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Acetazolamide in High Altitude

Hypoxia is the cause of the hyperventilation in high altitude. This is followed by hypocapnia and respiratory alkalosis. As a consequence respiration rhythm related alkalosis and hypocapnia causing cerebral vasospasm, respiratory center failure, that is manifested by headaches, sleep disturbances and periodical breathing (hyperpnoea - apnoea).

    Acetazolamide (Diamoxe) as a carbonic anhydrase inhibitor contributes excretion of bicarbonates (NAHCO3), increases diuresis and decreases alkalosis. These features are widely used for acclimatization in high altitude to compensate alkalosis and stimulate a respiratory center when periodic breathing is presented.

    We observed 12 alpinists at 4200-6600 meters in mountains of Pamir (Kyrgyzstan) in June of 2004.

During first days five alpinists had developed headaches and insomnia. In addition, three of them were suffering due to periodic breathing at night. All of them had acidic diuresis (Ph 3.0 – 4.3).

    Acetazolamide 125mg daily dose was given to all alpinists, one hour before the bedtime during three days.

    After receiving this drug urine ph was elevating (7.5 – 8.0) and the patients had fewer complaints.

    Their acclimatization process became smoother, and they reached the pick of communism successfully.

    One alpinist returned from the altitude of 6800m due to non medication related gastrointestinal problems.

    Because of the low dose were used, no one had side effects as numbness of the leaps and extremities, change of the test or allergic reactions.

    Our observation of the features of the acetazolamide confirmed the given literature data according to which acetazolamide suggested as the effective remedy to prevent, reduce and treat negative presentations of acclimatization and acute mountain sickness.

Dr. Zurab Astakhishvili

Case Report By Mark Stanton

Recently whilst doing a few road shifts when I was back in SA (South Africa) on leave, I was dispatched to a motor vehicle accident (MVA) on a freeway between Johannesburg east rand and Pretoria. Time was around 05h30 on a Sunday morning and it was fairly cold and overcast out.

    I arrived 1st on scene to find a small Kia hatchback sitting on the outside of the road, significantly damaged post-rollover with a single female patient who had been ejected from the vehicle, and was lying approximately 15m away from it. She was in the left lateral position and had an initial GCS of 9/15 (E1/V3/M5) and was moaning a lot. Primary survey revealed that there were significant rhales in all lung fields and decreased air entry bilaterally, some blood coming out of her mouth, and no immediately life threatening injuries. I placed her on a 60% partial rebreather mask 8l/min and decided to leave her lateral as her airway appeared to be maintained in this position, whilst I put up IV’s monitors etc.

    At this point (3 min after my arrival) the first ambulance crew stopped on scene, with an ILS and two BLS crew members. I asked them to bring all their immobilization equipment and lay it out behind the patient so that we could logroll her straight onto it. I put up a line in her right ACF, 18g catheter onto a 15d/ml admin set, with a warmed ringers (which I luckily had in my RV (response vehicle) after watching the weather change the night before). Whilst the BLS (basic life support) crew were preparing the equipment, I suctioned her mouth, and asked the ILS (intermediate life support) crew to get a set of vital signs whilst I drew up some morphine and midazolam to prepare her for intubation once we had supinated her onto the spinal board.

    Her vitals at this time came back as – Respiratory rate 32/min, shallow, irregular, SaO2 85-90% (FiO2 0.6), Pulse 102/min weak, regular, BP 80 systolic, HGT7.8mmol.l and her pupils were unequal and sluggish (L 4mm/R 6mm), with the right gaze being slightly conjugated. A second ALS arrived on scene from another private service and began to assist me with treating the patient. Whilst the ILS and ALS began a head to toe survey, I gave the patient 3mg morphine and 3mg midazolam along with 60mg of lignocaine 2% IV. Within seconds she had a GCS of 3/15 and was snoring quite loudly.

The head to toe survey revealed that she had multiple fractured ribs, bilaterally along the postero-lateral curvature of the chest wall, a semi-rigid abdomen, and some minor abrasions to her lower right leg.

    At this point I gave her another 1.5mg each of morphine and midazolam IV and we supinated the patient onto the spine board with a logroll, and I continued oxygenating her with a BVMR prior to intubation (all my intubation equipment was already prepared). She was clenching her jaws and I was unable to pen her mouth, but I was still able to ventilate her well. Performing a more detailed examination of her head, we noted that she was developing slight Battle’s signs, and peri-orbital heamatomas bilaterally. I noted after opening her lips that she had shattered most of her teeth and had lacerated her tongue quite badly, but it was no longer bleeding and her airway was still acceptable. She had a significant amount of oedema to the anterior part of her neck and I asked the other ALS if he could feel for any subcutaneous emphysema, which he confirmed was not present. She had no obvious le Forte fractures that we could see.

    I asked him to administer a further 3mg of morphine and 3mg of midazolam to the patient whilst I continued to assist ventilations in order for her to relax her jaw muscles so we could intubate her. At this point I was considering performing a surgical chrichothyrotomy as her airway was becoming less maintained as time passed. The ILS was putting up a second IV in her left ACF, 16g catheter, with 15d/ml admins set and 2nd ringers, and the BLS crew were immobilizing her with spider harness and headblocks etc. The monitor was attached to the patient by this time and there was a sinus tachy on the ECG, with no abnormalities.

    At this point I noticed the patients colour change dramatically to a dark shade, and her jaw relaxed. Looking at the ECG I noted that she had gone into asystole, and the 2nd ALS immediately began chest compressions, whilst I took the opportunity of  intubating her (7.0cuff @ 21cm teeth, with an OPT as a bite block). I noticed her tongue was badly macerated and removed two loose teeth from her mouth. On confirming my ETT placement I noted there was significant decreased air entry bilaterally and her trachea was deviated slightly to the left. The ILS took over chest compressions and the other ALS performed needle thoracocentesis (14g catheter) on the anterior right mid-clavicular line (2nd IC space). This relieved the immediate tension, and we immediately got a pulse back on the patient. CPR was done for approximately 2 minutes. The patient had strong radial pulses and we decided at this point to shoot through to hospital as it was some distance (33km) away. Unfortunately rotary wing evacuation was not possible at the time due to low cloud cover and the proximity to JHB international airport’s flight path.

Post-resus and thoracocentesis, the patients vital signs were as follows –

Respiratory Rate 15/min, irregular, deep, spontaneous assisted with Bag-valve, SaO2 93% (FiO2 1), Pulse of 89/min, regular, weak, with a BP of 100systolic. Her pupils were unreactive and at 3mm bilaterally, and she was slightly discordant when it came to assisting her respirations, not tolerating the tube well. I administered further doses of morphine and midazolam on the way to hospital to a total of 15mg/15mg by the time we reached the emergency room, but she continued clenching on the tube (unfortunately the bite block wasn’t working very well as she had no teeth left in the front of her mouth and was biting on the tube with her molars). During transport we performed a further two needle thoracocentesis (14g catheters) in the same position on the right hemi-thorax, with her left side not appearing to tension, but air entry still bilaterally decreased and both hemi-thoraces were hyper-resonant an tapping. Her abdomen remained rigid, but we could find no apparent reason for this.

    The hospital, Unitas, in Centurion (most accessible Level 1 facility by road) was notified of our approach and were ready for us in resus when we arrived. The patient was given bilateral intercostal drains, as she had bilateral pneuomothoraces. Some of the rib fractures were noticeable on plain AP CXR, with some pulmonary contusion and evidence of aspiration (probably the cause of the rhales noticeable on my arrival).

    She was given a large amount of IV anaesthesia to try and prevent her from clenching on the tube, and sent for CT scans. Her CT’s came back confirming multiple rib fractures, as well as a small sub-arachnoid haemorrhage on the left hemisphere. Her initial blood gases were not great, showing a pH of 7.1, PCO2 of 68mmHg and PaO2 of 87mmHg. Once she had stopped clenching and was more settled on the ventilator (SIMV-pressure support) these improved significantly to normal (or as we wanted them to be).

I contacted the hospital on the Tuesday to follow up, and they informed me that she was still ventilated, but they had woken her up that morning to assess her neurological status, which was 100%, no signs of diffuse axonal injury, the sub arachnoid bleed was stable and they were treating it conservatively, and her ABG’s were 100%.

    I again contacted them on the Friday, and they informed me that she was awake, off the ventilator, and they had removed her IC drains, and she was improving steadily. I did not get the opportunity to follow up further, as I had to leave SA again and go back to another contract up in the wilds of Africa.

    All in all it was a very good, challenging call. The patient presented with isolated head and chest injuries, which although complex were within our scope to manage.

It would have been nice to perhaps have inducted the patient using RSI drugs, but as a CCA (Critical Care Attendant) this isn't on protocol, perhaps one day it will be when the powers that be get off their ego-trips. I do not know whether it would have made a significant difference in the treatment and management of this patient, but she may have been intubated by the time she arrested, and our scene time (40min) may have been less if we could have secured her airway earlier (not having to wait so long to let the drugs have effect). It probably worked out for the better, as it would have been more difficult to resus the patient in-transit, and we would not have had as many hands available (the second ALS (Advanced life support) rode with me to hospital with the patient, which was a huge assistance as we were both pretty busy in the back of the ambulance)

    Something to note, with regards to the ETT, if a patient has removed most of their teeth, or has deformity from le Forte fractures, it might be wise to use a much wider bite block, as well as to ensure the ETT does not move to the side of the mouth. With the incisors removed the molars come together much closer when the patient clenches on the bite block, and in this case, this did occlude the ETT somewhat, not enough to close it completely, but I am sure this contributed to her poor initial ABG’s (along with the contusions and aspiration and pneuomo’s – but why add to the mix?)

    CPR was started immediately the patient arrested, and I am sure that this, together with the rapid intervention of the needle thoracocentesis contributed to the successful return of her spontaneous cardio-respiratory effort.

    In cold weather it is important to try and administer warmed fluids to trauma patients (notwithstanding the specific treatment we give to pead drownings in SA where we try keep them slightly hypothermic for better neurological prognosis – but that’s a discussion for another day). I know we are not lucky enough to have fluid warmers in our vehicles, but I had two ringers in the engine compartment of my RV, tucked in behind the air filter where they would get warmed nicely, but not toasted to boiling point. In most ambulances you can find somewhere close to the engine compartment (such as behind the front seats on the old Toyota Hiace vans) where the engine heat will keep a litre or two of fluid warm. This patient had a very small physique and was well on the way to hypothermia when I arrived some 20 minutes after the accident occurred (it was a quiet freeway at that time of the morning and someone happened across the accident after it occurred and called it in). It also did not help that the patient wasn’t really appropriately dressed for the weather either.

    It was a very good team effort in saving this patients life, with a successful outcome, and it goes to show that adequate training and professional attitudes make a huge difference. If the ambulance crew were not as competent as they were, we might have been handing her over to the pathology guys instead of to an ER.

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WORDS AND PHRASES IN MEDICINE

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Conventional [ kən’venʆnəl]

1. [only before noun] a conventional method, product, practice etc has been used for a long time and is considered the usual type.

პროდუქტი, მეთოდი, პრაქტიკა, საქმიანობა, მიდგომა და ა.შ, ის რაც, გამოიყენება დიდი ხნის განმვლობაში, (და) ან მიღებულია როგორც ჩვეულებრივი, რიგითი, რუტინული.

Synonyms: current, customary, going, popular, prevailing, prevalent, standard, stock, usual.

Antonyms: nonstandard, unconventional, unpopular, unusual.

 “Large areas of conventional medicine thus represent particular aspects of traditional medicine systematically developed and extended.”

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Tailor - [teɪlə] = to make something so that it is exactly right for someone's particular needs or for a particular purpose.

"Treatment is tailored to the needs of each patient."

"It is reasonable for healthcare providers to tailor the sequence of rescue actions to the most likely cause of arrest."

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"Ischemia will reduce the oxygen and other nutrients and chemicals available to the heart, making the myocardium hypoxic and unable to function correctly, with contraction and compliance reduced."

 compliance [kəmˈplaɪəns] when someone (or something) obeys a rule, agreement, or demand. 

In compliance to...

According to ...

შესაბამისობა, შეთანხმება, თანხვედრა (მაგალითად ქმედების, აქტივობის, რიტმის, მოქმედების, მუშაობის, რაღაცის მიმართ).

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Recitation [res-i-tey-shuhn]

–noun

A recitation is a presentation made by a student to demonstrate knowledge of a subject or to provide instruction to others. In some academic institutions the term is used for a presentation by a teaching assistant or instructor, under the guidance of a senior faculty, that supplements course materials. In recitations that supplement lectures, the leader will often review the lecture, expand on the concepts, and carry on a discussion with the students. - http://en.wikipedia.org/wiki/Recitation -

1.

an act of reciting.

2.

a reciting or repeating of something from memory, esp. formally or publicly.

3.

oral response by a pupil or pupils to a teacher on a prepared lesson.

4.

a period of classroom instruction.

5.

an elocutionary delivery of a piece of poetry or prose, without the text, before an audience.

6.

a piece so delivered or for such delivery.

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1.	the act of reciting from memory, or a formal reading of verse before an audience
2.	something recited

 

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Explicit = clear and easy to understand = ნათელი და ადვილად მისახვედრი = to add details to what you have said = be more specific/be more explicit.

1. Suggested or understood without being stated directly

ￚ opposite explicit

Implicit criticism/threat/assumption Her words contained an implicit threat. 

მაგ: His statement is being seen as implicit criticism of the work of research laboratories.

2. Formal forming a central part of something, but without being openly stated

Implicit in

Confidentiality is implicit in your relationship with a counselor.

3. complete and containing no doubts

Implicit faith/trust/belief = they had implicit faith in his powers.

ￚ implicitly adverb = they believed implicitly in their own superiority.