克家庭診療手冊 毒蛇咬傷
8.大陸 外科學總論 毒蛇咬傷
9.台南衛生局 緊急救護常識
10.高榮醫訊 毒蛇咬傷
11.高醫醫訊 （只貼上部分標題） 臺灣海洋神經毒 常見的氣體中毒 簡介有毒植物的毒性成分及毒理作用 常見的農藥中毒 毒蛇咬傷的急症處理
蜂螫
1.蜂螫
2. 過敏性休克
3.蜂螫的治療 MANAGEMENT OF HYMENOPTERA ENVENOMATION (ROSEN 5TH EDITION P 794
萊姆病
1.2014-03-13 萊姆病治療 八隻腳咬傷治療
溺水
1.台東縣消防局 救護常識 急救大觀園 脫臼與骨折 溺水 毒蛇咬傷 燒(燙)傷 中暑 電擊 止血法 急救原則 求救方法 初步創傷評估 哈姆立克急救法 民眾版心肺復甦術
2.溺水處理
3.溺水及潛水急症~~ 三軍總醫院急診醫學部 陳穎信
腸胃炎
1.高山遇到腸胃炎
【登山醫學】上山+肚子不乖怎麼辦？
休克
1.anaphylaxis 過敏性休克 全身性過敏反應 (from Rosen 5th edition p 1619)
2.過敏性休克處理
3.破傷風疫苗的嚴重過敏反應與死亡個案
4.破傷風疫苗施打方式
醫藥箱
1. 台灣 登山醫藥箱 建議與討論
2. 量身訂做一個登山醫藥箱
40人隊伍的醫藥清單
2019年12月19日 星期四
野外與登山醫學----高海拔肺水腫成因
高海拔肺水腫成因，簡單說，是跟低壓和低氧有關。
單純的低氧疾病，例如慢性阻塞性肺病，在平地並不常引起肺水腫，所以低氧並非引起高海拔肺水腫唯一原因。
肺部的功能主要是進行氣體交換，當身體缺氧(以及含有高二氧化碳)的血液，流入肺部，新鮮空氣從氣管進入肺泡，氧氣和二氧化碳隨著血流會在肺泡進行氣體交換，接著含有氧氣的血液流回心臟，再由心臟送出到全身其他器官。
為了讓肺部能進行理想的氣體交換，身體會控制讓血液流入含有氧氣的肺泡，萬一生病或其他原因造成肺泡內的氧氣濃度低，身體會自動將該處肺泡血管收縮，減少血液流入缺氧的肺泡。
身體組織古老的生理反應，遇到缺氧時，缺氧部位的血管會擴張，讓更多血液流入，增加細胞氧氣供應，但肺部的反應剛好和其他身體組織相反，肺部在缺氧的部位，血管會收縮，讓局部血流減少，目的是希望血流流到氧氣濃度比較高的肺泡，當肺部沒有這種因缺氧造成的血液分流，會有一些血液流到沒有氧氣的肺泡，這些流經缺氧地區的血液，無法進行氣體交換，這些血流相當於是浪費了，但如果缺氧的肺部，不是局部，例如是因為高海拔，造成所有肺泡都處於缺氧狀態呢？
這時候悲劇就會發生了，缺氧的環境會讓整個肺部的血管收縮，血管收縮的結果，是肺部動脈壓力會上升，肺部血管壓力上升，造成血管內的液體（血漿、蛋白質）滲漏出去，漏到細胞間隙和肺泡，造成肺泡積水，肺泡的空間本來是要容納氣體進出的，一旦肺泡被水淹沒，就無法進行氣體交換，缺氧會更嚴重，缺氧更嚴重，肺動脈壓力又更高，血管滲漏又更嚴重，變成惡性循環，最嚴重的情況，會死翹翹。
在平地，低氧的疾病很多種，常見的有慢性阻塞性肺病，但單純低氧在這類病患，並不常引起肺水腫，所以低氧並非唯一因素，這是肯定的
引起高海拔肺水腫的原因還有更多因素
atrial natriuretic peptide(ANP,心房利鈉激素) 和 vasopressin(血管加壓素) 的分泌，ANP加重血管通透性，造成血管內的蛋白質和液體更容易滲出血管外，ANP也會讓末稍肺動脈血管擴張 ，促進鈉離子排出體外，造成低血鈉，抑制 RAA 系統。
vasopression會造成水分滯留，還有加重低血鈉的效應atrial natriuretic peptide(ANP,心房利鈉激素) 和 vasopressin(血管加壓素) 的分泌，ANP加重血管通透性，造成血管內的蛋白質和液體更容易滲出血管外，ANP也會讓末稍肺動脈血管擴張 ，促進鈉離子排出體外，造成低血鈉，抑制 RAA 系統。
http://www.nejm.org/doi/full/10.1056/NEJM199607183350313
RAA 系統這裡有解說： http://highscope.ch.ntu.edu.tw/wordpress/?p=2853
在這個網站文章也有提到成因：http://big5.wiki8.com/feishuizhong_20530/
高原性肺水腫是急性高原病最嚴重的類型之一，系高海拔缺氧環境下所引起的肺水腫。快速登高、重度體力勞動和寒冷是發病誘因。最低發病高度為2600m，但多數發生在首次進入海拔4000m以上者。年輕而未適應高原環境者，或已適應的居民從低地旅居數周后重返高原者均較易發病，高原適應者迅速上升到更高地區時也會發病。曾發病者常易再發。發病機制尚未明確。可能因素為：①缺氧通過神經體液作用使肺小動脈收縮而致肺動脈高壓；②肺毛細血管內廣泛血栓形成，使得肺毛細血管壁通透性改變；③缺氧引起過度通氣，動脈血CO2分壓下降，導致呼吸性堿中毒，加重組織缺氧；④缺氧引起周圍血管收縮，血液重新分布致肺血容量增加；⑤劇烈運動又使右心回心血量增多，導致肺循環負荷過重；⑥個體因素。
王士豪醫師補充：
肺 動脈壓上升與白三烯素釋放是不同機轉，肺小動脈通透性也涉及許多複雜的分子的上升與下降、基因表現、蛋白質調控與酵素的配合，並非白三烯素而已。低氧時， 肺部發生了什麼事情，是直接觸及低氧研究的核心，了解這個，便有機會能得到未來更好的治療方式，但是，這是很漫長的努力過程。基礎的低氧醫學研究，十年一 劍，深深令人著迷，是全世界低氧醫學家族的科學家共同耕耘的園地。
另 外，Highlander（高地住民）與lowlander（低地住民）的差異也很有趣。Highlander住民，自受孕開始，他的媽媽孕期的生理表 現、胎盤、臍帶血管壓力、平均出生週數、平均出生體重，出生後對於高山病的感受度、以及在不同狀況下運動時生理與基因的表現，都與Lowlander大不 相同。甚至，經歷同樣的運動訓練後，運動表現（如：騎單車）的成績也不一樣。所謂的Highlander（高地住民），是指世居在海拔2500公尺以上的人們，全世界只有四群人是真正的Highlander：青藏高原的藏族、喜馬拉雅山區的雪巴人、南美洲安地斯山脈的人們、以及非洲衣索比亞高原的住民。
至於，台灣的原住民，在高海拔生理的角度來看，他們其實是與漢人無異的Lowlander（低地住民）。
至於，台灣的原住民，在高海拔生理的角度來看，他們其實是與漢人無異的Lowlander（低地住民）。
野外與登山醫學----寫給入門登山者的登山醫學
2018-05-22
昨天台大登山社中嚮課程. 報告七個主題. 檢討
1. 昆蟲學的部分. 因報告者對昆蟲-節肢動物有興趣, 所以講的還不少,
幸好此次主題不多, 所以沒有耽誤太多時間, 所有動物昆蟲節肢動物咬傷,
僅六種毒蛇有解毒劑可以打. 其他咬傷如果未發生過敏或感染, 僅傷口疼痛,
送醫能做的處理有限(給予止痛藥), 如果是輕微創傷,
或許十年以上沒有施打破傷風疫苗可考慮施打, 但破傷風疫苗並非必要,
算是送醫"附帶" 的治療. 關於破傷風疫苗施打建議可以參見 http://blog.xuite.net/ymmcc/twblog/114385621
2. 所有創傷傷口都應清洗乾淨, 有些部位感染率低, 是指清洗徹底的狀態下, 不需要另外給予口服抗生素預防感染
2. 所有創傷傷口都應清洗乾淨, 有些部位感染率低, 是指清洗徹底的狀態下, 不需要另外給予口服抗生素預防感染
3. 溺水的重點在於盡快給予病患腦部氧氣供應, 所以如果病患無適當呼吸,
盡早給予人工呼吸, 病患如果沒有正常呼吸或移動, 給予胸部按壓,
溺水的急救流程還是叫叫ABC. 因溺水患者通常是先耗盡血中氧氣,
之後才進展為心跳停止, 如果僅給予胸部按壓應該無效.
4. 通用急救流程 叫叫CAB. 先叫病患, 病患如果無法應,
則啟動緊急醫療救護系統(醫院外,請人幫忙用電話打 119). 盡快取得AED.
自動體外電擊去顫器, 評估病患有無正常呼吸, 有無移動, 5-10 秒鐘,
不要超過十秒鐘, 使用四個音節數七次, 1001 -1002-1003-1004-1005-1006 -1007,
如果沒有正常呼吸或移動, 開始胸部按壓, 速率 100-120次/每分鐘, 不要超過
120次/每分鐘, 深度 5-6 公分, 不要超過 6 公分, 每壓 30 次胸部,
給予兩次人工呼吸, 人工呼吸需正確打開呼吸道, 每次吹氣一秒鐘, 不要超過一秒鐘,
每次胸部有起伏則算成功, 胸部下降可以吹第二口氣, 吹氣之後馬上轉換成胸部按壓,
每壓 30 次 吹兩口氣, 算一個循環, 五個循環之後, 如果有AED
可重新評估是否需電擊, 如果無AED
則重複一直做到有急救隊來現場為止.
2018-04-10 .
2014年上課前寫的, 關於登山相關的醫療問題.
請回答下面的問題，有些題目也許出的不太好，可以來討論看看怎麼改比較妥當
1. 喝酒能禦寒嗎?
2. 以前曾經得過AMS急性高山病，上山前可以先吃止痛藥物，避免發生高山病
3. 丹木斯可以預防AMS急性高山病.
4. 丹木斯可以治療AMS急性高山病.
5. 類固醇可以預防AMS急性高山病.
6. 類固醇可以治療AMS急性高山病.
7. 利尿劑可以預防高海拔腦水腫 HACE
8. 利尿劑可以治療高海拔腦水腫 HACE
9. 降血壓藥物 nefidipine 可以治療AMS急性高山病.
10. 降血壓藥物 nefidipine 可以治療高海拔肺水腫
11. 威而剛可以加速高度適應，預防及治療AMS急性高山病.
12. 犀利士可以加速高度適應，預防及治療AMS急性高山病.
13.
高海拔環境下，出現咳嗽有濃痰、發燒、倦怠等等症狀，應先考慮是流感或肺炎
14. 高海拔肺水腫症狀包括：頭痛、倦怠、呼吸困難、喘？
15. 高海拔腦水腫症狀包括：呼吸急促、呼吸困難、癲癇、昏迷？
16. 發生AMS急性高山病.之後，如果已經吃藥治療，可以繼續上升
17. 發生高海拔腦水腫HACE，最重要的治療是給類固醇
18. 發生高海拔肺水腫HAPE，如果合併發燒，可考慮使用抗生素
19. 高海拔環境，出現咳嗽、流鼻水、發燒、咳嗽等症狀，應使用抗生素
20. 在野外環境，遇到燙傷，應盡快塗抹燙傷藥膏，以減少燙傷的嚴重度
21. 如果身邊有冰雪，燙傷後建議盡快冰敷
22. 遇到動物昆蟲咬傷螫傷，傷口應盡快塗抹優碘
23. 摔倒擦傷或被刀子割傷，建議盡快將優碘塗抹在傷口上
24. 拉傷扭傷的肢體，發生的前幾天間隔性熱敷讓組織比較快恢復
25.
遇到過敏應盡快注射抗過敏藥物(抗組織胺、類固醇)，以免發生過敏性休克
26. 發生過敏性休克，最重要的藥物是腎上腺素，建議靜脈注射給予
27. 腎上腺素劑量，有呼吸心跳的過敏性休克，一次可以肌肉注射 0.3～0.5 cc
(1cc=1mg)
28. 多數的過敏反應，如果沒有繼續接觸過敏原，都會自己恢復
29. 發生高海拔反應之後，即使治療痊癒，也不應該繼續上升高度
30. 上山之前鍛鍊身體，增加體適能，以減少高海拔反應的機率。
31. 高山路線多增建山屋，以減少AMS急性高山病.發生率
32. 水泡到底可不可以弄破
33. 傷口可以用優碘消毒嗎
34. 蜂螫可以塗氨水嗎
2016-05-25 寫在台大中嚮上課前
學員交ptt檔案時間太晚. 參考資料太少,
引用的內容沒有經過嚴格考照.
2015-03-12 上課檢討:
肺水腫的部分, X光分析可以省略
失溫重點在於避免死亡
凍傷重點在於避免殘障(凍傷部位擴大)
威而鋼無法預防AMS
無法使用丹木斯, 可以使用類固醇預防AMS or HACE
中暑定義: 高溫(通常大於 40.5~ 41 度C 合併中樞神經症狀: 神智不清, 昏迷,
癲癇)
中暑是高溫造成中樞神經失調
熱衰竭是水分電解質大量流失
寫給入門登山者的登山醫學
在山上可能會發生什麼跟醫療有相關的事情呢?
其實多爬山就知道了，不過如果你願意在上山之前先做做功課，請你繼續耐心往下看。
內容
1. 外傷、足部水泡、燒襠、曬傷
2.內科疾病： 腸胃炎、感冒、個人慢性病的突然惡化、其他內科疾病
3. 高海拔疾病 AMS HACE HAPE
4. 肌肉抽筋
5. 熱衰竭、熱痙攣、中暑
6. 失溫
7. 動物昆蟲咬傷螫傷
8. 壕溝足
1. 外傷、足部水泡、燒襠、曬傷
在山上，聽過兩起山刀砍傷腳的案例，傷口流血後，第一件事情應該是先加壓止血，加壓時間有可能需要幾十分鐘，如果傷口很髒，先用飲用水清洗乾淨之後，再加壓止血，不要將優碘倒入傷口內，不要在傷口內灑抗生素藥粉，加壓止血請勿使用止血帶，請用直接加壓止血。
穿著適當的衣物和鞋子，如果預期可能會燒襠，可以在大腿內側先塗上凡士林，我也嘗試過貼透氣膠帶，但塗上凡士林之後，就無法貼膠帶，兩個只能選一個。PP內褲不能完全保證不燒襠。胖的人比較容易燒襠。天氣濕熱容易燒襠。男生比較容易燒襠，但我也遇過女生燒襠的。
足部悶濕，走路的時間過長容易起水泡，登山鞋不合腳，也容易起水泡，水泡處理有另一篇文章提了，水泡產生之前，我會用透氣膠帶貼很多層在摩擦比較厲害的地方，例如腳後跟、前腳掌，代替皮膚讓它跟鞋子磨。
外傷，我自己都是用抗生素藥膏擦上去，然後貼上透氣膠帶，連OK繃都不用。但傷口如果太髒，有沙子泥土異物，應該先用飲用的水沖洗過，再來才上藥，清洗傷口遠比將傷口泡在消毒水重要。傷口泡優碘並無法降低感染率。
2.內科疾病： 腸胃炎、感冒、個人慢性病的突然惡化、其他內科疾病
還沒想到寫什麼。
3. 高海拔疾病 AMS HACE HAPE
社團裡面很多文章了，有興趣記得看。認識高海拔疾病，當發生在自己或隊員身上時，要知道你可能得了哪一種疾病，並且知道如何處理它，我想這是主要的重點。預防之道，緩慢上升，增加高度適應時間，不過在台灣很難做到，只好靠藥物來預防。
丹木斯(目前是另一種學名藥，但說這個大家比較知道)可以加速高度適應，可以預防高海拔疾病，可以治療高海拔疾病。類固醇，當無法吃丹木斯，可以考慮使用類固醇預防高山症，但類固醇無法加速高度適應，且停用之後可能造成高山症症狀惡化。
4. 肌肉抽筋
抽筋時，將抽筋的肌肉緩慢伸展，避免過度抽筋引起肌肉受傷，爬山時遇到肌肉抽筋，再來可能不是休息一兩個小時就會好的，如果是長天數的行程，建議直接休息紮營。過度抽筋引起的疼痛可以吃止痛藥。
5. 熱衰竭、熱痙攣、中暑
熱可能引起水分大量流失，伴隨電解質流失，補充水分也可以避免身體散熱機制超過負荷，不要一次補充大量純水，會引起低血鈉，低血鈉可能會頭暈、無力，甚至癲癇發作。肌肉過熱可能造成抽筋，這時後的處理主要是休息降溫、停止活動、補充水分電解質，但爬山遇到的可能不單純只有熱痙攣，更多時候是體適能不足，這個不是降溫就可以恢復的。以前聽說按摩會讓未來的歲月更容易發生抽筋，這是沒有根據的說法，適當的按摩是可以的。抽筋過度引起的疼痛可以吃止痛藥。當身體無法調
控過高的體溫，可能變成中暑。醫學講的中暑，第一要件是體溫超過40度C，伴隨神智異常，沒有適當治療，死亡率高達 50％，所以一般民眾到醫院後說的中暑，常常只能算熱急症而已，因為熱造成的身體不適。中暑吃退燒藥物並沒有作用，需要的應該是離開熱源、5-10分鐘內積極降溫到 39 度 C 以下。
控過高的體溫，可能變成中暑。醫學講的中暑，第一要件是體溫超過40度C，伴隨神智異常，沒有適當治療，死亡率高達 50％，所以一般民眾到醫院後說的中暑，常常只能算熱急症而已，因為熱造成的身體不適。中暑吃退燒藥物並沒有作用，需要的應該是離開熱源、5-10分鐘內積極降溫到 39 度 C 以下。
6. 失溫
失溫重點是要知道自己或隊員可能出現失溫，避免繼續失溫，嚴重失溫者，回溫的地方盡量靠近軀幹中軸。在野外保溫的課程應該不屬於登山醫學範疇。
7. 動物昆蟲咬傷螫傷
昆蟲和動物咬傷可能引起疼痛、傷口流血、感染等等問題，蜂螫有人會出現過敏的症狀，但不是每個人都會。在台灣，除了六大毒蛇咬傷有抗毒血清可以解毒，其他昆蟲、動物、節肢動物咬傷並沒有解藥，醫師能給予的治療不外乎減輕疼痛，處理併發症，例如傷口感染，或者病原菌傳染，例如恙蟲叮咬引起的恙蟲病、蜱咬傷引起的萊姆症。
在山上，動物昆蟲咬傷處理比照一般外傷，不過毒蛇咬傷需盡快下山打抗毒血清，彈性繃帶可以打，但效果不大，而且不能綁太緊。毒蛇急救器可以用，但不能依賴這個。不要用嘴巴吸出蛇毒，也不要用刀子切開傷口，沒有用。
蜂螫除非引起過敏性休克，不然腎上腺素沒有作用。腎上腺素主要是治療嚴重過敏。蜂螫引起的疼痛可以吃止痛藥物。
蜈蚣咬傷會造成疼痛，目前台灣沒有致死案例。
隱翅蟲體液造成的皮膚灼傷，比照一般燙傷處理即可。
其他可能被動物昆蟲咬傷引起的傳染病，在山上其實能做的不多，下山處理即可（除非在山上還要待很久，一兩星期）
昆蟲叮咬. 如果有局部皮膚症狀. 病患沒有藥物過敏. 擦曼秀雷敦. 外傷藥膏,
抗過敏藥膏都無妨.
8. 壕溝足
症狀：足部痛，非常痛，刺痛，可能持續數天至一個月以上，可能在晚上痛醒。
成因：濕、冷、受壓時間過久，造成血液循環不足，引起肌肉及神經傷害。
預防：避免長時間穿著濕的鞋走路，休息的時候盡量將腳弄乾弄暖
治療：如果足部濕冷，小心回溫，用40度的溫水浸泡雙腳，回溫時可能也會造成疼痛，皮膚紅腫。可以吃止痛藥物減輕症狀。
其他參考文章
NEJM 2013 acute high altitude illness 翻譯
野外與登山醫學----如果要登高山的話比較推薦哪一款預防 AMS 急性高山病的藥?
有人問: 如果要登高山的話比較推薦哪一款AMS 急性高山病的藥?
回答:
建議使用丹木斯預防高山症, 無法吃丹木斯,才使用類固醇. 丹木斯可以加速高度適應, 類固醇無法加速高度適應, 吃丹木斯,.上山沒症狀,停用藥物通常還好, 吃類固醇, 停藥之後可能會突然出現高山症症狀.
建議使用丹木斯預防高山症, 無法吃丹木斯,才使用類固醇. 丹木斯可以加速高度適應, 類固醇無法加速高度適應, 吃丹木斯,.上山沒症狀,停用藥物通常還好, 吃類固醇, 停藥之後可能會突然出現高山症症狀.
類固醇通常是給無法吃 acetazolamide 或 嚴重 AMS 病患使用, 尤其是可以輔助於下降撤退
高海拔疾病藥物劑量
2015-01-22 更新 rosen 8th edition page 1933 (rosen 高海拔疾病在 144 章, page 1928, 如果看 PDF...
2015-01-22 更新 rosen 8th edition page 1933 (rosen 高海拔疾病在 144 章, page 1928, 如果看 PDF...
Acetazolamide=diamox丹木斯
可預防及治療高山症，可加速高度適應
預防AMS：每次 125-250 mg 一天兩次，上升前一天開始吃，上山後持續再吃兩三天，直到感覺適應為止，停藥後並不會誘發高山症，磺胺類藥物過敏患者禁用。
治療AMS：每次 250mg，一天兩次，直到症狀改善
預防AMS：每次 125-250 mg 一天兩次，上升前一天開始吃，上山後持續再吃兩三天，直到感覺適應為止，停藥後並不會誘發高山症，磺胺類藥物過敏患者禁用。
治療AMS：每次 250mg，一天兩次，直到症狀改善
請看這篇 http://goo.gl/s0J0Dx
野外與登山醫學----高海拔是否會增加氣胸發生的機率Bullous lung disease
高海拔是否會增加氣胸發生的機率Bullous lung disease (EUROPEAN RESPIRATORY JOURNAL Eur Respir J 2007; 29: 770–792)
Bullous lung disease (EUROPEAN RESPIRATORY JOURNAL Eur Respir J 2007; 29: 770–792)
野外與登山醫學----止血帶的使用 1~~ Tourniquet basics- WMS 2014年指引
2024-01-30 17:30 編輯
止血帶參考資料很多. 放一起感覺文章太龐大. 所以拆成四篇文章
下面資料引用自 WMS 2014年指引. 僅列出止血帶的內容
Wilderness Medical Society Practice Guidelines for Basic Wound Management in the Austere Environment
Tourniquet basics
止血帶寬度至少四公分，可以持續打兩小時，不需要一直鬆開，不需要間隔性讓血流稍微流向缺血的肢體，如果一條止血帶效果不理想，直接在近心部位，靠著第一條止血帶附近，再打第二條止血帶，要讓動脈完全不流血為止，打上止血帶之後，可以儘速將傷患脫離現場，或進一步使用其他方式止血。如果止血了，可以鬆掉止血帶，如果再次流血，重新綁上止血帶，肢體通常可以承受很長的缺血時間，多數人的肢體可以承受缺血六小時之久，雖然有個體差異，但兩小時缺血時間，並不會增加殘障機率（不會增加截肢機率），間隔性容許肢體有微量血流，並不會增加肢體保存的成功率。
A tourniquet can be placed for up to 2 hours with minimal risk of complication.38, 39, 40 A tourniquet must have a width sufficient to obstruct blood flow. The minimum acceptable width is 4 cm (1.5 inches). If placement of a tourniquet fails to control bleeding, a second tourniquet should be placed immediately adjacent and proximal to the first, effectively increasing the tourniquet width and its effectiveness. The tourniquet must have a windlass device of some sort; otherwise sufficient force to overcome arterial pressure cannot be developed. A standard belt cannot be used as a tourniquet because it cannot be pulled tight enough to occlude arterial flow. A tourniquet must always be applied with sufficient force to occlude arterial pressure, which can be confirmed by the absence of distal pulses after proper application.41 Failure to do so, occluding only venous pressure, can increase bleeding.42 When used as a stopgap technique, the tourniquet is applied immediately to control bleeding. The injured individual can then be moved or further treated until a proper dressing can be applied. Once this dressing is in place, the tourniquet can be released. If there is no further bleeding, the tourniquet is no longer required. If bleeding recurs, the tourniquet can be tensioned again to regain control of bleeding. A tourniquet that has been left on for longer than 2 hours should remain in place until definitive medical evaluation occurs.43 There is no utility in the old recommendation of releasing a tourniquet every so often to allow a “little perfusion” to occur. Bleeding is either controlled in the first 2 hours or not. There are many cases of limb salvage with prolonged tourniquet times, or secondary to other reasons for lack of limb perfusion. Although individual variation exists, most limbs can tolerate up to 6 hours of ischemia time. After 2 hours of tourniquet time there is no evidence that the rate of limb salvage is improved with intermittent perfusion.42, 43
Wilderness Medical Society Practice Guidelines for Basic Wound Management in the Austere Environment
Tourniquet basics
止血帶寬度至少四公分，可以持續打兩小時，不需要一直鬆開，不需要間隔性讓血流稍微流向缺血的肢體，如果一條止血帶效果不理想，直接在近心部位，靠著第一條止血帶附近，再打第二條止血帶，要讓動脈完全不流血為止，打上止血帶之後，可以儘速將傷患脫離現場，或進一步使用其他方式止血。如果止血了，可以鬆掉止血帶，如果再次流血，重新綁上止血帶，肢體通常可以承受很長的缺血時間，多數人的肢體可以承受缺血六小時之久，雖然有個體差異，但兩小時缺血時間，並不會增加殘障機率（不會增加截肢機率），間隔性容許肢體有微量血流，並不會增加肢體保存的成功率。
A tourniquet can be placed for up to 2 hours with minimal risk of complication.38, 39, 40 A tourniquet must have a width sufficient to obstruct blood flow. The minimum acceptable width is 4 cm (1.5 inches). If placement of a tourniquet fails to control bleeding, a second tourniquet should be placed immediately adjacent and proximal to the first, effectively increasing the tourniquet width and its effectiveness. The tourniquet must have a windlass device of some sort; otherwise sufficient force to overcome arterial pressure cannot be developed. A standard belt cannot be used as a tourniquet because it cannot be pulled tight enough to occlude arterial flow. A tourniquet must always be applied with sufficient force to occlude arterial pressure, which can be confirmed by the absence of distal pulses after proper application.41 Failure to do so, occluding only venous pressure, can increase bleeding.42 When used as a stopgap technique, the tourniquet is applied immediately to control bleeding. The injured individual can then be moved or further treated until a proper dressing can be applied. Once this dressing is in place, the tourniquet can be released. If there is no further bleeding, the tourniquet is no longer required. If bleeding recurs, the tourniquet can be tensioned again to regain control of bleeding. A tourniquet that has been left on for longer than 2 hours should remain in place until definitive medical evaluation occurs.43 There is no utility in the old recommendation of releasing a tourniquet every so often to allow a “little perfusion” to occur. Bleeding is either controlled in the first 2 hours or not. There are many cases of limb salvage with prolonged tourniquet times, or secondary to other reasons for lack of limb perfusion. Although individual variation exists, most limbs can tolerate up to 6 hours of ischemia time. After 2 hours of tourniquet time there is no evidence that the rate of limb salvage is improved with intermittent perfusion.42, 43
野外與登山醫學----WMS---燒燙傷(截錄自傷口處置指引)
Burns
用冷水沖洗或浸泡可以減少受傷程度以及減輕疼痛，但要避免組織凍傷或溫度過低，最近系統性回顧發現，磺胺銀比起生物合成敷料或矽敷料，更會導致傷口癒合不良，水凝膠處理的傷口比傳統換藥癒合較佳。環狀燒燙傷會因焦痂束縛而導致腔室症候群，可能需要作焦痂切開術。
A paucity of high-quality evidence exists to provide recommendations for wilderness burn wound care. Irrigation or submersion of the burned area in cool water has been shown to limit the extent of the burn and is helpful in controlling pain. Care must be taken to avoid tissue freezing and hypothermia.120 A recent systematic review of dressings for superficial and partial-thickness burns demonstrated that silver sulfadiazine was consistently associated with poorer healing outcomes than biosynthetic and silicon-coated dressings, whereas hydrogel-treated burns had better healing outcomes than those treated with standard dressings.121 Circumferential burns can result in compartment syndrome secondary to the constricting effect of the resulting eschar. Patients with circumferential burns should be watched for the development of compartment syndrome. In these patients, an escharotomy may be required.
除了以上傷口例行照護，現存證據對於燒燙傷無法提供更多特殊建議
Recommendation Beyond routine wound care as described above, we are unable to provide specific recommendations regarding care of burn wounds based on existing evidence.
建議：環狀燒燙傷如果有腔室症候群的危險，需進行焦痂切開術（1A）
Recommendation Escharotomy should be performed in circumferential burns with risk of compartment syndrome. Recommendation grade: 1A.
對於燙傷，預防性抗生素使用的研究比較少 一個系統性回顧研究發現，使用磺胺銀，相對於一般換藥，會增加傷口感染率。另一項系統性回顧研究指出，沒有證據支持使用含銀敷料或其他局部物質來預防感染，
There is little compelling evidence to support the prophylactic use of antibiotics for burn wounds. One systematic review concluded that the use of topical silver sulfadiazine is associated with a significant increase in the rate of burn wound infections when compared with dressings or skin substitutes.128 The same review concluded that there was not enough evidence to enable reliable conclusions to be drawn regarding the use of systemic antibiotics. Another systematic review concluded that there was insufficient evidence to support the use of silver-containing dressings or other topical agents in the prevention of infection.129
燙傷不需要使用預防性全身性抗生素
Recommendation Treatment with systemic antibiotics is not indicated for prophylactic use in burn wounds. Recommendation grade: 1C.
磺胺銀對於傷口癒合不利，可能增加感染率
Recommendation Silver sulfadiazine may negatively affect wound healing and may increase infection rate. Recommendation grade: 1A.
野外與登山醫學---傷口感染 抗生素選擇
即使經過適當處置，傷口感染率約 1％～12％，已經縫合的傷口，如果出現感染跡象，需重新打開，將膿瘍引流出來，以增加抗生素治療的成功率，也可以減輕不適，可適當抬高患處，尤其是發生蜂窩性組織炎時。
細菌培養結果無法立即得知（通常要 3-7 天）而且很多感染是多重菌種，經驗性抗生素需考慮環境因素和可能菌種，例如海洋環境、哺乳動物咬傷。動物咬傷或其他皮膚感染第一選擇通常是 augmentin 。
Moxifloxacin 可以用於皮膚及軟組織感染，包括動物咬傷，對 penicillin 過敏的患者，對於暴露在水環境傷口(會感染格藍氏陰性菌)是第一選擇。
其他可以選擇的抗生素包括：口服第二代或第三代頭孢素，對於巴士德類的菌種、口腔厭氧菌比第一代頭孢素、doxycycline, Baktar好。對於葡萄球菌、鏈球菌效果，跟第一代頭孢素、doxycycline, Baktar相當。
在所有情況，沒有一種單一藥物優於所有其他藥物
Wound Infections
If appropriate equipment and training are available, wounds with signs of infection after closure should be opened and any abscess collection should be drained. These maneuvers will increase the success of antibiotic treatment and will improve patient comfort. Elevation of the involved extremity may be helpful, particularly if there is a cellulitic component.131
Because culture information will not be available and many infections are likely to be polymicrobial in nature, empiric therapy is indicated with a consideration of any unique environmental issues associated with the inoculum (marine environment, mammalian bites, etc). Antimicrobial selection may also be guided practically by which items are available in the first aid kit. Amoxicillin/clavulanate is often a first choice for infected animal bites and other skin and soft tissue infections (SSTI).132, 133 Moxifloxacin is suitable for SSTI, including animal bites, in the penicillin-allergic patient and is a good first-choice agent for infections caused by aquatic exposures,134, 135 which have a higher likelihood of a gram-negative microbial etiology.136, 137
Other suitable antibiotics may include oral second- or third-generation cephalosporins. These have better activity against such relevant entities as Pasteurella spp, and oral anaerobes, and equal activity against staphylococci and streptococci compared with first-generation agents such as cephalexin, doxycycline, and trimethoprim-sulfamethoxazole. No single particular agent will be reliably effective in all scenarios. Furthermore, the data supporting the use of many antibiotics in specific clinical situations are supported less by randomized clinical trials and more by extrapolation of studies of the bacteriology of particular wounds or environments.
野外與登山醫學----預防及避免傷口感染
感染預防及避免 Infection Prophylaxis And Prevention
根本原則，不管有沒有給予 預防性抗生素，傷口都需要密切觀察，併發症可能很快產生，包括局部續發性感染、深部組織穿透性感染，細菌可能經由血液造成全身性症狀（發燒、忽冷忽熱、倦 怠、虛弱），除了特殊的傷口情況，目前沒有足夠證據支持使用預防性全身性抗生素（口服、注射），開放性骨折需要使用預防性抗生素（醫院通常是靜脈注射）降 低感染率，避免日後骨髓發炎。所有開放性傷口都會有細菌，但不一定需要處理，局部有細菌不一定造成感染，人咬傷之後預防性使用抗生素，在統計上能降低感染 的機率，但貓狗咬傷則否（手部除外）。手部被哺乳動物咬傷，使用預防性抗生素能顯著降低感染率，局部塗抹抗生素可促進傷口癒合、降低感染率。
An overall principle of wound management is that whether or not prophylactic antibiotics are given, wounds should be monitored closely. Complications can develop rapidly or in an indolent manner. These include local secondary infection, undetected penetration of deeper structures, and systemic illnesses that can result from hematogenous seeding of organisms inoculated into the wound. With the exception of certain specific wound categories, there is scant evidence to support the routine use of systemic antibiotics for prophylaxis against wound infection. A notable exception is an open fracture, in which acute antibiotic administration significantly lowers the rate of infection.54, 122 This is of particular significance given the substantial morbidity associated with subsequent osteomyelitis. Virtually all open wounds are colonized with microorganisms, but this is usually without clinical consequences.123 The presence of colonizing bacteria does not constitute infection. A systematic review of mammalian bites showed a statistically significant reduction in the rate of infection with the use of prophylactic antibiotics after bites by humans but not after bites by cats or dogs, except bites of the hand.124 There was a statistically significant reduction in the rate of infection with the use of prophylactic antibiotics after mammalian bites to the hand. Although dated, there is evidence to support the use of topical antibiotics to promote wound healing and decrease infection.125, 126, 127
開放性骨折需給予全身性預防性抗生素
Recommendation～ Treatment with systemic antibiotics is indicated in the presence of open fractures. Recommendation grade: 1A.
人咬傷需給予全身性預防性抗生素
Recommendation～ Treatment with systemic antibiotics is indicated in the presence of human bites. Recommendation grade: 1B.
哺乳動物咬傷手部需給予全身性預防性抗生素
Recommendation～ Treatment with systemic antibiotics is indicated in the presence of mammalian bites to the hand. Recommendation grade: 1B.
局部塗抹抗生素可以促進傷口癒合，降低感染率，對於沒有過敏的人，壞處很少
Recommendation ～Use of topical antibiotics may promote wound healing and decrease the incidence of infection, with little downside risk in the nonallergic patient. Recommendation grade: 2C.
對於燙傷，預防性抗生素使用的研究比較少 一個系統性回顧研究發現，使用磺胺銀，相對於一般換藥，會增加傷口感染率。另一項系統性回顧研究指出，沒有證據支持使用含銀敷料或其他局部物質來預防感染，
There is little compelling evidence to support the prophylactic use of antibiotics for burn wounds. One systematic review concluded that the use of topical silver sulfadiazine is associated with a significant increase in the rate of burn wound infections when compared with dressings or skin substitutes.128 The same review concluded that there was not enough evidence to enable reliable conclusions to be drawn regarding the use of systemic antibiotics. Another systematic review concluded that there was insufficient evidence to support the use of silver-containing dressings or other topical agents in the prevention of infection.129
燙傷不需要使用預防性全身性抗生素
Recommendation Treatment with systemic antibiotics is not indicated for prophylactic use in burn wounds. Recommendation grade: 1C.
磺胺銀對於傷口癒合不利，可能增加感染率
Recommendation Silver sulfadiazine may negatively affect wound healing and may increase infection rate. Recommendation grade: 1A.
野外與登山醫學---2013 NEJM HAI 高海拔疾病 guideline 2013-07-13
Acute High-Altitude Illnesses 這篇研究是在 2013 年刊登於 NEJM 的.
(下面是文章開始了)
AMS 急性高山病
隨著海拔上升引起的頭痛是AMS急性高山病主要症狀, 會伴隨食慾不振、噁心、疲憊、頭暈、倦怠、失眠等症狀。AMS 通常在上升到海拔2500公尺以上, 6-12小時之後發生。海拔越高，嚴重度及盛行率越高。沒有做高度適應的人，海拔2500公尺發生率 10-25%, 但症狀通常輕微，在海拔4500-5500公尺發生率50-85%. 且可能病倒。
在一個回溯性研究, 發現下列三項主要危險因子, 另一個對於海拔4000-8848公尺的健行者和登山客的前瞻性研究發現, 有相似的危險因子
AMS主要的危險因子
1. 曾經罹患高山症,
2. 海拔2000公尺以上, 一天上升超過 625公尺,
3. 沒有做高度適應(在最近兩個月,於高度3000公尺以上環境,待超過五天)
次要危險因子:
4. 女性
5. 46歲以下 (腦部相對萎縮,能代償腦部水腫)
6. 有偏頭痛病史 (比較容易頭痛)
在高海拔地區進行運動可能會讓AMS急性高山病惡化, 但良好的體適能並沒有保護效果. (體力好的人一樣可能得到AMS急性高山病).
適當處置之後通常1-2天症狀會改善 (如果症狀太多天, 考慮其他診斷)
HACE 高海拔腦水腫(high altitude cerebral edema) HACE 是 AMS 末期表現, 可視為同一種疾病.
HACE特徵是軀幹運動失調 truncal ataxia, 神智變差, 通常會輕微發燒 (所以發燒無法排除腦水腫或肺水腫)
如果沒有治療會快速昏迷, 24小時內因為腦部疝氣造成腦死. (腦水腫沒有黃金時間. 隨時會死亡. 應立即下降高度, 切勿原地待援)
對於一般止痛藥物(NSAID非類固醇消炎止痛藥)反應不佳的頭痛及嘔吐代表病患可能由AMS正在惡化. 往 HACE 進展
但沒有頭痛或其他AMS症狀也不能直接排除HACE (HAPE造成的缺氧, 症狀會與 HACE 相似, 無法區別, 故只能當成同時罹患 HACE 同時治療)
HACE通常發生於海拔 4000公尺以上, 至少停留兩天以上的時間, 在海拔4000公尺至5000公尺的盛行率約0.5~1%, MRI可以發現血管性腦水腫, 主要在胼胝體 corpus callosum 部位出現微量出血.
HAPE 高海拔肺水腫
HAPE特徵: 沒有精力、呼吸困難、運動時乾咳、之後出現休息時呼吸困難、呼吸有囉音、發紺、咳嗽、粉紅色泡沫痰。
氣體交換狀況惡化也會增加得到HACE的危險，這種狀況通常在海拔超過3000公尺之後的兩天發生，在海拔2500-3000公尺比較少見。
HAPE的危險隨著高度以及上升速度增加，例如，如果不知道過去的疾病史，在四天時間上升超過海拔4500公尺以上, 得到HAPE的機率是 0.2%, 如果是七天時間上升至海拔5500公尺, 得到HAPE的機率是 2%, 如果在一兩天之內到達上述海拔，機率各增加為 6%, 15%.
(所以上升到同樣高度，花的時間越短，得到HAPE機率越大，從 0.2%變成 6%，2% 變成 15%)
如果之前曾經得到HAPE, 再次得到的機會越大，在兩天時間上升至海拔4500公尺, 得到HAPE的機率是 60% (一般人6%)
沒有治療的HAPE, 死亡率約 50%.
HAPE是非心因性的肺水腫, 起因於低血氧造成的肺血管收縮. 以及異常的肺動脈高壓, 微血管壓力上升. 這種異常的高壓造成非發炎性及出血性的肺泡滲漏, 之後可能再引起續發性的發炎反應。
(白話文: 一開始是因為血管內壓力大, 造成血管內的液體往外漏到肺泡, 正常肺泡內不應該有液體, 這種狀況一開始是物理性反應, 並不是發炎(化學性)反應, 但之後可能因為肺泡內有液體而造成後續有發炎發應)
The Clinical Problem
Persons who are not acclimatized and ascend rapidly to high altitudes are at risk for any of several debilitating and potentially lethal illnesses (Table 1) that occur with-in the first days after arrival at high altitudes. Traditionally, 2500 m has been used as the threshold for high-altitude illnesses; in rare cases, mild illness occurs in persons who have ascended above 2000 m but below 2500 m.
Acute Mountain Sickness
Headache that occurs with an increase in altitude is the cardinal symptom of acute mountain sickness and is usually accompanied by anorexia, nausea, dizziness, malaise, sleep disturbance, or a combination of these symptoms. Acute mountain sickness generally occurs within 6 to 12 hours after a person ascends to 2500 m or higher. Its prevalence and severity increase with increasing altitude. Acute moun-tain sickness occurs in approximately 10 to 25% of unacclimatized persons who ascend to 2500 m. Symptoms are usually mild at this altitude and have little effect on activity. However, acute mountain sickness occurs in 50 to 85% of unacclimatized persons at 4500 to 5500 m and may be incapacitating.
In a retrospective study, major independent risk factors for acute mountain sick-ness included a history of acute mountain sickness, fast ascent (≥625 m per day above 2000 m), and lack of previous acclimatization (A prospective study involving trekkers and climbers who went to altitudes between 4000 and 8848 m showed the same major risk factors for incapacitating acute mountain sickness and other severe altitude illnesses (described below). Other possible risk factors include female sex, an age younger than 46 years, and a history of migraine. Exercise may exacerbate acute mountain sickness, but good physical fitness is not protective. Symptoms usually resolve within 1 to 2 days when appropriate measures are taken (see below).
High-Altitude Cerebral Edema
High-altitude cerebral edema is characterized by truncal ataxia, decreased con-sciousness, and usually mild fever.
Without appropriate treatment, coma may evolve rapidly, followed by death from brain herniation within 24 hours. Headache that is poorly responsive to nonsteroidal anti-inflammatory drugs (NSAIDs) and vomiting indicate probable progression of acute mountain sickness to high-altitude cerebral edema, but the absence of headache and other symptoms of acute mountain sickness does not rule it out.
High-altitude cerebral edema usually develops after at least 2 days at altitudes above 4000 m. The prevalence is estimated to be 0.5 to 1.0% among persons at 4000 to 5000 m. Magnetic resonance imaging in patients with high-altitude cerebral edema shows vasogenic edema and microhemorrhages that are located predominantly in the corpus callosum.
High-Altitude Pulmonary Edema
High-altitude pulmonary edema is characterized by loss of stamina, dyspnea, and dry cough with exertion, followed by dyspnea at rest, rales, cyanosis, cough, and pink, frothy sputum. Deterioration in gas exchange also increases the risk of high-altitude cerebral edema. This condition develops 2 or more days after exposure to altitudes above 3000 m and is rare in persons at altitudes below 2500 to 3000 m. The risk increases with increased altitude and faster ascent. For example, the incidence among persons with an unknown history of high-altitude pulmonary edema is 0.2% if they ascend to 4500 m in 4 days and 2% if they ascend to 5500 m in 7 days; the incidence increases to 6% and 15%, respectively, when these altitudes are reached within 1 to 2 days.
The risk is further increased among persons with a history of high-altitude pulmonary edema (e.g., the risk of recurrence is 60% among persons who ascend to 4500 m in 2 days). The estimated mortality among persons with untreated high-altitude pulmonary edema is 50%. This disorder is a noncardiogenic pulmonary edema caused by exaggerated hypoxic pulmonary vasoconstriction and abnormally high pulmonary-artery pressure and capillary pressure.
These high pressures lead to a noninflammatory and hemorrhagic al-veolar capillary leak that secondarily may evoke
an inflammatory response.
策略及證據 Strategies and Evidence
風險評估
在高海拔停留時, 要針對可能在高海拔惡化的心肺疾病做臨床評估，雖然在這篇文章，並非討論個人疾病受到高海拔的影響，不過有一些回顧性的文章可以參考。
過去如果曾經得到高海拔疾病, 再發的可能性會上升, 過去病患曾經在高海拔的經歷, 先前登高的適應狀況, 攀登及睡覺的最高海拔, 上升速率, 以及任何高海拔疾病都要詳細了解, 此次風險的評估, 以過去相似海拔的上升速率最高海拔做參考比較可靠.
Risk Assessment
Risk assessment (Table 2) should start with a clinical evaluation directed toward any cardiopulmonary diseases that might worsen during a sojourn involving high altitude. Although a discussion of the effect of altitude in persons with preexisting disease is not within the scope of this article, reviews of this topic are available.
Given that previous altitude illness is a strong predictor of recurrence, detailed information about the person’s history with respect to visits to high-altitude areas, acclimatization before previous ascents, maximum altitudes for climbing and sleeping, rates of ascent, and any altitude illness should be obtained. The estimation of risk is most reliable for persons with previous rates of ascent and final altitudes that were similar to those planned.
雖然運動員比一般人容易登頂, 但體適能與是否容易得到 AMS 或 HAPE 無關,
因此, 運動(體能)測試無法用來評估登山者是否容易發生高海拔疾病,
平時常規的運動量和運動強度, 以及體適能表現, 有助於評估是否有足夠的儲備能力以應付高海拔造成的體力下降
(超過1500公尺海拔, 每上升 100 公尺約下降 1%).
平時沒有訓練體力的人, 建議在開始攀登前的數星期到數個月, 尤其是預期在高海拔進行嚴酷的戶外活動時, 應進行常規體能訓練.
Other Assessments
The assessment of ventilation in response to exposure to hypoxic conditions at rest or during exercise has been proposed as a means of refining risk prediction for altitude sickness. The increase in ventilation at rest or during exercise while breathing 11.5% oxygen, as well as arterial oxygen saturation after the first 30 minutes of exposure to an altitude of 3000 m or to corresponding normobaric hypoxic conditions, is on average significantly lower in persons who are susceptible to acute altitude sickness than in those who are not.
However, considerable overlap between groups classified as susceptible and those classified as not susceptible in a retrospective study and between a group classified as having acute mountain sickness and a group classified as unaffected in a prospective study makes it impossible to define cutoff values that are sufficiently sensitive and specific to be useful in practice. A multivariate analysis of risk factors for severe high-altitude illness showed that the hypoxic ventilatory response and other physiological measurements under hypoxic conditions add little to the discrimination provided by patient characteristics and history (i.e., sex, level of physical activity, rate of previous ascent, and status with respect to previous severe high-altitude illness and migraines). Persons who are considered to be susceptible to high-altitude pulmonary edema because of two previous episodes of high-altitude pulmonary edema have abnormally high systolic pulmonary-artery pressure (>40 mm Hg) under hypoxic conditions (12% oxygen in ambient air at sea level). In a study of a western European population, exaggerated hypoxic pulmonary-artery pressure was detected in about 10% of study participants, but high-altitude pulmonary edema develops in only 15% of persons with exaggerated hypoxic pulmonary-artery pressure responses who make a rapid ascent (unpublished data). For this reason and because of a very low pretest probability of high-altitude pulmonary edema (e.g., an incidence of 1 to 2% among trekkers to the Mount Everest base camp), measurement of pulmonary-artery pressure under hypoxic conditions cannot be recommended as a means of identifying persons who are susceptible to high-altitude pulmonary edema. Although athletic persons are more likely to reach the summit than persons who are not athletic, physical fitness appears to have no association or at most a modest association with susceptibility to acute mountain sickness and high-altitude pulmonary edema. Thus, an exercise test is not indicated to assess the risk of acute high-altitude illness. Information about the amount and intensity of the person’s regular exercise as well as his or her level of athletic performance is helpful in estimating whether there is sufficient reserve to cope with the expected loss of exercise capacity at high altitudes of about 1% for every 100 m above 1500 m. Persons without athletic training should be encouraged to begin regular physical exercise several weeks to months before the planned ascent, particularly when rigorous outdoor activities are planned at high altitudes.
table 2 (所有海拔高度都是指睡覺的海拔)
預防HAPE藥物
第一線: NIFEDIPINE 30mg 緩慢釋放劑型, 每天兩次(8-12小時一次)
第二線: PD5抑制劑(例如 tadalafil 犀利士一天一顆分兩次吃, 每次半顆10mg, 8-12小時吃一次) 或 DEXAMETHASONE 每次 8mg, 一天兩次(8-12小時吃一次).
第三線: 吸入型SALMETEROL (每次125ug每天兩次)效果比要差, 副作用在某些人會出現顫抖, 心跳快.
Method ~~~~~~~~~~~~~~~~~~~~~~~~~~~~Description
Acclimatization before exposure ~~~~~~~~~Sojourning several days at intermediate altitudes at or above 2000 m (staging), hiking or climbing on day tours above 3000 m, or both
Slow ascent ~~~~~~~~~~~~~~~~~~~~~~~~ Ascent rate of 300–500 m/day above 2500–3000 m, with a day of rest every 3–4 days; appropriate treatment of early symptoms of acute mountain sickness for prevention of severe high-altitude disease
Drugs for prevention of acute mountain sickness,high-altitude cerebral edema, or both
Moderate risk ~~~~~~~~~~~~~~ Acetazolamide, 125 mg twice/day; if there are side effects with or contraindications to acetazolamide, dexamethasone, 4 mg twice/day, can be used
High risk Acetazolamide, 250 mg two or three times/day (three times/day recommended for rapid ascent, though efficacy uncertain); dexamethasone, 4 mg three times/day, if acetazolamide has unacceptable side effects or is contraindicated
Drugs for prevention of high-altitude pulmonary edema in persons with history of this condition
First line ~~~~~~~~~~~~~~~ Nifedipine, 30 mg of slow-release formulation twice/day
Second line~~~~~~~~~~~~~ Phosphodiesterase-5 inhibitors (e.g., tadalafil, 10 mg twice/day) or dexamethasone, 8 mg twice/day
Third line~~~~~~~~~~~~~~~ Inhaled salmeterol (125 μg twice/day) appears to be less effective than other options and may cause tremor and tachycardia in some persons with this dose
作者 Peter Bärtsch, M.D., and Erik R. Swenson, M.D.
N Engl J Med 2013; 368:2294-2302June 13, 2013DOI: 10.1056/NEJMcp1214870
統一名詞翻譯
HAI 高海拔疾病 high altitude illness
AMS 急性高山病(最好不要翻譯成急性高山症) (與他人溝通時-直接講AMS比較明確)
HACE 高海拔腦水腫 high altitude cerebral edema
HAPE 高海拔肺水腫 high altitude pulmonary edema
acetazolamide 下面都以"丹木斯" 代替 (學名不容易記.,且中文翻譯也不一致)
AMS 急性高山病(最好不要翻譯成急性高山症) (與他人溝通時-直接講AMS比較明確)
HACE 高海拔腦水腫 high altitude cerebral edema
HAPE 高海拔肺水腫 high altitude pulmonary edema
acetazolamide 下面都以"丹木斯" 代替 (學名不容易記.,且中文翻譯也不一致)
dexamethasone 下面以類固醇代替 (類固醇有很多種類. 並非只有這種)
(在高海拔疾病研究 . dexamethasone 相關研究最多)
(在高海拔疾病研究 . dexamethasone 相關研究最多)
重點整理
AMS主要危險因子包括:
1. 曾經罹患高山症,
2. 海拔2000公尺以上, 一天上升超過 625公尺,
3. 沒有做高度適應(在最近兩個月,於高度3000公尺以上環境,待超過五天)
AMS次要危險因子包括
4. 女性
5. 46歲以下 (腦部相對萎縮,能代償腦部水腫)
6. 有偏頭痛病史 (比較容易頭痛)
AMS主要危險因子包括:
1. 曾經罹患高山症,
2. 海拔2000公尺以上, 一天上升超過 625公尺,
3. 沒有做高度適應(在最近兩個月,於高度3000公尺以上環境,待超過五天)
AMS次要危險因子包括
4. 女性
5. 46歲以下 (腦部相對萎縮,能代償腦部水腫)
6. 有偏頭痛病史 (比較容易頭痛)
體能鍛鍊無法降低高海拔疾病風險(但鍛鍊體能還是登山必要的準備)
運動會讓AMS症狀惡化
同一海拔前三天沒事, 第四天開始出現AMS症狀, 要考慮其他原因(不像AMS)
HACE (腦水腫)通常發生在海拔 4000 公尺以上(低海拔也有案例)
HAPE (肺水腫)通常發生在海拔 3000 公尺以上(低海拔也有案例)
HAPE (肺水腫)通常發生在海拔 3000 公尺以上(低海拔也有案例)
使用Lake Louise Score 評估AMS, 建議在抵達六小時(維持相同海拔)之後再評估 (以減少因為脫水, 體力不濟等等因素的干擾)
預防高海拔疾病最好的方式還是緩慢提升海拔高度, 當行程無法修改. 只好藉助藥物來降低發生機率.
(下面是文章開始了)
臨床問題
一開始文章開頭問了一個有趣的問題
45歲健康男性，想花五天時間攀登吉立馬札羅山(5895公尺)，從海拔 1800 公尺開始攀登，最近的體能測驗是正常的，他每一週跑10公里四到五次，去年花了不到四小時完成馬拉松，他想知道如何在高海拔避免生病，是否上山前幾週進行常壓低氧環境的訓練或睡眠會有幫忙，你的建議呢？
A 45-year-old healthy man wishes to climb Mount Kilimanjaro (5895 m) in a 5-day
period, starting at 1800 m. The results of a recent exercise stress test were normal; he runs 10 km 4 or 5 times per week and finished a marathon in less than 4 hours last year. He wants to know how he can prevent becoming ill at high altitude and whether training or sleeping under normobaric hypoxic conditions in the weeks before the ascent would be helpful. What would you advise?
＊－。－。－。－。－。－。－。－－。－。－。－。－＊
在低氧常壓的環境做訓練或睡覺, 是否能避免高山症發生?
傳統上, 海拔超過 2500 公尺的環境會引起高海拔疾病, 但少數人因為體質關係, 可能在 2000-2500 公尺的高度就出現高海拔疾病症狀。
一開始文章開頭問了一個有趣的問題
45歲健康男性，想花五天時間攀登吉立馬札羅山(5895公尺)，從海拔 1800 公尺開始攀登，最近的體能測驗是正常的，他每一週跑10公里四到五次，去年花了不到四小時完成馬拉松，他想知道如何在高海拔避免生病，是否上山前幾週進行常壓低氧環境的訓練或睡眠會有幫忙，你的建議呢？
A 45-year-old healthy man wishes to climb Mount Kilimanjaro (5895 m) in a 5-day
period, starting at 1800 m. The results of a recent exercise stress test were normal; he runs 10 km 4 or 5 times per week and finished a marathon in less than 4 hours last year. He wants to know how he can prevent becoming ill at high altitude and whether training or sleeping under normobaric hypoxic conditions in the weeks before the ascent would be helpful. What would you advise?
＊－。－。－。－。－。－。－。－－。－。－。－。－＊
在低氧常壓的環境做訓練或睡覺, 是否能避免高山症發生?
傳統上, 海拔超過 2500 公尺的環境會引起高海拔疾病, 但少數人因為體質關係, 可能在 2000-2500 公尺的高度就出現高海拔疾病症狀。
AMS 急性高山病
隨著海拔上升引起的頭痛是AMS急性高山病主要症狀, 會伴隨食慾不振、噁心、疲憊、頭暈、倦怠、失眠等症狀。AMS 通常在上升到海拔2500公尺以上, 6-12小時之後發生。海拔越高，嚴重度及盛行率越高。沒有做高度適應的人，海拔2500公尺發生率 10-25%, 但症狀通常輕微，在海拔4500-5500公尺發生率50-85%. 且可能病倒。
在一個回溯性研究, 發現下列三項主要危險因子, 另一個對於海拔4000-8848公尺的健行者和登山客的前瞻性研究發現, 有相似的危險因子
AMS主要的危險因子
1. 曾經罹患高山症,
2. 海拔2000公尺以上, 一天上升超過 625公尺,
3. 沒有做高度適應(在最近兩個月,於高度3000公尺以上環境,待超過五天)
次要危險因子:
4. 女性
5. 46歲以下 (腦部相對萎縮,能代償腦部水腫)
6. 有偏頭痛病史 (比較容易頭痛)
在高海拔地區進行運動可能會讓AMS急性高山病惡化, 但良好的體適能並沒有保護效果. (體力好的人一樣可能得到AMS急性高山病).
適當處置之後通常1-2天症狀會改善 (如果症狀太多天, 考慮其他診斷)
HACE, HAPE 患者都可能會發燒. 不能用發燒來排除高海拔疾病(低海拔, 發燒最常見原因是感染症)
HACE 高海拔腦水腫(high altitude cerebral edema) HACE 是 AMS 末期表現, 可視為同一種疾病.
HACE特徵是軀幹運動失調 truncal ataxia, 神智變差, 通常會輕微發燒 (所以發燒無法排除腦水腫或肺水腫)
如果沒有治療會快速昏迷, 24小時內因為腦部疝氣造成腦死. (腦水腫沒有黃金時間. 隨時會死亡. 應立即下降高度, 切勿原地待援)
對於一般止痛藥物(NSAID非類固醇消炎止痛藥)反應不佳的頭痛及嘔吐代表病患可能由AMS正在惡化. 往 HACE 進展
但沒有頭痛或其他AMS症狀也不能直接排除HACE (HAPE造成的缺氧, 症狀會與 HACE 相似, 無法區別, 故只能當成同時罹患 HACE 同時治療)
HACE通常發生於海拔 4000公尺以上, 至少停留兩天以上的時間, 在海拔4000公尺至5000公尺的盛行率約0.5~1%, MRI可以發現血管性腦水腫, 主要在胼胝體 corpus callosum 部位出現微量出血.
HAPE 高海拔肺水腫
HAPE特徵: 沒有精力、呼吸困難、運動時乾咳、之後出現休息時呼吸困難、呼吸有囉音、發紺、咳嗽、粉紅色泡沫痰。
氣體交換狀況惡化也會增加得到HACE的危險，這種狀況通常在海拔超過3000公尺之後的兩天發生，在海拔2500-3000公尺比較少見。
HAPE的危險隨著高度以及上升速度增加，例如，如果不知道過去的疾病史，在四天時間上升超過海拔4500公尺以上, 得到HAPE的機率是 0.2%, 如果是七天時間上升至海拔5500公尺, 得到HAPE的機率是 2%, 如果在一兩天之內到達上述海拔，機率各增加為 6%, 15%.
(所以上升到同樣高度，花的時間越短，得到HAPE機率越大，從 0.2%變成 6%，2% 變成 15%)
如果之前曾經得到HAPE, 再次得到的機會越大，在兩天時間上升至海拔4500公尺, 得到HAPE的機率是 60% (一般人6%)
沒有治療的HAPE, 死亡率約 50%.
HAPE是非心因性的肺水腫, 起因於低血氧造成的肺血管收縮. 以及異常的肺動脈高壓, 微血管壓力上升. 這種異常的高壓造成非發炎性及出血性的肺泡滲漏, 之後可能再引起續發性的發炎反應。
(白話文: 一開始是因為血管內壓力大, 造成血管內的液體往外漏到肺泡, 正常肺泡內不應該有液體, 這種狀況一開始是物理性反應, 並不是發炎(化學性)反應, 但之後可能因為肺泡內有液體而造成後續有發炎發應)
The Clinical Problem
Persons who are not acclimatized and ascend rapidly to high altitudes are at risk for any of several debilitating and potentially lethal illnesses (Table 1) that occur with-in the first days after arrival at high altitudes. Traditionally, 2500 m has been used as the threshold for high-altitude illnesses; in rare cases, mild illness occurs in persons who have ascended above 2000 m but below 2500 m.
Acute Mountain Sickness
Headache that occurs with an increase in altitude is the cardinal symptom of acute mountain sickness and is usually accompanied by anorexia, nausea, dizziness, malaise, sleep disturbance, or a combination of these symptoms. Acute mountain sickness generally occurs within 6 to 12 hours after a person ascends to 2500 m or higher. Its prevalence and severity increase with increasing altitude. Acute moun-tain sickness occurs in approximately 10 to 25% of unacclimatized persons who ascend to 2500 m. Symptoms are usually mild at this altitude and have little effect on activity. However, acute mountain sickness occurs in 50 to 85% of unacclimatized persons at 4500 to 5500 m and may be incapacitating.
In a retrospective study, major independent risk factors for acute mountain sick-ness included a history of acute mountain sickness, fast ascent (≥625 m per day above 2000 m), and lack of previous acclimatization (A prospective study involving trekkers and climbers who went to altitudes between 4000 and 8848 m showed the same major risk factors for incapacitating acute mountain sickness and other severe altitude illnesses (described below). Other possible risk factors include female sex, an age younger than 46 years, and a history of migraine. Exercise may exacerbate acute mountain sickness, but good physical fitness is not protective. Symptoms usually resolve within 1 to 2 days when appropriate measures are taken (see below).
High-Altitude Cerebral Edema
High-altitude cerebral edema is characterized by truncal ataxia, decreased con-sciousness, and usually mild fever.
Without appropriate treatment, coma may evolve rapidly, followed by death from brain herniation within 24 hours. Headache that is poorly responsive to nonsteroidal anti-inflammatory drugs (NSAIDs) and vomiting indicate probable progression of acute mountain sickness to high-altitude cerebral edema, but the absence of headache and other symptoms of acute mountain sickness does not rule it out.
High-altitude cerebral edema usually develops after at least 2 days at altitudes above 4000 m. The prevalence is estimated to be 0.5 to 1.0% among persons at 4000 to 5000 m. Magnetic resonance imaging in patients with high-altitude cerebral edema shows vasogenic edema and microhemorrhages that are located predominantly in the corpus callosum.
High-Altitude Pulmonary Edema
High-altitude pulmonary edema is characterized by loss of stamina, dyspnea, and dry cough with exertion, followed by dyspnea at rest, rales, cyanosis, cough, and pink, frothy sputum. Deterioration in gas exchange also increases the risk of high-altitude cerebral edema. This condition develops 2 or more days after exposure to altitudes above 3000 m and is rare in persons at altitudes below 2500 to 3000 m. The risk increases with increased altitude and faster ascent. For example, the incidence among persons with an unknown history of high-altitude pulmonary edema is 0.2% if they ascend to 4500 m in 4 days and 2% if they ascend to 5500 m in 7 days; the incidence increases to 6% and 15%, respectively, when these altitudes are reached within 1 to 2 days.
The risk is further increased among persons with a history of high-altitude pulmonary edema (e.g., the risk of recurrence is 60% among persons who ascend to 4500 m in 2 days). The estimated mortality among persons with untreated high-altitude pulmonary edema is 50%. This disorder is a noncardiogenic pulmonary edema caused by exaggerated hypoxic pulmonary vasoconstriction and abnormally high pulmonary-artery pressure and capillary pressure.
These high pressures lead to a noninflammatory and hemorrhagic al-veolar capillary leak that secondarily may evoke
an inflammatory response.
策略及證據 Strategies and Evidence
風險評估
在高海拔停留時, 要針對可能在高海拔惡化的心肺疾病做臨床評估，雖然在這篇文章，並非討論個人疾病受到高海拔的影響，不過有一些回顧性的文章可以參考。
過去如果曾經得到高海拔疾病, 再發的可能性會上升, 過去病患曾經在高海拔的經歷, 先前登高的適應狀況, 攀登及睡覺的最高海拔, 上升速率, 以及任何高海拔疾病都要詳細了解, 此次風險的評估, 以過去相似海拔的上升速率最高海拔做參考比較可靠.
Risk Assessment
Risk assessment (Table 2) should start with a clinical evaluation directed toward any cardiopulmonary diseases that might worsen during a sojourn involving high altitude. Although a discussion of the effect of altitude in persons with preexisting disease is not within the scope of this article, reviews of this topic are available.
Given that previous altitude illness is a strong predictor of recurrence, detailed information about the person’s history with respect to visits to high-altitude areas, acclimatization before previous ascents, maximum altitudes for climbing and sleeping, rates of ascent, and any altitude illness should be obtained. The estimation of risk is most reliable for persons with previous rates of ascent and final altitudes that were similar to those planned.
其他評估
曾有報告提出, 休息時及運動時, 由缺氧狀態引發的換氣反應, 曾被假定為預測發生高海拔疾病風險的工具
曾有報告提出, 休息時及運動時, 由缺氧狀態引發的換氣反應, 曾被假定為預測發生高海拔疾病風險的工具
容易罹患高海拔疾病的病人, 在氧氣濃度 11.5% 的環境休息或運動時增加的換氣量, 在 3000 公尺海拔經過 30 分鐘後的動脈氧氣濃度, 或相應的常壓低氧的環境, 其數值會比常人低. (換氣量低，氧氣濃度低)
不過在一篇回溯性研究發現, 容易得高海拔疾病與不易得高海拔疾病的兩組人, 會有顯著重疊的現象,
另一篇前瞻性研究發現, 容易得到 AMS 的一組, 與不容易得病的一組, 也是有重疊現象
所以無法訂出一個絕對的數值, 來推測登山者是否容易或不容易得到高海拔疾病.
不過在一篇回溯性研究發現, 容易得高海拔疾病與不易得高海拔疾病的兩組人, 會有顯著重疊的現象,
另一篇前瞻性研究發現, 容易得到 AMS 的一組, 與不容易得病的一組, 也是有重疊現象
所以無法訂出一個絕對的數值, 來推測登山者是否容易或不容易得到高海拔疾病.
一篇關於嚴重高海拔疾病的危險因子的多變項分析指出, 依照個人的體質及疾病史 (性別、體能、上升速率、先前得到嚴重高海拔疾病及偏頭痛的狀態) 得到的推測, 如果加上使用其他數據, 像是低氧的通氣量反應, 其他低氧環境的生理數值, 也無助於評估是否容易得到高海拔疾病.
曾經罹患兩次 HAPE 的登山者, 容易再罹患 HAPE, 這類病患在低氧環境 (海平面壓力12%氧氣濃度) 的肺動脈壓力會異常上升 (大於40 mmHg)
一篇西歐人種的研究指出, 10% 的人在低血氧時肺動脈壓力會增高, 但在這群肺動脈高的人在快速上升後, 只有 15% 會得到HAPE. 而HAPE測試前的可能性本來就低(在聖母峰基地營的健行者約1-2%), 因此在低氧環境測量肺動脈壓力, 也無法預估病患是否容易得到HAPE.
曾經罹患兩次 HAPE 的登山者, 容易再罹患 HAPE, 這類病患在低氧環境 (海平面壓力12%氧氣濃度) 的肺動脈壓力會異常上升 (大於40 mmHg)
一篇西歐人種的研究指出, 10% 的人在低血氧時肺動脈壓力會增高, 但在這群肺動脈高的人在快速上升後, 只有 15% 會得到HAPE. 而HAPE測試前的可能性本來就低(在聖母峰基地營的健行者約1-2%), 因此在低氧環境測量肺動脈壓力, 也無法預估病患是否容易得到HAPE.
雖然運動員比一般人容易登頂, 但體適能與是否容易得到 AMS 或 HAPE 無關,
因此, 運動(體能)測試無法用來評估登山者是否容易發生高海拔疾病,
平時常規的運動量和運動強度, 以及體適能表現, 有助於評估是否有足夠的儲備能力以應付高海拔造成的體力下降
(超過1500公尺海拔, 每上升 100 公尺約下降 1%).
平時沒有訓練體力的人, 建議在開始攀登前的數星期到數個月, 尤其是預期在高海拔進行嚴酷的戶外活動時, 應進行常規體能訓練.
Other Assessments
The assessment of ventilation in response to exposure to hypoxic conditions at rest or during exercise has been proposed as a means of refining risk prediction for altitude sickness. The increase in ventilation at rest or during exercise while breathing 11.5% oxygen, as well as arterial oxygen saturation after the first 30 minutes of exposure to an altitude of 3000 m or to corresponding normobaric hypoxic conditions, is on average significantly lower in persons who are susceptible to acute altitude sickness than in those who are not.
However, considerable overlap between groups classified as susceptible and those classified as not susceptible in a retrospective study and between a group classified as having acute mountain sickness and a group classified as unaffected in a prospective study makes it impossible to define cutoff values that are sufficiently sensitive and specific to be useful in practice. A multivariate analysis of risk factors for severe high-altitude illness showed that the hypoxic ventilatory response and other physiological measurements under hypoxic conditions add little to the discrimination provided by patient characteristics and history (i.e., sex, level of physical activity, rate of previous ascent, and status with respect to previous severe high-altitude illness and migraines). Persons who are considered to be susceptible to high-altitude pulmonary edema because of two previous episodes of high-altitude pulmonary edema have abnormally high systolic pulmonary-artery pressure (>40 mm Hg) under hypoxic conditions (12% oxygen in ambient air at sea level). In a study of a western European population, exaggerated hypoxic pulmonary-artery pressure was detected in about 10% of study participants, but high-altitude pulmonary edema develops in only 15% of persons with exaggerated hypoxic pulmonary-artery pressure responses who make a rapid ascent (unpublished data). For this reason and because of a very low pretest probability of high-altitude pulmonary edema (e.g., an incidence of 1 to 2% among trekkers to the Mount Everest base camp), measurement of pulmonary-artery pressure under hypoxic conditions cannot be recommended as a means of identifying persons who are susceptible to high-altitude pulmonary edema. Although athletic persons are more likely to reach the summit than persons who are not athletic, physical fitness appears to have no association or at most a modest association with susceptibility to acute mountain sickness and high-altitude pulmonary edema. Thus, an exercise test is not indicated to assess the risk of acute high-altitude illness. Information about the amount and intensity of the person’s regular exercise as well as his or her level of athletic performance is helpful in estimating whether there is sufficient reserve to cope with the expected loss of exercise capacity at high altitudes of about 1% for every 100 m above 1500 m. Persons without athletic training should be encouraged to begin regular physical exercise several weeks to months before the planned ascent, particularly when rigorous outdoor activities are planned at high altitudes.
table 2 (所有海拔高度都是指睡覺的海拔)
攀登玉山，第一天住排雲山莊，海拔 3402 公尺，第二天清晨三點開始爬山，上升到玉山 3952 公尺再下山。
1. 快速上升，第一天住宿時就上升 3402 公尺。
2. 第二天一樣是快速上升，海拔三千公尺以上，一天上升 500 公尺。
所以至少是中度以上風險。
~~~低風險:
上升速率慢 (海拔2500公尺以上,每天上升500公尺以下). 過去在相同海拔沒有AMD、HACE、HAPE; 已經稍微適應的登山者, 快速上升 (海拔2500公尺以上, 每天上升超過 500 公尺) (在未來幾星期, 停留在海拔 3000 公尺以下)
Slow ascent (≤500 m/day above 2500 m); no history of acute mountain sickness, high-altitude cerebral edema, or high-altitude pulmonary edema with previous exposure to similar altitude; rapid ascent (>500 m/day above 2500 m) for persons who are partially acclimatized (exposure to high altitudes of
~~~中度風險:
不知道是否曾有AMS, HACE, HAPE的病史, 快速上升(海拔3000公尺以上, 每天上升大於 500 公尺
不知道是否AMS, 快速上升 (一天上升到海拔 3000 公尺以上)
(台灣高山的登山口有些海拔就超過 3000公尺了, 所以從平地開車上去, 第一天海拔就破表 )
Unknown history of acute mountain sickness, high-altitude cerebral edema, or high-altitude pulmonary edema and fast ascent (>500 m/day above 3000 m); unknown history of acute mountain sickness and rapid ascent (ascent to >3000 m in 1 day)
~~~高度風險:
不知道是否曾有AMS, HACE, HAPE的病史,非常快速上升(通常指一天超過500公尺).最後停留在海拔超過4000公尺.
過去在相同海拔曾經有AMS, HACE, HAPE(與此次計畫要攀登的海拔相似)
Unknown history of acute mountain sickness, high-altitude cerebral edema, or high-altitude pulmonary edema, very rapid ascent (considerably >500 m/day), and high final altitude (>4000 m); history of acute mountain sickness, high-altitude cerebral edema, or high-altitude pulmonary edema with previous exposure to high altitude that is similar to the planned ascent
Table 3. Prevention of High-Altitude Illnesses. 預防高海拔疾病
在暴露前先適應: 先到中等海拔, 2000公尺以上海拔待幾天, 或到 3000公尺以上海拔健行或攀登一天(當天下來).
慢慢上升: 海拔 2500~3000 公尺, 每天上升 300~500公尺, 每三四天休息一天, 適當的治療高海拔疾病早期症狀, 以避免嚴重高海拔疾病.
預防AMS, HACE的藥物
中度風險: ACETAZOLAMIDE 半顆 125mg, 早晚各一次 (一天一顆分兩次吃), 如果副作用強, 或者有禁忌症無法吃 ACETAZOLAMIDE, 改成吃 DEXAMETHASONE 早晚各 4mg.
高度風險: 每次一顆ACETAZOLAMIDE, 一天吃兩次到三次(一天兩次, 中間間隔8-12小時; 一天三次, 中間間隔 4-8 小時), 或 DEXAMETHASONE 每次 4mg 一天三次.
1. 快速上升，第一天住宿時就上升 3402 公尺。
2. 第二天一樣是快速上升，海拔三千公尺以上，一天上升 500 公尺。
所以至少是中度以上風險。
~~~低風險:
上升速率慢 (海拔2500公尺以上,每天上升500公尺以下). 過去在相同海拔沒有AMD、HACE、HAPE; 已經稍微適應的登山者, 快速上升 (海拔2500公尺以上, 每天上升超過 500 公尺) (在未來幾星期, 停留在海拔 3000 公尺以下)
Slow ascent (≤500 m/day above 2500 m); no history of acute mountain sickness, high-altitude cerebral edema, or high-altitude pulmonary edema with previous exposure to similar altitude; rapid ascent (>500 m/day above 2500 m) for persons who are partially acclimatized (exposure to high altitudes of
~~~中度風險:
不知道是否曾有AMS, HACE, HAPE的病史, 快速上升(海拔3000公尺以上, 每天上升大於 500 公尺
不知道是否AMS, 快速上升 (一天上升到海拔 3000 公尺以上)
(台灣高山的登山口有些海拔就超過 3000公尺了, 所以從平地開車上去, 第一天海拔就破表 )
Unknown history of acute mountain sickness, high-altitude cerebral edema, or high-altitude pulmonary edema and fast ascent (>500 m/day above 3000 m); unknown history of acute mountain sickness and rapid ascent (ascent to >3000 m in 1 day)
~~~高度風險:
不知道是否曾有AMS, HACE, HAPE的病史,非常快速上升(通常指一天超過500公尺).最後停留在海拔超過4000公尺.
過去在相同海拔曾經有AMS, HACE, HAPE(與此次計畫要攀登的海拔相似)
Unknown history of acute mountain sickness, high-altitude cerebral edema, or high-altitude pulmonary edema, very rapid ascent (considerably >500 m/day), and high final altitude (>4000 m); history of acute mountain sickness, high-altitude cerebral edema, or high-altitude pulmonary edema with previous exposure to high altitude that is similar to the planned ascent
Table 3. Prevention of High-Altitude Illnesses. 預防高海拔疾病
在暴露前先適應: 先到中等海拔, 2000公尺以上海拔待幾天, 或到 3000公尺以上海拔健行或攀登一天(當天下來).
慢慢上升: 海拔 2500~3000 公尺, 每天上升 300~500公尺, 每三四天休息一天, 適當的治療高海拔疾病早期症狀, 以避免嚴重高海拔疾病.
預防AMS, HACE的藥物
中度風險: ACETAZOLAMIDE 半顆 125mg, 早晚各一次 (一天一顆分兩次吃), 如果副作用強, 或者有禁忌症無法吃 ACETAZOLAMIDE, 改成吃 DEXAMETHASONE 早晚各 4mg.
高度風險: 每次一顆ACETAZOLAMIDE, 一天吃兩次到三次(一天兩次, 中間間隔8-12小時; 一天三次, 中間間隔 4-8 小時), 或 DEXAMETHASONE 每次 4mg 一天三次.
預防HAPE藥物
第一線: NIFEDIPINE 30mg 緩慢釋放劑型, 每天兩次(8-12小時一次)
第二線: PD5抑制劑(例如 tadalafil 犀利士一天一顆分兩次吃, 每次半顆10mg, 8-12小時吃一次) 或 DEXAMETHASONE 每次 8mg, 一天兩次(8-12小時吃一次).
第三線: 吸入型SALMETEROL (每次125ug每天兩次)效果比要差, 副作用在某些人會出現顫抖, 心跳快.
Method ~~~~~~~~~~~~~~~~~~~~~~~~~~~~Description
Acclimatization before exposure ~~~~~~~~~Sojourning several days at intermediate altitudes at or above 2000 m (staging), hiking or climbing on day tours above 3000 m, or both
Slow ascent ~~~~~~~~~~~~~~~~~~~~~~~~ Ascent rate of 300–500 m/day above 2500–3000 m, with a day of rest every 3–4 days; appropriate treatment of early symptoms of acute mountain sickness for prevention of severe high-altitude disease
Drugs for prevention of acute mountain sickness,high-altitude cerebral edema, or both
Moderate risk ~~~~~~~~~~~~~~ Acetazolamide, 125 mg twice/day; if there are side effects with or contraindications to acetazolamide, dexamethasone, 4 mg twice/day, can be used
High risk Acetazolamide, 250 mg two or three times/day (three times/day recommended for rapid ascent, though efficacy uncertain); dexamethasone, 4 mg three times/day, if acetazolamide has unacceptable side effects or is contraindicated
Drugs for prevention of high-altitude pulmonary edema in persons with history of this condition
First line ~~~~~~~~~~~~~~~ Nifedipine, 30 mg of slow-release formulation twice/day
Second line~~~~~~~~~~~~~ Phosphodiesterase-5 inhibitors (e.g., tadalafil, 10 mg twice/day) or dexamethasone, 8 mg twice/day
Third line~~~~~~~~~~~~~~~ Inhaled salmeterol (125 μg twice/day) appears to be less effective than other options and may cause tremor and tachycardia in some persons with this dose
CLINICAL KEY POINT 臨床關鍵重點
高海拔疾病發生於海拔2500公尺以上的頭幾天, 無法適應高度的人, 依據個人體質及過去病史會有很大的差異性.
頭痛是AMS主要症狀, 如果AMS沒有好好治療, 會進展成危及生命的HACE或HAPE (這句話很怪, 因為AMS/HACE. 與 HAPE 其實是兩種不同生理病理反應. 不同疾病. HAPE 病患與AMS病患雖然重疊部分很高. 但可單獨出現. )
高海拔疾病能夠藉由控制上升速度來避免(海拔3000公尺以上, 每天300-500公尺, 每3-4天要有一個休息天)
高海拔疾病發生於海拔2500公尺以上的頭幾天, 無法適應高度的人, 依據個人體質及過去病史會有很大的差異性.
頭痛是AMS主要症狀, 如果AMS沒有好好治療, 會進展成危及生命的HACE或HAPE (這句話很怪, 因為AMS/HACE. 與 HAPE 其實是兩種不同生理病理反應. 不同疾病. HAPE 病患與AMS病患雖然重疊部分很高. 但可單獨出現. )
高海拔疾病能夠藉由控制上升速度來避免(海拔3000公尺以上, 每天300-500公尺, 每3-4天要有一個休息天)
使用acetazolamide 或 dexamethasone 可以降低AMS或HACE的機率.
使用nifedipine、phosphodiesterase-5 inhibitors(威而鋼、犀利士)、dexamethasone,可以降低HAPE的機率
使用nifedipine、phosphodiesterase-5 inhibitors(威而鋼、犀利士)、dexamethasone,可以降低HAPE的機率
AMS的頭痛可使用NSAID或休息來治療, 但嚴重的狀況應該下降或給氧氣, 嚴重的AMS或HACE可使用dexamethasone。HAPE可以使用 nifedipine或 phosphodiesterase-5 inhibitors來治療, 治療過後應該盡可能立即下降. (藥物可以爭取時間, 但並非絕對安全, 治療結果不一定能好轉, 及早下降)
註解:
AMS 急性高山症 acute mountain sickness
HACE 高海拔腦水腫 high altitude cerebral edema
HAPE 高海拔肺水腫 high altitude pulmonary edema
NSAID 非類固醇消炎止痛藥 (電視廣告的肌立即屬於此類)
phosphodiesterase-5 inhibitors =PDE5抑制劑, 如威而剛、樂威壯、犀利士
acetazolamide 乙酰唑胺片, 以前大家比較知道的是DIAMOX丹木斯, 不過丹木斯2006年停產, 目前台灣可以買到同成分的藥物
dexamethasone 類固醇 http://tinyurl.com/n8j2hey
nifedipine 降血壓藥物, 屬於鈣離子阻斷劑, 內科醫師常用於突發性血壓升高 http://tinyurl.com/mtrxcdp(但不建議血壓突然升高的患者直接使用nifedipine)
Acute High-Altitude Illnesses
• Acute high-altitude illnesses occur in persons who are not acclimatized during the first days at an altitude of 2500 m or higher, with wide variation in the incidence according to patient characteristics and history.
• Headache is the major symptom of acute mountain sickness. If acute mountain sickness is not treated adequately, it can progress to life-threatening high-altitude cerebral or pulmonary edema.
• High-altitude illnesses can be prevented by ascending 300 to 500 m per day at altitudes above 3000 m and including a rest day every 3 to 4 days.
• Risks of acute mountain sickness and high-altitude cerebral edema are reduced with the use of acet-azolamide or dexamethasone; the risk of high-altitude pulmonary edema is reduced with the use of nifedipine, phosphodiesterase-5 inhibitors, or dexamethasone.
• Acute mountain sickness may be treated by a day of rest and nonsteroidal antiinflammatory drugs for headache, but when it is severe, descent or supplemental oxygen is indicated. Dexamethasone is indi-cated for severe acute mountain sickness or high-altitude cerebral edema, and nifedipine or phospho-diesterase-5 inhibitors are indicated for high-altitude pulmonary edema; treatment with these agents should be followed by descent as soon as possible.
預防
非藥物方式 雖然系統性評估上升速率(指連續兩晚睡眠海拔的增加)對於預防高海拔疾病的影響, 缺乏前瞻性研究的數據, 海拔3000公尺以上的攀登指引建議每天上升速率 300-500 公尺, 每 3-4 天應該休息一天. (請看table 3). 對於不同攀登者, 攀登速率與結果存在著很大的差異, 沒有高海拔攀登經驗的登山者建議遵照此指引, 如果預計的攀登速率更快, 其他的方式, 例如攀登前的適應策略, 或用藥物預防. 登山者或者高地居民在3000公尺海拔進行體能訓練數星期, 接著攀登 4500 公尺以上海拔, 發生AMS的機率會比較低(不受個人體質與上升速率影響). 在海拔 2000 公尺以上停留一星期之後, 與海平面做比較, 攀登4500 公尺海拔的AMS發生率以及嚴重度會下降 50%. 曾有人假設, 攀登前暴露於相當於海拔 2500-3000 公尺的常壓低氧的環境, 可能對有預防AMS的效果, 在一個雙盲試驗發現, 重複間隔性暴露在相當於海拔2500-4500公尺的常壓低氧環境 60-90 分鐘, 或持續在相當於 2500-4500 公尺海拔的常壓低氧狀態睡 8 小時, 連續七天, 對於降低4300~4559公尺的AMS的機率和嚴重度沒有影響. 因此, 要降低高海拔疾病的風險, 建議待在海拔 2000-3000 公尺大約一星期, 以及在更高海拔從事日間健行或攀登, 且要在攀登前的時間做，因為不知道這種高度適應有效的時間能持續多久
Prevention Nonpharmacologic Approaches Although data are lacking from prospective studies that systematically assess the influence of the rate of ascent (defined as the gain in altitude between the altitudes at which one sleeps on 2 consecutive nights) on prevention of acute high-altitude illnesses, guidelines for ascents to altitudes above 3000 m recommend ascent rates of 300 to 500 m per day and a day of rest every 3 to 4 days (Table 3). However, there are large differences among persons with respect to ascent rates that are not associated with poor outcomes. A person without previous experience in high altitudes should follow the ascent rates recommended by these guidelines. If the planned ascent rate is faster, additional measures, such as acclimatization strategies before the ascent or prophylactic medications, should be considered. Mountaineering or residence with regular physical activity at altitudes above 3000 m in the weeks preceding a climb to 4500 m is associated with a reduced incidence of acute mountain sickness that is independent of the person’s susceptibility to this condition and the rate of ascent. An ascent made after 1 week at an altitude of 2000 m or higher, as compared with an ascent from near sea level, reduces both the incidence and severity of acute mountain sickness at 4300 m by 50%. It has been hypothesized that exposure to normobaric hypoxic conditions before an ascent might provide protection against acute mountain sickness. In double-blind, placebo-controlled trials, however, repeated intermittent exposure to normobaric hypoxia equivalent to an altitude of 2500 to 4500 m for 60 to 90 minutes or continuous exposure to normobaric hypoxia equivalent to an altitude of 2500 to 3000 m during 8 hours of sleep on 7 consecutive nights did not significantly reduce the incidence or severity of acute mountain sickness at altitudes of 4300 to 4559 m. On the basis of these data, a recommended strategy to reduce the risk of high-altitude illness is to remain at an altitude between 2000 and 3000 m for about a week and to include day hiking or climbing at higher altitudes. This should be done as close in time as possible to the trek or expedition, since it is not known how quickly acclimatization diminishes with time.
一項隨機性安慰劑對照的實驗指出，上升前一小時，服用 320mg 的水楊酸，吃三次，每次間隔四小時，或者上升前數小時吃 600mg 的 ibuprofen 一天三次，在攀登到 3480～4920 公尺海拔時，能顯著的降低頭痛的機率。 頭痛是 AMS 的定義症狀，在這些研究都發現能降低頭痛的機率，但只能維持一到兩天 (如果真的得到 AMS，吃止痛藥物無法真正治療 AMS，只能緩和症狀而已，所以當 AMS 變更嚴重，藥物就感覺沒效了) 吃止痛藥物(NSAID類)的風險是腸胃道出血，在高海拔發生機率會增加，但目前缺乏研究來評估這種風險。 當風險評估指出有高度可能性得到高山症 AMS，建議吃 acetazolamide。 在一個大型的前瞻性觀察性研究，使用 acetazolamide 能降低 44% 的嚴重高海拔疾病風險。 一個多變項分析研究指出，在上升前服用各種劑量的 acetazolamide，能明顯減少 AMS，作者總結，預防性的最低有效劑量是 125mg，一天兩次 (在台灣目前常用的劑量是一顆 125mg，等於一次半顆，一天早晚各吃一次，一天總共吃一顆) 一次 125mg 一天兩次的劑量能預防 1600 公尺海拔上升到 4300公尺海拔的高山症 AMS，或降低在 4200公尺沒有高山症的健行者，繼續上升至 4900 公尺海拔時的高山症 AMS 機率。 然而，另一項研究，使用每次 250mg，一天兩次的劑量，在吉立馬札羅山快速上升時(五天內上升到 5895 公尺海拔），發生高山症機率 50%，所以低劑量 acetazolamide 對於更快速的上升以及更高的海拔可能不夠。但更高劑量是否更有效果，目前仍不知道。 acetazolamide 需要在上升前一天開始服用，在最高海拔之後持續再吃兩天，或服用到下降為止。 一個多變項分析指出，服用 acetazolamide 的病人，35-90% 會出現手指頭麻木(感覺異常)，在前幾次服用時， 8-55% 會出現多尿的症狀。4-14% 在喝碳酸飲料時會出現味覺異常。在低海拔(表示非高山症)服用 acetazolamide 250mg 一天三次的人，20% 會出現噁心、疲倦的症狀。 因此，建議在上山前先服用 acetazolamide ，對於上山之後區分是藥物副作用，或者是得到高山症，會有幫忙
Prophylactic Medication
Randomized, placebo-controlled trials have shown a significant reduction in the risk of headache with the use of acetylsalicylic acid at a dose of 320 mg taken three times at 4-hour intervals, starting 1 hour before ascent, 31 or ibuprofen at a dose of 600 mg three times per day, 32,33 starting a few hours before ascent to altitudes between 3480 and 4920 m. Headache is a defining symptom of acute mountain sickness, and the incidence of this condition was reduced in all these trials, which lasted 1 or 2 days only. A risk associated with these medications is gastrointestinal bleeding, which may be increased at high altitudes, 34 but studies were not powered to assess this risk. When risk assessment indicates a high probability of the development of acute mountain sickness (Table 2), acetazolamide is recommended. In a large, prospective, observational study, the use of acetazolamide was associated with a 44% reduction in the risk of severe high-altitude illnesses. 7 A meta-analysis of randomized trials of various doses of acetazolamide initiated before ascent likewise showed a significantly reduced risk of acute mountain sickness; the authors of this meta-analysis concluded that the lowest effective dose for prevention is 125 mg twice per day. 35 This dose has been shown to be effective in reducing the incidence of acute mountain sickness associated with rapid ascent from a baseline altitude of 1600 to 4300 m 36 or during further ascent to 4900 m among trekkers who have ascended to 4200 m without illness. However, a study that showed acute mountain sickness in more than 50% of persons who received acetazolamide at a dose of 250 mg twice per day during a rapid ascent of Mount Kilimanjaro (5895 m in 5 days) 38 suggested that low-to-moderate doses may be inadequate with more rapid ascents and higher final altitudes; it is not known whether higher doses are more effective in persons at these altitudes. Acetazolamide should be started 1 day before the ascent and discontinued after 2 days at the final altitude or during the descent. A meta-analysis showed that acral paresthesias occurred in 35 to 90% of persons receiving acetazolamide, and polyuria occurred with the first several doses in 8 to 55%, with distaste for carbonated beverages in 4 to 14%. Nausea and tiredness developed in about 20% of persons who received 250 mg of acetazolamide three times per day at low altitudes. Thus, testing for side effects of the drug before the ascent might be useful to avoid confusion of a side effect with a symptom of acute mountain sickness. If side effects occur, the person should be advised not to use this prophylactic agent. If there is a contraindication to acetazolamide or if it has intolerable side effects, an alternative is dexamethasone at a dose of 4 mg two or three times per day. In a randomized, placebo-controlled trial, dexamethasone was associated with a significant reduction in the incidence and severity of acute mountain sickness among persons who ascended to 2700 m. 40 Several smaller randomized trials, including one head-to-head trial, have also shown these results at 4300 to 4570 m, with a magnitude of effect similar to that of acetazolamide. 10 Given the potential adverse effects of dexamethasone (e.g., hyperglycemia, adrenal suppression, and psychosis), its use for prevention of acute mountain sickness should be limited to persons with unequivocal indications, and it should be administered fo less than 1 week. Since there appears to be a continuum from acute mountain sickness to high-altitude cerebral edema, drugs that prevent the first condition will probably also reduce the risk of the second one. However, systematic data are lacking to confirm this theory.
高海拔肺水腫的預防 可以使用 nifedipine 每天兩次, 每次 30mg, Tadalafil 每天兩次, 每次 10mg 類固醇是可以用的，每天吃兩次 8mg dexamethasone 可以將HAPE發生率從 70% 降低至 10% 以下
高劑量吸入性氣管擴張劑 salmeterol 每天兩遍, 每一遍噴五下, 效果比較不好, 但在一篇研究報告指出, 可以將HAPE機率從 74% 降低到 33%
Small randomized trials involving persons with a history of high-altitude pulmonary edema have shown that the risk of recurrence can be reduced with the use of medications that lower the high pulmonary-artery pressure that is typical in susceptible persons. Nifedipine in a slow-release formulation at a dose of 30 mg twice perday, 41 tadalafil (a phosphodiesterase-5 inhibitor) at a dose of 10 mg twice per day, and dexamethasone at a dose of 8 mg twice per day 42 appear to be similarly effective in lowering pulmonaryartery pressure and reducing the incidence of high-altitude pulmonary edema from approximately 70% to approximately 10% or less. Although it has not been compared directly with these agents, inhaled salmeterol, a long-acting β 2 -agonist, at a high dose of 5 puffs (125 μg) twice per day, appears to be less effective; in a placebo-controlled trial, it was associated with a reduction in the incidence of high-altitude pulmonary edema from 74% to 33%.
治療 Treatment
通用處置: 下降, 給氧氣, 加壓艙
藥物
輕度至中度的AMS通常需要休息一天, 吃NSAID止痛, 或吃止吐藥物治療嘔吐, 吃IBUPROFEN 可以顯著降低頭痛症狀, 氧氣及丹木斯可以加速復原 (雖然在已經出現AMS症狀的人, 服用丹木斯的研究報告目前不多)
在偏遠地區, 如果經過休息或治療, 仍持續有AMS症狀應該下降 500-1000 公尺. 如果無法下降, 可以採取下列方式: 給予類固醇 DEXAMETHASONE 4-8 mg 每六小時吃一次, 給予氧氣, 使用加壓艙.
The treatment of mild-to-moderate acute mountain sickness (Table 4) generally consists of a day of rest, NSAIDs for headache, and possibly antiemetic drugs. One small, placebo-controlled, crossover trial showed that ibuprofen reduced headache significantly in affected persons. Treatment with oxygen and acetazolamide may also facilitate more rapid recovery, although there are only limited data from randomized trials to support the benefit of acetazolamide in persons in whom acute mountain sickness has already developed. In remote areas, a descent of 500 to 1000 m is indicated if symptoms of acute mountain sickness persist despite a day of rest and symptomatic treatment. If descent is not possible because of logistical constraints or the person’s condition, improvement sufficient to allow descent can be achieved with one or a combination of the following interventions: administration of dexamethasone at a dose of 4 to 8 mg every 6 hours, provision of supplemental oxygen (2 to 4 liters per minute), or treatment in a manually pressurized, body-length, portable hyperbaric bag.
嚴重症狀需要立即下降, 因為可能已經出現高海拔腦水腫, 或高海拔肺水腫
高海拔肺水腫病患, 可以使用氧氣降低肺動脈壓, 下降至較低海拔, 使用肺動脈擴張劑(NIFEDIPINE). 有文獻報告指出犀利士或威而鋼治療高海拔肺水腫會有好處, 但類固醇 地塞米松 dexamethasone 則無證據支持。
雖然治療高海拔肺水腫主要是需要下降, 但將一個輕度至中度症狀的清醒病患, 留置在偏遠地區, 使用氧氣及口服肺血管擴張劑, 同時在當地有急救設施或有醫師可以幫助觀察, 是合理的,.
利尿劑對於高海拔肺水腫無效.
Immediate descent is lifesaving when severe symptoms suggest the onset of high-altitude cerebral edema or high-altitude pulmonary edema. In persons with high-altitude pulmonary edema, pulmonary-artery pressure should be lowered by means of supplemental oxygen (2 to 4 liters per minute), descent to a lower altitude, or pulmonary vasodilators (of which only nifedipine has been tested in a prospective study, which was uncontrolled). Anecdotal reports describe a benefit of phosphodiesterase-5 inhibitors for the treatment of high-altitude pulmonary edema, but they do not provide support for the use of dexamethasone. Although descent to a lower altitude is the primary goal for the management of high-altitude pulmonary edema in remote areas, allowing a fully conscious person with mild-to-moderate high-altitude pulmonary edema to remain in a mountainous resort area is reasonable when supplemental oxygen and oral pulmonary vasodilators can be provided under the supervision of a local physician or in an emergency facility. There is no role for diuretics in the treatment of high-altitude pulmonary edema.
註解:
AMS 急性高山症 acute mountain sickness
HACE 高海拔腦水腫 high altitude cerebral edema
HAPE 高海拔肺水腫 high altitude pulmonary edema
NSAID 非類固醇消炎止痛藥 (電視廣告的肌立即屬於此類)
phosphodiesterase-5 inhibitors =PDE5抑制劑, 如威而剛、樂威壯、犀利士
acetazolamide 乙酰唑胺片, 以前大家比較知道的是DIAMOX丹木斯, 不過丹木斯2006年停產, 目前台灣可以買到同成分的藥物
dexamethasone 類固醇 http://tinyurl.com/n8j2hey
nifedipine 降血壓藥物, 屬於鈣離子阻斷劑, 內科醫師常用於突發性血壓升高 http://tinyurl.com/mtrxcdp(但不建議血壓突然升高的患者直接使用nifedipine)
Acute High-Altitude Illnesses
• Acute high-altitude illnesses occur in persons who are not acclimatized during the first days at an altitude of 2500 m or higher, with wide variation in the incidence according to patient characteristics and history.
• Headache is the major symptom of acute mountain sickness. If acute mountain sickness is not treated adequately, it can progress to life-threatening high-altitude cerebral or pulmonary edema.
• High-altitude illnesses can be prevented by ascending 300 to 500 m per day at altitudes above 3000 m and including a rest day every 3 to 4 days.
• Risks of acute mountain sickness and high-altitude cerebral edema are reduced with the use of acet-azolamide or dexamethasone; the risk of high-altitude pulmonary edema is reduced with the use of nifedipine, phosphodiesterase-5 inhibitors, or dexamethasone.
• Acute mountain sickness may be treated by a day of rest and nonsteroidal antiinflammatory drugs for headache, but when it is severe, descent or supplemental oxygen is indicated. Dexamethasone is indi-cated for severe acute mountain sickness or high-altitude cerebral edema, and nifedipine or phospho-diesterase-5 inhibitors are indicated for high-altitude pulmonary edema; treatment with these agents should be followed by descent as soon as possible.
預防
非藥物方式 雖然系統性評估上升速率(指連續兩晚睡眠海拔的增加)對於預防高海拔疾病的影響, 缺乏前瞻性研究的數據, 海拔3000公尺以上的攀登指引建議每天上升速率 300-500 公尺, 每 3-4 天應該休息一天. (請看table 3). 對於不同攀登者, 攀登速率與結果存在著很大的差異, 沒有高海拔攀登經驗的登山者建議遵照此指引, 如果預計的攀登速率更快, 其他的方式, 例如攀登前的適應策略, 或用藥物預防. 登山者或者高地居民在3000公尺海拔進行體能訓練數星期, 接著攀登 4500 公尺以上海拔, 發生AMS的機率會比較低(不受個人體質與上升速率影響). 在海拔 2000 公尺以上停留一星期之後, 與海平面做比較, 攀登4500 公尺海拔的AMS發生率以及嚴重度會下降 50%. 曾有人假設, 攀登前暴露於相當於海拔 2500-3000 公尺的常壓低氧的環境, 可能對有預防AMS的效果, 在一個雙盲試驗發現, 重複間隔性暴露在相當於海拔2500-4500公尺的常壓低氧環境 60-90 分鐘, 或持續在相當於 2500-4500 公尺海拔的常壓低氧狀態睡 8 小時, 連續七天, 對於降低4300~4559公尺的AMS的機率和嚴重度沒有影響. 因此, 要降低高海拔疾病的風險, 建議待在海拔 2000-3000 公尺大約一星期, 以及在更高海拔從事日間健行或攀登, 且要在攀登前的時間做，因為不知道這種高度適應有效的時間能持續多久
Prevention Nonpharmacologic Approaches Although data are lacking from prospective studies that systematically assess the influence of the rate of ascent (defined as the gain in altitude between the altitudes at which one sleeps on 2 consecutive nights) on prevention of acute high-altitude illnesses, guidelines for ascents to altitudes above 3000 m recommend ascent rates of 300 to 500 m per day and a day of rest every 3 to 4 days (Table 3). However, there are large differences among persons with respect to ascent rates that are not associated with poor outcomes. A person without previous experience in high altitudes should follow the ascent rates recommended by these guidelines. If the planned ascent rate is faster, additional measures, such as acclimatization strategies before the ascent or prophylactic medications, should be considered. Mountaineering or residence with regular physical activity at altitudes above 3000 m in the weeks preceding a climb to 4500 m is associated with a reduced incidence of acute mountain sickness that is independent of the person’s susceptibility to this condition and the rate of ascent. An ascent made after 1 week at an altitude of 2000 m or higher, as compared with an ascent from near sea level, reduces both the incidence and severity of acute mountain sickness at 4300 m by 50%. It has been hypothesized that exposure to normobaric hypoxic conditions before an ascent might provide protection against acute mountain sickness. In double-blind, placebo-controlled trials, however, repeated intermittent exposure to normobaric hypoxia equivalent to an altitude of 2500 to 4500 m for 60 to 90 minutes or continuous exposure to normobaric hypoxia equivalent to an altitude of 2500 to 3000 m during 8 hours of sleep on 7 consecutive nights did not significantly reduce the incidence or severity of acute mountain sickness at altitudes of 4300 to 4559 m. On the basis of these data, a recommended strategy to reduce the risk of high-altitude illness is to remain at an altitude between 2000 and 3000 m for about a week and to include day hiking or climbing at higher altitudes. This should be done as close in time as possible to the trek or expedition, since it is not known how quickly acclimatization diminishes with time.
一項隨機性安慰劑對照的實驗指出，上升前一小時，服用 320mg 的水楊酸，吃三次，每次間隔四小時，或者上升前數小時吃 600mg 的 ibuprofen 一天三次，在攀登到 3480～4920 公尺海拔時，能顯著的降低頭痛的機率。 頭痛是 AMS 的定義症狀，在這些研究都發現能降低頭痛的機率，但只能維持一到兩天 (如果真的得到 AMS，吃止痛藥物無法真正治療 AMS，只能緩和症狀而已，所以當 AMS 變更嚴重，藥物就感覺沒效了) 吃止痛藥物(NSAID類)的風險是腸胃道出血，在高海拔發生機率會增加，但目前缺乏研究來評估這種風險。 當風險評估指出有高度可能性得到高山症 AMS，建議吃 acetazolamide。 在一個大型的前瞻性觀察性研究，使用 acetazolamide 能降低 44% 的嚴重高海拔疾病風險。 一個多變項分析研究指出，在上升前服用各種劑量的 acetazolamide，能明顯減少 AMS，作者總結，預防性的最低有效劑量是 125mg，一天兩次 (在台灣目前常用的劑量是一顆 125mg，等於一次半顆，一天早晚各吃一次，一天總共吃一顆) 一次 125mg 一天兩次的劑量能預防 1600 公尺海拔上升到 4300公尺海拔的高山症 AMS，或降低在 4200公尺沒有高山症的健行者，繼續上升至 4900 公尺海拔時的高山症 AMS 機率。 然而，另一項研究，使用每次 250mg，一天兩次的劑量，在吉立馬札羅山快速上升時(五天內上升到 5895 公尺海拔），發生高山症機率 50%，所以低劑量 acetazolamide 對於更快速的上升以及更高的海拔可能不夠。但更高劑量是否更有效果，目前仍不知道。 acetazolamide 需要在上升前一天開始服用，在最高海拔之後持續再吃兩天，或服用到下降為止。 一個多變項分析指出，服用 acetazolamide 的病人，35-90% 會出現手指頭麻木(感覺異常)，在前幾次服用時， 8-55% 會出現多尿的症狀。4-14% 在喝碳酸飲料時會出現味覺異常。在低海拔(表示非高山症)服用 acetazolamide 250mg 一天三次的人，20% 會出現噁心、疲倦的症狀。 因此，建議在上山前先服用 acetazolamide ，對於上山之後區分是藥物副作用，或者是得到高山症，會有幫忙
Prophylactic Medication
Randomized, placebo-controlled trials have shown a significant reduction in the risk of headache with the use of acetylsalicylic acid at a dose of 320 mg taken three times at 4-hour intervals, starting 1 hour before ascent, 31 or ibuprofen at a dose of 600 mg three times per day, 32,33 starting a few hours before ascent to altitudes between 3480 and 4920 m. Headache is a defining symptom of acute mountain sickness, and the incidence of this condition was reduced in all these trials, which lasted 1 or 2 days only. A risk associated with these medications is gastrointestinal bleeding, which may be increased at high altitudes, 34 but studies were not powered to assess this risk. When risk assessment indicates a high probability of the development of acute mountain sickness (Table 2), acetazolamide is recommended. In a large, prospective, observational study, the use of acetazolamide was associated with a 44% reduction in the risk of severe high-altitude illnesses. 7 A meta-analysis of randomized trials of various doses of acetazolamide initiated before ascent likewise showed a significantly reduced risk of acute mountain sickness; the authors of this meta-analysis concluded that the lowest effective dose for prevention is 125 mg twice per day. 35 This dose has been shown to be effective in reducing the incidence of acute mountain sickness associated with rapid ascent from a baseline altitude of 1600 to 4300 m 36 or during further ascent to 4900 m among trekkers who have ascended to 4200 m without illness. However, a study that showed acute mountain sickness in more than 50% of persons who received acetazolamide at a dose of 250 mg twice per day during a rapid ascent of Mount Kilimanjaro (5895 m in 5 days) 38 suggested that low-to-moderate doses may be inadequate with more rapid ascents and higher final altitudes; it is not known whether higher doses are more effective in persons at these altitudes. Acetazolamide should be started 1 day before the ascent and discontinued after 2 days at the final altitude or during the descent. A meta-analysis showed that acral paresthesias occurred in 35 to 90% of persons receiving acetazolamide, and polyuria occurred with the first several doses in 8 to 55%, with distaste for carbonated beverages in 4 to 14%. Nausea and tiredness developed in about 20% of persons who received 250 mg of acetazolamide three times per day at low altitudes. Thus, testing for side effects of the drug before the ascent might be useful to avoid confusion of a side effect with a symptom of acute mountain sickness. If side effects occur, the person should be advised not to use this prophylactic agent. If there is a contraindication to acetazolamide or if it has intolerable side effects, an alternative is dexamethasone at a dose of 4 mg two or three times per day. In a randomized, placebo-controlled trial, dexamethasone was associated with a significant reduction in the incidence and severity of acute mountain sickness among persons who ascended to 2700 m. 40 Several smaller randomized trials, including one head-to-head trial, have also shown these results at 4300 to 4570 m, with a magnitude of effect similar to that of acetazolamide. 10 Given the potential adverse effects of dexamethasone (e.g., hyperglycemia, adrenal suppression, and psychosis), its use for prevention of acute mountain sickness should be limited to persons with unequivocal indications, and it should be administered fo less than 1 week. Since there appears to be a continuum from acute mountain sickness to high-altitude cerebral edema, drugs that prevent the first condition will probably also reduce the risk of the second one. However, systematic data are lacking to confirm this theory.
高海拔肺水腫的預防 可以使用 nifedipine 每天兩次, 每次 30mg, Tadalafil 每天兩次, 每次 10mg 類固醇是可以用的，每天吃兩次 8mg dexamethasone 可以將HAPE發生率從 70% 降低至 10% 以下
高劑量吸入性氣管擴張劑 salmeterol 每天兩遍, 每一遍噴五下, 效果比較不好, 但在一篇研究報告指出, 可以將HAPE機率從 74% 降低到 33%
Small randomized trials involving persons with a history of high-altitude pulmonary edema have shown that the risk of recurrence can be reduced with the use of medications that lower the high pulmonary-artery pressure that is typical in susceptible persons. Nifedipine in a slow-release formulation at a dose of 30 mg twice perday, 41 tadalafil (a phosphodiesterase-5 inhibitor) at a dose of 10 mg twice per day, and dexamethasone at a dose of 8 mg twice per day 42 appear to be similarly effective in lowering pulmonaryartery pressure and reducing the incidence of high-altitude pulmonary edema from approximately 70% to approximately 10% or less. Although it has not been compared directly with these agents, inhaled salmeterol, a long-acting β 2 -agonist, at a high dose of 5 puffs (125 μg) twice per day, appears to be less effective; in a placebo-controlled trial, it was associated with a reduction in the incidence of high-altitude pulmonary edema from 74% to 33%.
治療 Treatment
通用處置: 下降, 給氧氣, 加壓艙
藥物
輕度至中度的AMS通常需要休息一天, 吃NSAID止痛, 或吃止吐藥物治療嘔吐, 吃IBUPROFEN 可以顯著降低頭痛症狀, 氧氣及丹木斯可以加速復原 (雖然在已經出現AMS症狀的人, 服用丹木斯的研究報告目前不多)
在偏遠地區, 如果經過休息或治療, 仍持續有AMS症狀應該下降 500-1000 公尺. 如果無法下降, 可以採取下列方式: 給予類固醇 DEXAMETHASONE 4-8 mg 每六小時吃一次, 給予氧氣, 使用加壓艙.
The treatment of mild-to-moderate acute mountain sickness (Table 4) generally consists of a day of rest, NSAIDs for headache, and possibly antiemetic drugs. One small, placebo-controlled, crossover trial showed that ibuprofen reduced headache significantly in affected persons. Treatment with oxygen and acetazolamide may also facilitate more rapid recovery, although there are only limited data from randomized trials to support the benefit of acetazolamide in persons in whom acute mountain sickness has already developed. In remote areas, a descent of 500 to 1000 m is indicated if symptoms of acute mountain sickness persist despite a day of rest and symptomatic treatment. If descent is not possible because of logistical constraints or the person’s condition, improvement sufficient to allow descent can be achieved with one or a combination of the following interventions: administration of dexamethasone at a dose of 4 to 8 mg every 6 hours, provision of supplemental oxygen (2 to 4 liters per minute), or treatment in a manually pressurized, body-length, portable hyperbaric bag.
嚴重症狀需要立即下降, 因為可能已經出現高海拔腦水腫, 或高海拔肺水腫
高海拔肺水腫病患, 可以使用氧氣降低肺動脈壓, 下降至較低海拔, 使用肺動脈擴張劑(NIFEDIPINE). 有文獻報告指出犀利士或威而鋼治療高海拔肺水腫會有好處, 但類固醇 地塞米松 dexamethasone 則無證據支持。
雖然治療高海拔肺水腫主要是需要下降, 但將一個輕度至中度症狀的清醒病患, 留置在偏遠地區, 使用氧氣及口服肺血管擴張劑, 同時在當地有急救設施或有醫師可以幫助觀察, 是合理的,.
利尿劑對於高海拔肺水腫無效.
Immediate descent is lifesaving when severe symptoms suggest the onset of high-altitude cerebral edema or high-altitude pulmonary edema. In persons with high-altitude pulmonary edema, pulmonary-artery pressure should be lowered by means of supplemental oxygen (2 to 4 liters per minute), descent to a lower altitude, or pulmonary vasodilators (of which only nifedipine has been tested in a prospective study, which was uncontrolled). Anecdotal reports describe a benefit of phosphodiesterase-5 inhibitors for the treatment of high-altitude pulmonary edema, but they do not provide support for the use of dexamethasone. Although descent to a lower altitude is the primary goal for the management of high-altitude pulmonary edema in remote areas, allowing a fully conscious person with mild-to-moderate high-altitude pulmonary edema to remain in a mountainous resort area is reasonable when supplemental oxygen and oral pulmonary vasodilators can be provided under the supervision of a local physician or in an emergency facility. There is no role for diuretics in the treatment of high-altitude pulmonary edema.
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