The7summitsmedic

Tic-bourne infections

🦠 Lyme’s disease (Borrelia Burgodorferi/mayonii bacteria). Symptoms: Flu-like, characteristic skin rash - erythema migrans (looks like a fried egg) Late symptoms: neurological, cardiac and joint inflammatory conditions. Last Ride risk countries: Argentina, Europe.

🦠 Anaplasmosis (A. phagocytophilum bacteria) Symptoms: Flu-like, Rash uncommon. Late: Respiratory failure, coagulopathies. Treatment Doxycycline. Last Ride risk: Nepal/ Argentina/ Europe

🦠 Babesiosis (Babesia spp. parasite) Symptoms: Flu-like, rash uncommon. Late: Haemolytic anemia, jaundice, dark urine, thrombocytopenia, DIC. Treatment: Indicated for severe cases- combination therapy : Atovaquone + azithromycin, or Clindamycin + quinine. Last Ride risk: Europe/ USA

🦠 Ehrlichiosis (Ehrlichia chaffeensis/ewingii bacteria) Symptoms: Flu-like, confusion, rash in 1/3, Late: Resp failure, encephalitis, coagulopathies. Treatment: Doxycycline. Last Ride risk: USA

🦠 Powassan Virus Disease (Powassan Virus) Symptoms: Flu-like, Late: Encephalitis, Meningitis. Treatment: Symptom management. Last Ride risk: USA

🦠Borrelia Miyamotoi Disease (Borrelia miyamotoi Bacteria) Symptoms: Flu-like. Rash uncommon. Late: Neuropathies, unknown. Treatment: Doxycycline. Relatively unstudied/ rare.

🦠Borrelia Mayonii Disease. Symptoms: Flu-like with diffuse flat rash, gastro-intestinal involvement. Treatment: Doxycycline. Relatively unstudied/ rare.

🦠Tularemia (Francisella tularensis bacteria). Symptoms: Flu-like, skin ulcer, enlarged lymph nodes. Treatment: Streptomycin, gentamicin, doxycycline, and ciprofloxacin. Last Ride risk:: USA, Europe

🦠 Tic-bourne encephalitis (Tic-bourne encephalitis virus) Symptoms: Flu-like, Late: Encephalitis, meningitis, cranial neuritis, myelitis. Treatment: Symptom management. Last Ride risk: Europe. Vaccine Available.

🦠Rickettsiosis (Rickettsiae bacteria). Symptoms: Flu-like, rash (sparse maculopapular or papulovesicular eruptions on the trunk and extremities). Treatment, Doxycycline. Last Ride risk: Nepal, USA, Indonesia.

Basically, Take some Doxy ;)

I took this picture at Thukla pass Everest memorial on the Everest base camp trek in 2014. It had a really big impact on me. After a long trek up to Thukla pass at 4800m, we reached the memorial. As we caught our breath, we walked around the different memorials. I came across this one of Sean Egan. I don’t know if it was the exhaustion and altitude but, I nearly broke down in tears reading it. “Always aim high” - to me it means chase your dreams and don’t let anything get in your way, always push for the top, be your best person despite all the challenges, never settle for second best. I felt very close to the mountains. I didn’t know Sean but he had a big impact on me. I never thought back then that I might have the chance to aim as high as he did. Chase your dreams and good things will happen. Always aim high✌🏼

An expedition in fjord lands national park, New Zealand. This was my first time having to get rescued by a helicopter. Milford is the wettest place in New Zealand due cold moist air coming in from the Tasman sea. The place sees 6m of fall a year and pretty much rains every other day. That day we had what felt like 1/2 a meter of rainfall which cut off the trailhead. Expedition skills learnt - management of trench-foot and how to approach a helicopter ☑️ ☑️

New Zealand 2019 Milford Track, Routeburn Track, Queenstown 👌

HIGH AlTITUDE RESP ASSESSMENT Ctd

2 RED FLAGS

Speaking full sentences (Life threatening asthma)
Distress
Stridor (Anaphylaxis, epiglottitis)
Wheeze that suddenly stops (Life threatening asthma/COPD)
Chest Pain
Acutely increasing /Decreasing RR
Haemoptysis (PE, TB, Ca, CCF/HAPE, bronchiectasis, anticoags, coagulopathies)

3 FOCUSSED HX

Epidemiology: At 4500m HAPE increases 0.6-6%, At 5500m 2%-15%. Higher risk in male, rapid ascents, previous HAPE, sleeping tablets, excessive salt, over exert. Mortality11% treated vs 50% untreated. Typical 2-5 days after arrival at altitude
Baseline
Pain - SOCRATES (HAPE - pleuritic, non-radiating worse on exertion, feeling of drowning)
Cough - production/acute/chronic/day/night (asthma, croup, PND, altitude), on exertion (HAPE/AMS), after liquids
Sputum - Mucoid - clear/gray/white (altitude/congestion), Purulent - thick/yellow/green (IECOPD, RTI, lung abscess) , Serous - clear/frothy, can be pink (CCF, HAPE) Haemoptysis.

4 INSPECTION - HANDS

Cold/ blue/ CRT >2s (PVD, hypothermia, hypoxia, hypovolemia, sepsis, frostbite)
Tar staining (COPD/Lung Ca)
Clubbing. Schamroth sign (Lung Ca, ILD, Bronchiectasis, infective endocarditis)
-Pulse rate & rhythm. Bounding (C02 rtn, Infection, FAF, Weak pulse - CCF/HAPE)
RR & Pattern.
Pulsus Paradoxus - Pulse wave volume decreases with inspiration (Asthma/COPD)
Asterix/Fine tremor (cerebellar hypoxia, B2 antagonist)
Flapping tremor (C02 retention/ COPD)

5 INSPECTION - HEAD AND NECK

Lymph nodes ( left supraclavicular fossa - virchows nodes enlarged gastric Ca - Trosier’s sign), cervical lymph nodes (along sternocleidomastoid) common in viral/bac RTI. Bilat/unilat, localisation, soft/rubbery/hard, tender, splenomegaly (lymphoma)
Central cyanosis. Acute/chronic. Altitude/polycythaemia red herring - increased hemoglobin-blue)
Accessory muscles/nasal flaring
Central trachea
JVP (Pulmonary hypertension/overload//HAPE)
Eyes/mouth. Xanthelasma - yellow fat deposits around eyelids (Hyperchol) Corneal Arcus - bilateral circumferential arc around cornea - gray/white/ yellow (Hypercholesterol/lipidemia) Conjunctival Pallor (anemia, Jaundice)

HIGH ALTITUDE RESPIRATORY ASSESSMENT

1 - GENERAL FIRST GLANCE + BASELINE OBS

- ?Life threat emergencies
- ?Treatment adjuncts - nebs, inhalers, oxygen, bloody tissues - ?HAPE
- ?SOB - Nasal flaring, pursed lips, accessory muscles, ?full sentences
- ?Central cyanosis (2500/3000m:

General Altitude cough

Productive cough white/ clear sputum/ dry cough/ tickly/ nocturnal element. Treatment: Inhale steam.

Chest infections

Productive cough with purulent sputum (bacterial/ viral with secondary bacterial)/ non-productive cough (viral). Tachycardia, pyrexia, tachypnoea, shallow resps, low saturations, fatigue, muscle aches, nausea or vomiting. Viral typically more rhinitis, myalgia, fatigue, swollen joints/ stiff neck/ lower incidences of pleuritic chest pain and rigors. Treatment: Viral - rest/ symptom management, trial antihistamines. Bacterial - Antibiotics.

Upper airway cough syndrome (post nasal drip)

Nasal congestion and rhinitis common. Acute onset, dry cough with feeling of something stuck in throat/ congestion. Treatment: Sleep with two pillows, gargle saltwater, inhale steam. Nasal do**he. Trial antihistamines.

AMS / subclinical HAPE

Dry non-productive / productive with clear/ white sputum. Tachycardia, tachypnoe. Above 2500/3000m. SOBOE and reduced exercise tolerance. Treatment: Rest day/s at current altitude. Adjust ascent profile - slower.

HAPE

Productive with gurgling chest/ pink frothy sputum in advanced cases - acute onset, SOBOE or at rest or Orthopnea. Cyanosis, tachypnoea, tachycardia and temperature generally upto 38.5°C. Life threatening. Treatment: Dexamethasone 8mg IM. Nifedipine 10mg IR, O2 aiming for PaSO2 >90%- normally 4L/min + portable hyperbaric chamber stored at highest camp - all buys time to descend. Descend 500-1000m or until symptoms resolve

Blood gases on Everest ctd..

It typically takes 24 hours for the kidneys to achieve these bicarb levels but takes much longer to achieve a steady state (normocapnia and balanced PH) I.e. A study in people living at altitudes of 3500m showed normocapnia and pH - They are physiologically adapted. You can see by these blood gases on Everest - who have probably been on the mountain acclimatising for 6-8 weeks - have still not found a balance. This is one of the reasons why Sherpas are absolute machines on mountains.

Respiratory Alkalosis produces some of the symptoms of acute mountain sickness (AMS): Dizziness, nausea, lightheadedness, confusion, SOB, tingling in hands and feet, headache, chest pain, loss of appetite, sleep disturbances - similar to symptoms of panic attacks. Breathing into a paper bag can help relieve symptoms (t6-12 natural breaths into a paper bag then breathe normally, repeat until symptoms have improved). Diamox (or Acetazolamide) - a diuretic is a common prophylactic for AMS. It is a carbonic anhydrase inhibitor that essentially increases bicarbonate excretion - speeding up the metabolic compensation for hypocapnia. This increases diuresis and reduces bicarb levels to combat the respiratory alkalosis and reduce symptoms. It has also shown benefits for sleep at high altitude - by reducing alkalosis symptoms and improving oxygenation.

Around 50-85% of individuals travelling to 4500-5500m get symptoms of AMS. The preferred method of reducing symptoms is adequate acclimatisation. Where this is not possible on a short trip - Diamox is a good option to combat symptoms. However studies have shown reduced production of erythropoietin - therefore reduced RBC’s and haemoglobin with Diamox use, So not advised for longer trips like Everest where you really need your Hb, Shorter trips like Kilimanjairo is fine. Side effects of Diamox can mimic effects of AMS so it is important to ensure that you stop ascending if symptoms develop / descend if mild symptoms do not resolve after 8 hours.

Blood Gases on Mount Everest.

Really interesting Article:

M.P.W et al. 2009. Arterial Blood Gases and Oxygen Content in Climbers on Mount Everest. N Engl J Med; 360:140-149

Samples obtained in London (75m) Everest Basecamp (5300m) Camp 2 (6400m) Camp 3 (7100m) during the descent from the summit on the Balcony (8400m). Samples taken on the mountain were taken from the femoral artery. It must be extremely nippy popping your trouser off for a blood gas. Sample taken in 2ml heparinized syringe and transported in an iced vacuum container for transport to lab at (6400m).

Above 7100m climbers used 2-3litres O2 per minute whilst climbing, 0.5L whilst sleeping.

Oxygen was not indicated up to 7100m. At or below 7100m PaO2 was low but this was compensated by increased haemoglobin levels - as shown by arterial oxygen saturations which were stable and appropriate for the relative altitude (PaO2=4.1kPa, SaO2=78%). So where at sea level type one respiratory failure is diagnosed below 8kPa. At 7100m after acclimatisation - effective haemoglobin compensation means Type 1 respiratory failure is actually diagnosed around and below this figure of 4.1kPA.

Above 7100, the haemoglobin is unable to compensate for lack of oxygen and reduced atmospheric pressure - Type 1 respiratory failure begins - so climbers have to compensate for this with supplemental oxygen.

At 8400m - with supplemental oxygen, participants have a partially compensated respiratory alkalosis (Average pH 7.53, PaCO2 1.77kPa, Bicarb 10.8mmol/L). Because of hyperventilation from the climb - individuals blow off increasing amounts of CO2 creating respiratory alkalosis, The kidneys try to compensate by decreasing the amount of Bicarb production and increased urinary H+ excretion with reduced levels of antidiuretic hormone. This results in increasing diuresis - so climbers often find themselves waking up 5 times a night to go to the toilet - quite annoying but it shows your body is adapting. This results in a dehydration and loss of urinary sodium and other electrolytes. To counteract this climbers need to drink an extra 1-1.5 litres of water a day (3-4L total) + electrolyte replacement

Management of Third & Fourth degree frostbite.

Recognition: Third degree - burn penetrating all layers of skin/ into muscle. Hard (frozen) waxy appearance. Progresses from second degree frostbite to a darker blue/purple. Reduced and eventually complete loss of sensation. Reduced mobility as muscles may not work properly. Fourth Degree - burn affecting all layers of skin and muscle + tracking into bones/ ligaments.

Management

Management as with second degree frostbite +
May receive thrombolysis typically tissue plasminogen activator (tPA )Alteplase)+ continuous heparin infusion within the first 24 hours after rewarming. Studies have shown this reduces the likelihood or need for amputation. If lysis not-effective:
Amputation of affected area. Physicians may wait 4-12 weeks before amputation to allow the area the best chance of healing - this reduces the likelihood of accidentally removing healthy tissue that is healing.

Thrombolysis / Indications

3rd/4th degree
Absent/weak doppler pulses post rewarming
24 hours of warm ischemia time
Repeated freeze/thaw cycles
Concurrent or recent (within 1mo) intracranial haemorrhage, subarach/ trauma with active bleeding.
Oesophageal varices, coagulopathies, AAA / dissections
Reduced GCS, coma,
Severe uncontrollable hypertension
Acute pancreatitis, recent surgery including dental extraction, bacterial endocarditis

Relative contraindications for thrombolysis:

History of GI bleed or stroke within 6 mo.
Recent intracranial or intraspinal surgery or serious head trauma within 3 months
Pregnancy

Management of second degree (superficial) frostbite.

Frostbite typically sets in after 30 minutes of skin exposure to sub zero temperatures and time is halved to 15 minutes if it is windy. Blood supply is reduced to peripheries reducing warm blood supply and oxygen supply. As a result, fluid in peripheries freeze forming crystals that damage blood vessels.
Recognition : Initial frostnip progressing - skin begins to turn from a reddish colour to a paler colour. In some cases, it may appear blue. Waxy/ hard appearance. Area may feel hard (frozen), swollen. Ice crystals and blisters may form.

Note * Upon re-warming. Blood flow is restored resulting in a reperfusion injury - damaged blood vessels leak fluid resulting in oedema and is followed by fluid filled blisters that appear roughly 24-28 following re-warming. Platelet aggregation occurs in damaged blood vessels causing clots that further worsen circulation creating purplish colour.

Management

Remove rings, Evacuation to ensure same day emergency care due to risk of septicaemia and gangrene. Transfer to specilist burns unit. Staying on the mountain can cause refreezing which causes more damage. Re-warm once off the mountain and/or constant temperature can be achieved. 37-39℃ water bath for 30 minutes. Strong pain relief for rewarming, Antibiotic ointment and loose non-adherent dressing after rewarming as the injury may blister or swell. IV rehydration and Antibiotic prophylaxis
Aspirin + Tetanus Prophylaxis

Observations: The outcome of treatment is a good marker of what degree of frostbite the patient has suffered. With second degree - following effective treatment, patients may experience increased perfusion to the affected area, increased capillary refill, improved colour / temperature / pain and no signs of infection (Local signs of infection or systemic (tachycardia, tachypnoea, hypotension, pyrexia)).

Hyperbaric oxygen therapy - Some patients show improved symptoms after this therapy but more studies are needed. Whirlpool therapy; Soaking in a whirlpool bath can aid healing by cleansing and naturally removing dead tissue.

Management of first degree frostbite (Aka. frostnip)

Recognition: Numbness, tingling, reduced movement / clumsiness, pale (can resemble raynauds) / slightly red and waxy appearance. Typical in fingers, ears, cheeks, toes, nose.

Management - Use emergency bothy shelter to stop and warm. Take off gloves and boots, rewarm hands under armpit. Do not rub. Rewarm feet in the armpit / abdomen of a team mate. Put boots back on after 30 minutes as feet are at risk of swelling and may struggle to get boots back on. Return to basecamp for further re-warming. 40℃ water bath for 30 minutes (Do not use camp stoves to rewarm - high risk of causing burn). Re-warming is likely to be painful. Ibuprofen + Aloe Vera gel x3 times a day. Loose dressing to avoid friction. Elevate. Avoid further cold exposure until fully resolved. Advise patients to hold expedition until pain and inflammation has settled - Area now vulnerable to frostbite. No need for evacuation. Second bout of frostnip in the same area and in the same season however does require evacuation.

Prevention the best form of treatment. Suitable clothing. Avoid gloves and boots that are too tight. Mittens are preferred. Overboots in extreme cold environments. Change socks regularly to keep feet dry, moisture wicking socks can help with this (bamboo or merino). Stay hydrated, Don't drink alcohol before going into the cold as it can cause you to loose body heat faster. STOP if any signs of frostbite

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