Scenario 7: You are on an expedition in the Everest region of Nepal. You are at base camp 5300m.

1
Scenario 7 You are on an expedition in the
Everest region of Nepal. You are at base camp
(5300m).
2
It is late afternoon and time for the scheduled
radio check with the team on the mountain. Paul
and Mark have established camp 2 at 6500m and are
well. Chris and Robin have climbed back up to
camp 1 at 6100m with additional food and
gas. Chris expresses concern over the radio that
Robin is looking a bit out of sorts.
3
Robin tries to play it down a bit, but is clearly
breathless when talking to you.He admits it was
a struggle getting back to camp 1 after spending
a few days back at base sitting out the bad
weather. He says it hell be all right and that
it cant be altitude sickness because hes
already been to that height a few days before
with no problems.
4
What is your working diagnosis?What other
questions might you ask tohelp you confirm
it?What do you tell Robin about his theory that
it cant be altitude related?What is your
management plan?
5
High Altitude Pulmonary Oedema is the working
diagnosis. You could ask about cough and
anorexia (compared to how his appetite has been
over the previous few days) and you could ask
Chris to look for tachycardia and orthopnoea.
Absence of these additional features does not
change your working diagnosis, however.
6
Unfortunately Robins theory is completely wrong.
Re-entrant pulmonary oedema is a recognised
condition occurring when a person reascends to an
altitude at which they were previously
acclimatised after a short spell at a lower
altitude.
7
Management is simple descent, descent and
descent! In this case descent to base camp is
most likely to be sufficient. Due to the shape of
the oxygen dissociation curve a relatively small
decent (500-1000m), in other words a relatively
small increase in partial pressure, results in a
relatively large increase in oxygen
saturation.Robin should be accompanied by Chris
on the descent.
8
Supplemental oxygen should be given but is
unlikely to be available. Similarly, a Gamow bag
(portable hyperbaric chamber) could be used, but
should not delay descent. It is unlikely that a
lightweight expedition such as this would have
one available.Nifedipine 10mg sublingual should
be given. This reduces pulmonary artery pressure
(pulmonary hypertension is a feature of high
altitude pulmonary oedema). Nifedipine has (along
with acetazolamide and dexamethasone) become a
standard drug on high altitude expeditions.
9
Although mortality from high altitude pulmonary
oedema is high, Robin has been diagnosed early
and was able to descend back to base camp, aided
by Chris, and made a full recovery.Robin
wonders why it happened to him after all he
says, he ascended slowly and was very fit. He
also wonders if he is at increased risk of
getting it in the future. What will you tell him?
10
It isnt clear why it affects some people and not
others. Individual physiological responses to
altitude vary. Youth and physical fitness confer
no protection.He is at higher risk in the
future, though it is by no means certain that it
will affect him again. He might like to consider
prophylactic acetazolamide on any future trips.