Important Trip Notes

High altitude sickness is the key thing on your travel in the mountain. It can take your life if you ignore this or if you don't have at least the basic knowledge of high altitude sickness.

EVERYONE MUST KNOW SOME SIMPLE THINGS ABOUT ALTITUDE SICKNESS BEFORE HEADING TO THE REMOTE AREAS AND HIGH MOUNTAINS. 

GENERAL KNOWLODGE ABOUT ALTITUDE SICKNESS:
Causes:

• Due to the less molecules of oxygen available because of the low atmospheric pressure. In sea level, the concentration of oxygen is 21%, while barometric pressure is 760 mm hg. As you climb in the high altitude, the barometric pressure will be decreased. In result, the amount of oxygen molecules will be decreased so the oxygen molecules per breathe will decreased respectively. In result, you will get AMS. At the altitude of 12000 ft (3658m), the barometric pressure will be only 483mm hg, so roughly 40% fewer oxygen molecules per breathe. 
• Because of less acclimatize.
• Because of hypothermia.
• Due to the lack of fluid in the body.
• Due to the rapid ascent.

Table of "Atmospheric Pressure and PAO in relation to Altitude

Elevation	Atmospheric pressure (mm hg)	PAO in a young healthy person (mm hg)
Sea level	760	90 to 95
2800m (9200ft)	543	60
6100m (20140ft)	356	35

 Note: PAO = Partial pressure of arterial oxygen.
Altitude is defined on the following scale:

• High (8000ft-12000ft/2438m-3658m)
• Very High (12000ft-18000ft/3658m-5487m)
• Extremely (18000+ft/5500+m)

Signs & symptoms

• Headache ( often relieved by mild painkillers)
• Dizziness
• Loss of appetite
• Nausea and/or vomiting
• Tiredness, fatigue
• Irritably
• Disturbed sleep

Normal body's reaction at altitude

• Hyperventilation (breathing faster, deeper or both)
• Shortness of breath during exertion
• Changed breathing pattern at night
• Awakening frequently at night
• Sometime nightmare
• Increased urination

Prevention

• Climb slower as much as you go higher
• Above 2500m, 300m of ascent or less per day, with a day rest every three or four days
• Above 4000m, 150m of ascent or less per day, with a day rest every three or four days
• Climb high sleep low
• Avoid over-exercising and exhaustion while acclimatizing and especially while experiencing symptoms of AMS
• Avoid dehydration. Drink plenty of fluids to keep your urine pale and plentiful. Keep your urine pale and plentiful
• Avoid alcohol, tobacco and salt
• Avoid medications such as sleeping tablets, sedatives, strong painkillers and antihistamines, which depress the respiration and increase the risk of AMS, especially while sleeping
• Use the "Buddy System" to keep an eye on each other
• Wear proper clothes. Do not make your body to feel cold. Hypothermia may cause to develop AMS
• Keep in mind that different people will acclimatize at different rates. Make sure all of your party is properly acclimatized.
• Eat a high carbohydrate diet (more than 70% of your calories from carbohydrate) while at altitude
• Do not feel shame to tell your party about your health condition if you are feeling unwell concerning disturbance to your friends and to show yourself as fit as others. So do not force yourself to follow others' pace.
• Do not make your hike as a competition such as "who is faster?"
• Take it easy; don't over-exert yourself when you first get up to altitude. Light activities during the day is better than sleeping because respiration decreases during sleep, exacerbating the symptoms
• Flying or driving to high altitude increases the risk of developing severe AMS. Consider using Diamox™, first dose the day before you ascend, and continue for four or five days.

Severe forms of AMS

• HACE (High Altitude Cerebral Edema): The accumulation of water in or around the brain.
• HAPE (High Altitude Pulmonary Edema): The accumulation of water in the lungs.

HACE
Signs: Any or all of the following symptoms plus the symptoms of the Mild AMS.

• Severe headache that often worse on lying down (non-relievable by ibuprofen, paracetamol or aspirin)
• Tiredness, severe fatigue
• Nausea and/or vomiting (which may be severe and persistent)
• Loss of coordination, clumsiness. The victim needs help even for simple tasks such as tying shoelaces or packing the bag. They can't do the finger-nose test.
• Staggering, falling. They can't do heal-to-toe walking test or the standing test.
• Blurred or double vision, seeing haloes around the object.
• Loss of mental abilities such as memory. They can't do even simple mental arithmetic test. Such as; 12*8=? 16+28=?
• Confusions, hallucinations
• Change in behaviors (aggression, apathy etc)
• Drowsiness, difficult to wake up

• Coma

Tests for HACE

• Heel-to-toe walking test: The victim is asked to take 10 very small steps, placing the heel of one foot to the foot of the other foot as they go. Reasonably flat ground is necessary and the victim should not be helped.
• Standing test: The victim is asked to stand with eyes closed, feet together and arms by their sides-attention position.
• Finger-nose test: With eyes closed, the victim repeatedly and rapidly alternates between touching the tips of their nose with an index finger, and extending this arm to point into the distance (a useful test if the victim is in the sleeping bag).
• Mental arithmetic test: Give the victim a mental arithmetic test, for example-subtract 6 from 100, add 26 and 24, multiply 4 to 8 and so on (but memory of someone may be poor even in the sea-level.

Treatment:

• Descend immediately (at least 1000m/3280ft). Do not wait for day-break or good weather. Carry the victim if possible as the exertion can worse the HACE.
• Avoid even simple exertion
• Prop the victim in semi-reclining position as lying down flat may make the condition worse.
• If unconscious, give rescue breathing before stop breathing.
• Medications: Dexamethasone 8mg first and followed by 4mg 6-hourly. It takes several hours to work. Stop it once below 2500m/8200ft and after at least 3 days of treatment by tailing off dose slowly (give at last 3 doses 12-hourly). Doamox™ 250mg 8 to 12-hourly. For persistent vomiting treat with anti-vomiting medication.

HAPE
Signs: Any or all of the following symptoms plus the symptoms of the Mild AMS.

• A reduction in physical performance (tiredness, severe fatigue) and dry cough are often the earliest signs of HAPE developing.  
• Cough with frothy sputum that which may be bloodstained (pink or rust colored)
• Severe breathlessness (out of breath) on exertion
• Breathlessness at rest (at moderate altitude, the respiration rate is up to 20 breaths per breath)
• Blueness or darkness of face, lips, tongue and nails due to the lack of oxygen in the blood
• Wet sounds in the lungs when breathing deeply
• There may be no Wet Sounds in the lungs. If so, it is called Dry HAPE.
• Tiredness, severe fatigue
• There may be mild fever up to 38°c, a sense of inner cold, chest pain
• Drowsiness, difficult to wake up and coma

Treatment:

• As per the treatment of HACE
• Medications: Nifedine (10 to 20 mg 6 to 8-hourly)
• Keep the victim warm and fully-hydrate.
• Diamox™ 250mg (if children, 2.5mg per kg of the weight) 8 to 12 hourly
• Asthma reliever spray (2 puffs 4-hourly) may help.

Medication Chart:

Generic and/or Trade Name™	Uses	Dosage (Adult)	Remarks and Side Effects
Acetazolamide (Diamox™)	Prevention and Treatment of AMS	125 mg to 250 mg (depend on your weight) morning and night	Will produce feeling of tingling in fingers, lips and toes: this is not serious. May cause dehydration. Avoid in severe sulphur allergy.
Dexamethazone	High Altitude Cerebral Edema (HACE)	4 mg 6-hourly	Start with 8 mg. Can have seriously. Reduce dose slowly
Nifedipine (Adalat™) tablets	High Altitude Pulmonary Edema (HAPE)	10 to 20 mg 6 to 8 hourly	Can have seriously side effects: fall blood pressure, dizziness, flushing, headache

Painkillers:

Paracetamol (Panadol™)	Aches & pains, flu, headache, fever	500mg 6-hourly	Safest painkiller at high altitude. May be given with codeine or ibuprofen.
Ibuprofen (Brufen™)	Moderate to severe pain, pain with inflammation, sore-knee, period pains, strains, bruising, arthritis	400 mg 8-hourly	Take with food, may cause indigestion, stomach. Avoid if history of peptic ulcer or asthma. May be given with Paracetamol or codeine.
Codeine phosphate	moderate to severe pain, burns cough, diarrhea	30 to 60 mg 8-hourly 15 to 30 mg 12-hourly	Strong painkiller. May cause constipation, slow respiration (avoid at altitude). Do not give under 1 year old. May be given with Paracetamol and Ibuprofen.

 
Others: Water purification tablets, rehydration solutions, cold cream, bandages,