Contributor: Jorge Chalit-Hernandez, OMS3

Educational Pearls:

• Acute mountain sickness (AMS) is the term given to what is otherwise colloquially known as altitude sickness

• High altitude cerebral edema (HACE) is a severe form of AMS marked by encephalopathic changes

• Symptoms begin at elevations as low as 6500 feet above sea level for people who ascend rapidly

• • May develop more severe symptoms at higher altitudes

• The pathophysiology involves cerebral vasodilation

• • Occurs in everyone ascending to high altitudes but is more pronounces in those that develop symptoms

  • The reduced partial pressure of oxygen induces hypoxic vasodilation in the brain, which results in edema and, ultimately, HACE in some patients

• Symptomatic presentation

• • Headache, nausea, and sleeping difficulties occur within 2-24 hours of arrival at altitude

  • HACE may occur between 12-72 hours after AMS and presents with ataxia, confusion, irritability, and ultimately results in coma if left untreated

• Clinical presentation may be mistaken for simple exhaustion, so clinicians should maintain a high index of suspicion

• • Notably, if symptoms occur more than 2 days after arrival at altitude, clinicians should seek an alternative diagnosis but maintain AMS/HACE on the differential

• Treatment and management

• • AMS

  • • Adjunctive oxygen and descent to lower altitude

    • Acetazolamide is used as a preventive measure but is not helpful in acute treatment

    • +/- dexamethasone

  • HACE

  • • Patients with HACE should receive dexamethasone to help reduce cerebral edema

    • Immediate descent to a lower altitude

References

1. Burtscher M, Wille M, Menz V, Faulhaber M, Gatterer H. Symptom progression in acute mountain sickness during a 12-hour exposure to normobaric hypoxia equivalent to 4500 m. High Alt Med Biol. 2014;15(4):446-451. doi:10.1089/ham.2014.1039

2. Levine BD, Yoshimura K, Kobayashi T, Fukushima M, Shibamoto T, Ueda G. Dexamethasone in the treatment of acute mountain sickness. N Engl J Med. 1989;321(25):1707-1713. doi:10.1056/NEJM198912213212504

3. Luks AM, Beidleman BA, Freer L, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention, Diagnosis, and Treatment of Acute Altitude Illness: 2024 Update. Wilderness Environ Med. 2024;35(1_suppl):2S-19S. doi:10.1016/j.wem.2023.05.013

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Meghan Hurley, MD

Educational Pearls:

• Gastroenteritis clinical diagnoses:

• • Diarrhea with or without vomiting and fever

• Vomiting in the absence of diarrhea has a large list of differential diagnoses, so the combination of diarrhea and vomiting in a patient is helpful to indicate the gastroenteritis diagnosis

• Symptom timeline is usually 1-3 days, but can last up to 14 days – diarrhea persists the longest

• Treatment for mild to moderate dehydration: oral or IV rehydration

• • Begin orally to avoid unnecessary IV in a pediatric patient

1. Administer ODT Ondansetron (Zofran) to prevent vomiting

   1. Meta-analysis showed that 2-8 mg orally, based on body weight, decreased vomiting quickly

2. Wait 15-20 minutes for the medication to take effect

3. Use streamlined method for oral rehydration: Fluids such as over-the-counter Pedialyte, Infalyte, Rehydrate, Resol, and Naturalyte may be used

   1. If patient weighs less than 10kg: administer 5mL of fluid per minute for 20 minutes

   2. If patient weighs 10kg or more: administer 10mL of fluid for 20 minutes

4. If the patient can keep the fluid down, double the fluid volume and repeat

5. If the patient once again keeps the fluid down, double the fluid volume and repeat

• If successful with each attempt, the patient may be discharged home

• • Can prescribe ODT Zofran for 1-2 days at home

• If the patient vomits more than once during this oral rehydration process, intravenous rehydration must be initiated

References

1. Churgay CA, Aftab Z. Gastroenteritis in children: Part II. Prevention and management. Am Fam Physician. 2012 Jun 1;85(11):1066-70. PMID: 22962878.

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

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Contributor: Aaron Lessen, MD

Educational Pearls:

• If a patient sustains a cut, the provider has several options on how to close the wound. If they choose to suture the wound closed, it involves needles both in the form of injecting numbing medication (lidocaine) as well as with the suture itself. Other techniques are “needleless,” like closing the wound with adhesive strips (Steri-Strips) or skin adhesive (Dermabond). But which method is best?

• A recent study looked to compare guardian-perceived cosmetic outcomes of pediatric lacerations repaired with absorbable sutures, Dermabond, and Steri-Strips. It also assessed pain and satisfaction with the procedure from both guardian and provider perspectives.

• Participants: 55 patients were enrolled; 30 completed the 3-month follow-up.

• • Cosmetic Ratings (Median and IQR):

  • • Sutures: 70.5 (59.8–76.8)

    • Dermabond: 85 (73–90)

    • Steri-Strips: 67 (55–78)

    • (P = 0.254, no statistically significant difference)

  • Satisfaction and Pain:

  • • No significant differences in guardian or provider satisfaction

    • Pain levels were comparable across all methods

• Even though there was no statistically significant difference in guardian-perceived cosmetic outcomes, the Dermabond did have the highest ratings at the end of the study.

References

• Barton, M. S., Chaumet, M. S. G., Hayes, J., Hennessy, C., Lindsell, C., Wormer, B. A., Kassis, S. A., Ciener, D., & Hanson, H. (2024). A Randomized Controlled Comparison of Guardian-Perceived Cosmetic Outcome of Simple Lacerations Repaired With Either Dermabond, Steri-Strips, or Absorbable Sutures. Pediatric emergency care, 40(10), 700–704. https://doi.org/10.1097/PEC.0000000000003244

Summarized by Jeffrey Olson MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3

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