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Acute Mountain Sickness

Acosta Syndrome

Acute mountain sickness is a type of altitude sickness which develops within a few hours of an unacclimatized individual ascending rapidly to a high altitude. It is characterized by sudden onset of a bitemporal headache, nausea, fatigue, dizziness and can be life-threatening with the development of cerebral or pulmonary edema.


Presentation

Acute mountain sickness (AMS) is a common form of altitude sickness which affects between 10 to 80% of individuals climbing to high altitudes [1] [2] [3] [4] [5]. Symptoms are variable and usually commence within 24 hours of an unacclimatized individual ascending rapidly to altitudes > 8000 feet. Common symptoms include headaches, dizziness, vomiting, anorexia, fatigue, and insomnia [6] and they are due to the hypoxic and hypobaric environment at high altitudes [7]. Other symptoms like loss of appetite, light-headedness, lassitude, dyspnea and delirium may also be present. Some patients experience worsening of symptoms with the development of either cerebral edema (HACE - high altitude cerebral edema) and/or high altitude pulmonary edema (HAPE). But in a majority of the cases, the symptoms of AMS usually improve after a day unless the patient ascends again to a higher altitude, in which case the symptoms can worsen.

Fatigue
  • On ascent to 5085 m, ratings of perceived exertion (RPE ascent ), fatigue by Brunel Mood Scale, and AMS were recorded daily.[ncbi.nlm.nih.gov]
  • It is characterized by sudden onset of a bitemporal headache, nausea, fatigue, dizziness and can be life-threatening with the development of cerebral or pulmonary edema.[symptoma.com]
  • The concerns of this highly conscientious individual that initial signs of illness, such as fatigue with exertion, could be misinterpreted by others as poor work performance are described.[ncbi.nlm.nih.gov]
  • […] and weakness : Not tired or weak 0 Mild fatigue/weakness 1 Moderate fatigue/weakness 2 Severe fatigue/weakness 3 Dizziness and lightheadedness: Not dizzy 0 Mild dizziness 1 Moderate dizziness 2 Severe dizziness, incapacitating 3 Difficulty sleeping:[ultimatekilimanjaro.com]
  • Whereas headache scores up to 6 hours in hypoxia were not correlated with other AMS symptoms, nausea was correlated with dizziness and fatigue (r 0.45 and 0.56, p[ncbi.nlm.nih.gov]
Malaise
  • A 32-year-old Japanese woman with headache, anorexia and malaise, just after travelling cities of the altitude of over 4,000 m by a long-distance coach is described.[ncbi.nlm.nih.gov]
  • Symptoms of mild AMS include mild headaches, increased breathing, rapid pulse, nausea, loss of appetite, lack of energy, and general malaise. These are warning signs not to go any higher than you already are.[nps.gov]
  • Symptoms usually start 12-24 hours after arrival at altitude and include headache, dizziness, fatigue, shortness of breath, loss of appetite, nausea, disturbed sleep, and a general feeling of malaise.[medicinenet.com]
  • Symptoms usually start 12-24 hours after arrival at altitude and include headache , dizziness , fatigue , shortness of breath, loss of appetite, nausea, disturbed sleep , and a general feeling of malaise.[medicinenet.com]
Dyspnea
  • What are the initial manifestations of acute mountain sickness (1) Headache (Severe and persistent) (2) Lassitude (3) Drowsiness/Dizziness (4) Chilliness/Nausea and vomiting (5) Facial pallor/Dyspnea and cyanosis What are the late symptoms of acute mountain[quizlet.com]
  • Other symptoms like loss of appetite, light-headedness, lassitude, dyspnea and delirium may also be present.[symptoma.com]
  • Subjective benefits include improvement in sleep habits, tolerance to cold; decreased dyspnea, anginal symptoms and tachycardia and improved appetite, all of which are symptoms associated with high altitude illness.[clinicaltrials.gov]
  • […] at rest, ("one can no longer speak without gasping for breath "), and sometimes it eventually develops into life-threatening conditions (rare as high altitude pulmonary edema (HAPE) (fluid in the alveoli, with a dry cough that gets worse, fever and dyspnea[climbeverest.jimdo.com]
Periodic Breathing
  • Periodic breathing seems not to play a predominant role in the pathogenesis of acute mountain sickness.[erj.ersjournals.com]
  • Acetazolamide probably eliminates the periodic breathing during sleep, which is a common cause of frequent awakening at altitud& 8 .[jpma.org.pk]
  • This generally improves after several nights at a constant altitude, though periodic breathing (Cheyne-Stokes respiration) remains common above 2700 m.[emedicine.medscape.com]
  • Cheyne-Stokes Respirations Above 3,000 metres (10,000 feet) most people experience a periodic breathing during sleep known as Cheyne-Stokes Respirations.[traveldoctor.co.uk]
Dyspnea at Rest
  • […] at rest, and chest tightness.[quizlet.com]
  • […] at rest) and / or high altitude cerebral edema (HACE) (swelling of the brains, with headaches that no longer respond to analgesics, unsteady walk, increased vomiting and gradual loss of consciousness).[climbeverest.jimdo.com]
  • High-altitude pulmonary oedema dyspnea at rest, moist cough, severe weakness, drowsiness, cyanosis, tachycardia, tachypnea rales.[ncbi.nlm.nih.gov]
  • High-altitude pulmonary edema (HAPE) occurs most commonly two to three days after arrival at altitude and consists of dyspnea (difficulty breathing) with exercise, progressing to dyspnea at rest, a dry cough, weakness, chest tightness or congestion, and[hprc-online.org]
Nausea
  • Whereas headache scores up to 6 hours in hypoxia were not correlated with other AMS symptoms, nausea was correlated with dizziness and fatigue (r 0.45 and 0.56, p[ncbi.nlm.nih.gov]
  • Paracetamol (acetaminophen in the USA and Canada) and ondansetron were given as supportive management for headache and nausea. Arrangements were made to have her carried down by a porter immediately. After the descent, all her symptoms resolved.[ncbi.nlm.nih.gov]
  • It is mainly characterized by a headache which may be accompanied with nausea, vomiting, anorexia, dizziness, lethargy, fatigue, and sleep disturbance.[ncbi.nlm.nih.gov]
  • Abstract Acute mountain sickness (AMS), characterized by headache, nausea, fatigue, and dizziness when unacclimatized individuals rapidly ascend to high altitude, is exacerbated by exercise and can be disabling.[ncbi.nlm.nih.gov]
  • Symptoms of mild AMS include: mild to severe headache; nausea; vomiting; lack of appetite; lack of energy; altered balance and coordination; dizziness.[bigislandhikes.com]
Vomiting
  • A 55-year-old female Nepali pilgrim presented to the Himalayan Rescue Association Temporary Health Camp near the sacred Gosainkund Lake (4380 m) north of Kathmandu, Nepal, with a complaint of severe headache, vomiting and light-headedness.[ncbi.nlm.nih.gov]
  • It is mainly characterized by a headache which may be accompanied with nausea, vomiting, anorexia, dizziness, lethargy, fatigue, and sleep disturbance.[ncbi.nlm.nih.gov]
  • A Lake Louise score 3 and Lake Louise criteria [in the setting of a recent gain in altitude, the presence of headache and at least 1 of gastrointestinal discomfort (anorexia, nausea, or vomiting), fatigue or weakness, dizziness or lightheadedness, or[ncbi.nlm.nih.gov]
  • Stop it once below 2500m/8200ft AND after at least 3 days of treatment by tailing off the dose slowly (give the last 3 doses 12-hourly) ii) Diamox 250 mg 8 to12-hourly iii) Treat persistent vomiting with anti-vomiting medication Prop the victim up in[mountainmonarch.com]
  • 2 Severe nausea or vomiting 3 Fatigue and weakness : Not tired or weak 0 Mild fatigue/weakness 1 Moderate fatigue/weakness 2 Severe fatigue/weakness 3 Dizziness and lightheadedness: Not dizzy 0 Mild dizziness 1 Moderate dizziness 2 Severe dizziness,[ultimatekilimanjaro.com]
Loss of Appetite
  • Definition of acute mountain sickness : altitude sickness that is experienced usually within several hours to one day of ascending above 8000 to 10,000 feet (about 2500 to 3000 meters) and that is marked by headache, nausea, loss of appetite, vomiting[merriam-webster.com]
  • Other symptoms like loss of appetite, light-headedness, lassitude, dyspnea and delirium may also be present.[symptoma.com]
  • Symptoms of mild AMS include mild headaches, increased breathing, rapid pulse, nausea, loss of appetite, lack of energy, and general malaise. These are warning signs not to go any higher than you already are.[nps.gov]
Tachycardia
  • History will reveal recent ascent to high altitude by the unacclimatized patient while physical examination may reveal tachycardia, tachypnea, and pulmonary rales if the patient is developing pulmonary edema.[symptoma.com]
  • What are the late symptoms of acute mountain sickness (1) Facial flushing/Irritability (2) Difficulty concentrating/Vertigo (3) Tinnitus/Visual and Auditory disturbances (4) Anorexia/Insomnia (5) Increased dyspnea/Weakness on exertion (6) Palpitations/Tachycardia[quizlet.com]
  • Subjective benefits include improvement in sleep habits, tolerance to cold; decreased dyspnea, anginal symptoms and tachycardia and improved appetite, all of which are symptoms associated with high altitude illness.[clinicaltrials.gov]
  • Electrocardiography demonstrates sinus tachycardia and often, right ventricular strain.[ncbi.nlm.nih.gov]
  • In dexamethasone group, one person had ESQ score of 29 because of the symptoms like dyspnoea, tachycardia, gastrointestinal disturbance and irritability.[jpma.org.pk]
Headache
  • In AMS-, nitrate did not alter headache or sense of effort.[ncbi.nlm.nih.gov]
  • The most common symptom was sleep disturbance followed by dizziness, and headache. The prevalence of headache was 46.2% on Day 2 at 3,100 m, and 31.3% on Day 3 at the same altitude after climbing the summit (3,886 m).[ncbi.nlm.nih.gov]
  • A 36-year-old man with a history of migraine headache attempted to hike from Lukla, Nepal, to Mount Everest Base Camp. On the sixth day of hiking, he had a migraine headache.[ncbi.nlm.nih.gov]
  • A 55-year-old female Nepali pilgrim presented to the Himalayan Rescue Association Temporary Health Camp near the sacred Gosainkund Lake (4380 m) north of Kathmandu, Nepal, with a complaint of severe headache, vomiting and light-headedness.[ncbi.nlm.nih.gov]
  • Whereas headache scores up to 6 hours in hypoxia were not correlated with other AMS symptoms, nausea was correlated with dizziness and fatigue (r 0.45 and 0.56, p[ncbi.nlm.nih.gov]
Dizziness
  • It is characterized by sudden onset of a bitemporal headache, nausea, fatigue, dizziness and can be life-threatening with the development of cerebral or pulmonary edema.[symptoma.com]
  • […] and lightheadedness: Not dizzy 0 Mild dizziness 1 Moderate dizziness 2 Severe dizziness, incapacitating 3 Difficulty sleeping: Slept as well as usual 0 Did not sleep as well as usual 1 Woke many times, poor sleep 2 Could not sleep at all 3 A total score[ultimatekilimanjaro.com]
  • Whereas headache scores up to 6 hours in hypoxia were not correlated with other AMS symptoms, nausea was correlated with dizziness and fatigue (r 0.45 and 0.56, p[ncbi.nlm.nih.gov]
  • It is mainly characterized by a headache which may be accompanied with nausea, vomiting, anorexia, dizziness, lethargy, fatigue, and sleep disturbance.[ncbi.nlm.nih.gov]
  • Abstract Acute mountain sickness (AMS), characterized by headache, nausea, fatigue, and dizziness when unacclimatized individuals rapidly ascend to high altitude, is exacerbated by exercise and can be disabling.[ncbi.nlm.nih.gov]
Insomnia
  • RESULTS: Results showed that, at 500 m, AISS and insomnia prevalence were higher in older individuals. After acute exposure to altitude, the HR, AISS, and insomnia prevalence increased sharply, and the increase in older individuals was more marked.[ncbi.nlm.nih.gov]
  • The AMS subjects also experienced poorer sleep quality, as quantified using the Athens Insomnia Scale (AIS). Moreover, the AMS population exhibited more negative mood states, including anxiety, depression, hostility, fatigue and confusion.[ncbi.nlm.nih.gov]
  • Definition of acute mountain sickness : altitude sickness that is experienced usually within several hours to one day of ascending above 8000 to 10,000 feet (about 2500 to 3000 meters) and that is marked by headache, nausea, loss of appetite, vomiting, insomnia[merriam-webster.com]
  • Common symptoms include headaches, dizziness, vomiting, anorexia, fatigue, and insomnia and they are due to the hypoxic and hypobaric environment at high altitudes.[symptoma.com]
Irritability
  • […] of acute mountain sickness (1) Headache (Severe and persistent) (2) Lassitude (3) Drowsiness/Dizziness (4) Chilliness/Nausea and vomiting (5) Facial pallor/Dyspnea and cyanosis What are the late symptoms of acute mountain sickness (1) Facial flushing/Irritability[quizlet.com]
  • To recap, serious symptoms of altitude sickness include: A severe, enduring headache, which is not cured by ordinary painkillers Nausea and repeated vomiting Irritating dizziness or actual difficulty with balance and direction Visual disturbances with[mallatreknepal.com]
  • She added: "The symptoms of AMS (headache, nausea, dizziness, fatigue, loss of appetite, insomnia, irritability) occur in about 30% of people exposed to hypobaric hypoxia.[sciencedaily.com]
  • Mild acute mountain sickness If you have a mild case, you may experience: dizziness headache muscle aches insomnia nausea and vomiting irritability loss of appetite swelling of the hands, feet, and face rapid heartbeat shortness of breath with physical[healthline.com]
Sleep Disturbance
  • Sleep disturbance is the most common symptom, and the lower prevalence of headache on Day 3 may be due to the effects of medication and/or acclimatization.[ncbi.nlm.nih.gov]
  • It is mainly characterized by a headache which may be accompanied with nausea, vomiting, anorexia, dizziness, lethargy, fatigue, and sleep disturbance.[ncbi.nlm.nih.gov]
  • Differences to previous studies might be explained by the type of hypoxia, by different sample characteristics and by considering sleep disturbances in the calculation of the AMS score.[ncbi.nlm.nih.gov]
  • disturbance Anorexia * Most common symptoms![rmnp.com]
  • The AMS‐group experienced major subjective sleep disturbances at 4,559 m, whereas sleep disturbance in controls was only mild at 3,610 m and 4,559 m.[erj.ersjournals.com]

Workup

The clinician can diagnose AMS on the basis of the patient's clinical presentation, history, and physical examination findings. History will reveal recent ascent to high altitude by the unacclimatized patient while physical examination may reveal tachycardia, tachypnea, and pulmonary rales if the patient is developing pulmonary edema. Laboratory tests like complete blood count may be abnormal with elevated hematocrit, and erythrocytosis while arterial blood gas analysis will reveal respiratory alkalosis. Pulse oximetry values do not usually indicate the severity of AMS and are therefore not useful in either detecting or in the management of the condition although they may help to detect HAPE. An electrocardiogram may show variable features like right axis deviation, non-specific ST-T changes, sinus arrhythmias, and P wave abnormalities. Chest radiography is indicated only in patients suspected clinically to have HAPE.

The diagnosis and severity of AMS can be assessed using the Lake Louise score (LLS) [8] as well as the Environmental Symptoms Questionnaire (ESQ) [9] [10]. The LLS was developed by a consensus conference on Hypoxia and Mountain Medicine in 1991 and consists of a self-reported score which is the sum of responses to five questions [8] and can be verified by a clinician during an interview. The ESQ consists of an inventory of expected physiological and psychological symptoms and was developed by the United States army. A part of this inventory containing symptoms indicative of cerebral hypoxia (AMS-C) is used to assess AMS [11]. However, the two questionnaires do not corroborate to provide an identical diagnosis [12] and as yet there is no gold standard tool for the assessment of AMS [13] [14].

Despite the presence of AMS symptoms, magnetic resonance imaging does not detect brain edema or an increase in brain volume for up to 12 hours after hypoxia and is therefore not helpful in the diagnosis and management of AMS [14].

Right Axis Deviation
  • An electrocardiogram may show variable features like right axis deviation, non-specific ST-T changes, sinus arrhythmias, and P wave abnormalities. Chest radiography is indicated only in patients suspected clinically to have HAPE.[symptoma.com]
Hypocapnia
  • The current data revealed that on going to high altitude, the subjects experienced not only hypoxia but also developed hypocapnia, therefore, both hypoxia and hypocapnia may be the factors in genesis of AMS. The linear regression analysis of PaO2 S.[jpma.org.pk]
Erythrocytosis
  • Laboratory tests like complete blood count may be abnormal with elevated hematocrit, and erythrocytosis while arterial blood gas analysis will reveal respiratory alkalosis.[symptoma.com]
Non Specific ST-T Changes
  • An electrocardiogram may show variable features like right axis deviation, non-specific ST-T changes, sinus arrhythmias, and P wave abnormalities. Chest radiography is indicated only in patients suspected clinically to have HAPE.[symptoma.com]
Non Specific ST-T Changes
  • An electrocardiogram may show variable features like right axis deviation, non-specific ST-T changes, sinus arrhythmias, and P wave abnormalities. Chest radiography is indicated only in patients suspected clinically to have HAPE.[symptoma.com]
Sinus Arrhythmia
  • An electrocardiogram may show variable features like right axis deviation, non-specific ST-T changes, sinus arrhythmias, and P wave abnormalities. Chest radiography is indicated only in patients suspected clinically to have HAPE.[symptoma.com]
Sinus Arrhythmia
  • An electrocardiogram may show variable features like right axis deviation, non-specific ST-T changes, sinus arrhythmias, and P wave abnormalities. Chest radiography is indicated only in patients suspected clinically to have HAPE.[symptoma.com]

Treatment

  • The clinical findings and treatment in the field are described including the review of the current recommendations for prevention and treatment of AMS. Both patients developed a severe AMS due to too rapid ascent and their denial of the symptoms.[ncbi.nlm.nih.gov]
  • This analysis showed a significantly lower AMS-C score (0.38; 95% CI, 0.21 to 0.54) vs 1.10; 95% CI, 0.57 to 1.62; P .04) and lower Lake Louise Score (3.1; 95% CI, 2.2 to 4.1 vs 5.1; 95% CI, 3.6 to 6.6; P .07) for the treatment subgroup.[ncbi.nlm.nih.gov]
  • Symptomatic treatment, such as basic analgesics for headache and antiemetics, is often helpful. With conservative treatment, most patients successfully acclimatize over 24 to 48 hours and symptoms resolve.[openanesthesia.org]
  • A case is described in which the oral hypoglycemic agent acetohexamide, instead of acetazolamide, was mistakenly self-administered for the prophylaxis and treatment of altitude illness.[ncbi.nlm.nih.gov]
  • The treatment of this patient suggests that early intervention of CRRT may be a useful therapy for patient with severe AMS, especially those with MODS.[ncbi.nlm.nih.gov]

Prognosis

  • What is the prognosis for HAPE? HAPE tends to get better quickly on descent and outlook (prognosis) is that there is usually complete recovery.[patient.info]
  • Prognosis The prognosis is dismal. Lymphangiosarcomas are extremely aggressive tumors with a high local recurrence rate and a tendency to metastasize early to many areas. Long-term survivors are the exceptions.[emedicine.medscape.com]
  • Prognosis The outlook for altitude sickness depends on how quickly the person can be moved to a lower altitude, and how serious their symptoms are. Symptoms of altitude sickness can disappear in just a few days at lower altitudes.[drugs.com]

Etiology

  • A hemangiogenic and lymphangiogenic origin of this angiosarcoma has been documented. [16] Etiology The most important single causative agent in Stewart-Treves syndrome is prolonged chronic lymphedema.[emedicine.medscape.com]

Epidemiology

  • Aims: Previous epidemiological investigations of the relationship between smoking and acute mountain sickness (AMS) risk yielded inconsistent findings.[ncbi.nlm.nih.gov]
  • Like the previous study these trekkers completed the LLS together with an epidemiological questionnaire. Then at 4,730m another set of trekkers, this time 189 were recruited (demographics: male   108, female   68, mean age 33, range 18-71).[climbkilimanjaroguide.com]
  • Epidemiology: Prevalence Colorado ski resort: 25% of travelers Himalayas: 50% of travelers III.[fpnotebook.com]
Sex distribution
Age distribution

Pathophysiology

  • AIMS: Despite extensive research on acute mountain sickness (AMS), the underlying pathophysiology remains unclear.[ncbi.nlm.nih.gov]
  • Four cases are described and the pathophysiology of AMS is discussed.[ncbi.nlm.nih.gov]
  • Moreover, a relation between nitrate-induced cerebral vasodilation and high altitude cerebral edema is theoretically possible on a pathophysiological basis.[ncbi.nlm.nih.gov]
  • BACKGROUND: Acute mountain sickness (AMS) is a pathophysiological symptom complex that occurs in high-altitude areas. The incidence of AMS on Jade Mountain, the highest peak in Taiwan (3952 m), has been reported to be 36%.[ncbi.nlm.nih.gov]
  • KEYWORDS: acute mountain sickness; biomarkers; drug targets; pathophysiology[ncbi.nlm.nih.gov]

Prevention

  • BUD also could reduce LLS but not prevent AMS at 72 hours. Ipratropium bromide maybe the effective drug in COM work on the prevention of AMS alone.[ncbi.nlm.nih.gov]
  • BACKGROUND: Oral glucocorticoids can prevent acute mountain sickness (AMS). Whether inhaled budesonide (BUD) can prevent AMS remains unknown. OBJECTIVE: Our aim was to investigate the effectiveness of BUD in AMS prevention.[ncbi.nlm.nih.gov]
  • OBJECTIVE: Recent trials have demonstrated the usefulness of ibuprofen in the prevention of acute mountain sickness (AMS), yet the proposed anti-inflammatory mechanism remains unconfirmed. Acetaminophen and ibuprofen were tested for AMS prevention.[ncbi.nlm.nih.gov]
  • Prevention is the safest and the most efficient method in the care concerning AMS.[ncbi.nlm.nih.gov]
  • An elite mountaineer reported severe acute mountain sickness and ataxia during an 8000-m expedition and concomitant use of transdermal nitroglycerin patches aimed to prevent frostbites.[ncbi.nlm.nih.gov]

References

Article

  1. Gertsch JH, Seto TB, Mor J, Onopa J. Ginkgo biloba for the prevention of severe acute mountain sickness (AMS) starting one day before rapid ascent. High altitude medicine & biology. 2002;3(1):29–37.
  2. Honigman B, Theis MK, Koziol-McLain J, et al. Acute mountain sickness in a general tourist population at moderate altitudes. Ann Intern Med. 1993;118(8):587–92.
  3. Karinen H, Peltonen J, Tikkanen H. Prevalence of acute mountain sickness among Finnish trekkers on Mount Kilimanjaro, Tanzania: an observational study. High altitude medicine & biology. 2008;9(4):301–6.
  4. Maggiorini M, Buhler B, Walter M, Oelz O. Prevalence of acute mountain sickness in the Swiss Alps. BMJ. 1990;301(6756):853–5.
  5. Murdoch DR. Altitude Illness Among Tourists Flying to 3740 Meters Elevation in the Nepal Himalayas. J Travel Med. 1995;2(4):255–6.
  6. Barry PW, Pollard AJ. Altitude illness. BMJ. 2003;326(7395):915–9.
  7. Gallagher SA, Hackett PH. High-altitude illness. Emerg Med Clin North Am. 2004;22(2):329–55.
  8. Roach RC, Bartsch P, Hackett PH, Oelz O. The Lake Louise acute mountain sickness scoring system, in Hypoxia and Molecular Medicine. Queens City Press, Burlington, Va, USA, 1993; pp. 272–274.
  9. Kobrick JL, Sampson JB. New inventory for the assessment of symptom occurrence and severity at high altitude. Aviation Space and Environmental Medicine. 1979; 50: 9: 925–929
  10. Sampson JB, Kobrick JL. The environmental symptoms questionnaire: revisions and new filed data. Aviation Space and Environmental Medicine. 1980; 51: 9 (1): 872–877
  11. Beidleman BA, Muza SR, Fulco CS, Rock PB, Cymerman A. Validation of a shortened electronic version of the environmental symptoms questionnaire. High Altitude Medicine and Biology, 2007; 8 (3): 192–199.
  12. Wagner DR, Teramoto M, Knott JR, Fry JP. Comparison of scoring systems for assessment of acute mountain sickness. High Altitude Medicine and Biology. 2012; 13 (4): 245–251.
  13. Roach RC, Kayser B. Measuring mountain maladies. High Altitude Medicine and Biology. 2007; 8 (3): 171–172
  14. Bartsch P, Bailey DM, Berger MM, Knauth M, Baumgartner RW. Acute mountain sickness: controversies and advances. High Altitude Medicine & Biology. 2004; 5: (2): 110–124.

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Last updated: 2019-06-28 10:28