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.

Skin
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  • cardiovascular
    Tachycardia
    • 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]
    • Symptoms include the following: Dyspnea at rest Cough Weakness or decreased exercise performance Chest tightness or congestion Signs include the following: Rales or wheezing in at least 1 lung field Central cyanosis Tachypnea Tachycardia A chest radiograph[emedicine.medscape.com]
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  • gastrointestinal
    Nausea
    • Symptoms of mild AMS include: mild to severe headache; nausea; vomiting; lack of appetite; lack of energy; altered balance and coordination; dizziness.[bigislandhikes.com]
    • […] mountain sickness - nausea and shortness of breath experienced by mountain climbers above ten thousand feet[thefreedictionary.com]
    • Stay alert for acute mountain sickness symptoms such as headaches and nausea.[grindtv.com]
    • : 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, dizziness, and fatigue, and[merriam-webster.com]
    • Every year, rangers in Rocky Mountain National Park treat countless park visitors with headaches, nausea, dizziness, and a host of other ailments.[nps.gov]
    Vomiting
    • : 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, dizziness, and fatigue, and[merriam-webster.com]
    • More serious symptoms of AMS include increased tiredness, severe headaches, vomiting, loss of coordination, shortness of breath and coughing fits.[mallatreknepal.com]
    • 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]
    • Symptoms of mild AMS include: mild to severe headache; nausea; vomiting; lack of appetite; lack of energy; altered balance and coordination; dizziness.[bigislandhikes.com]
    Loss of Appetite
    • : 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, dizziness, and fatigue, and[merriam-webster.com]
    • Symptoms of mild AMS include mild headaches, increased breathing, rapid pulse, nausea, loss of appetite, lack of energy, and general malaise.[nps.gov]
    • Mild symptoms include headache, loss of appetite, nausea, fatigue, insomnia and dizziness.[mallatreknepal.com]
    • Signs of mountain sickness Early signs of acute mountain sickness include headache, nausea, loss of appetite and insomnia.[kalcounty.com]
    • Headaches, loss of appetite, nausea and even vomiting are common symptoms of people who head upward too quickly, and sometimes acute mountain sickness can turn into a real medical emergency.[grindtv.com]
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  • respiratoric
    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]
    • 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]
    • High-altitude pulmonary edema (HAPE) is a form of noncardiogenic pulmonary edema causing severe dyspnea and hypoxemia.[merckmanuals.com]
    • These patients are likely to experience additional symptoms, such as fatigue, dyspnea, or even syncope.[emedicine.medscape.com]
    Dyspnea at Rest
    • […] at rest, and chest tightness.[quizlet.com]
    • […] 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]
    • Life-threatening symptoms of altitude illness include the dyspnea at rest, wheezing, or crackles of high-altitude pulmonary edema (HAPE) or the altered mental status and ataxia seen in high-altitude cerebral edema (HACE).[journals.lww.com]
    • 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]
    • Symptoms include the following: Dyspnea at rest Cough Weakness or decreased exercise performance Chest tightness or congestion Signs include the following: Rales or wheezing in at least 1 lung field Central cyanosis Tachypnea Tachycardia A chest radiograph[emedicine.medscape.com]
    Periodic Breathing
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  • neurologic
    Headache
    • RCT Prevention of High Altitude Headache.[bestbets.org]
    • Treat the headache before going any higher.[nps.gov]
    • Many people think it is normal to have a headache at altitude when in fact it is not, it is very rare.[climbing-high.com]
    • 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]
    • This assesses five symptoms associated with high altitude: headache (“no headache at all” to “worst headache ever”), nausea (1.[journals.plos.org]
    Dizziness
    • : 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, dizziness, and fatigue, and[merriam-webster.com]
    • […] light-headedness Not dizzy Mild dizziness Moderate dizziness Severe dizziness 0 1 2 3 Difficulty sleeping Slept as well as usual Did not sleep as well as usual Woke many times, poor sleep Could not sleep at all 0 1 2 3 A total score of 3 to 5 mild AMS[patient.info]
    • Mild symptoms include headache, loss of appetite, nausea, fatigue, insomnia and dizziness.[mallatreknepal.com]
    • Dizziness, nausea, headaches, and shortness of breath are a few symptoms of this condition.[healthline.com]
    • […] acute mountain sickness as the presence of headache in an unacclimatized person who has recently arrived at an altitude above 2,500 m plus the presence of one or more of the following: gastrointestinal symptoms (anorexia, nausea, or vomiting), insomnia, dizziness[clinicaltrials.gov]
    Insomnia
    • : 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, dizziness, and fatigue, and[merriam-webster.com]
    • […] defined acute mountain sickness as the presence of headache in an unacclimatized person who has recently arrived at an altitude above 2,500 m plus the presence of one or more of the following: gastrointestinal symptoms (anorexia, nausea, or vomiting), insomnia[clinicaltrials.gov]
    • Significant reductions in frequency and severity of the most prominent symptoms of acute mountain sickness — headache, insomnia and gastrointestinal symptoms — were observed in treated subjects.[nejm.org]
    • At first the symptoms of acute mountain sickness are mild : the patient complains of headache, fatigue, loss of appetite, nausea, insomnia, dizziness and general malaise.[climbeverest.jimdo.com]
    • Mild symptoms include headache, loss of appetite, nausea, fatigue, insomnia and dizziness.[mallatreknepal.com]
    Irritability
    • 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]
    • […] 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]
    • 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]
    • 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]
    • Their level of consciousness is declining and the victim may have personality changes: disorientation, confusion, irritability, uncooperativeness, poor decision making.[trekking-in-bhutan.com]
    Lethargy
    • A severe headache, vomiting and lethargy will progress to unsteadiness, confusion, drowsiness and ultimately coma.[altitude.org]
    • As the brain continues to swell, lethargy and then coma will develop (late symptoms).[emedicinehealth.com]
    • There may be confusion, changes in behaviour, or lethargy.[ratnavoyages.com]
    • In addition to AMS symptoms, lethargy becomes profound, with drowsiness, confusion, and ataxia on tandem gait test, similar to alcohol intoxication.[wwwnc.cdc.gov]
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  • Face, Head & Neck
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  • Entire body system
    Fatigue
    • : 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, dizziness, and fatigue, and[merriam-webster.com]
    • However, increases in erythrocyte count, hematocrit and hemoglobin associated with EPO therapy have been shown to decrease fatigue and increase work capacity and exercise tolerance.[clinicaltrials.gov]
    • Moderate AMS : Moderate AMS includes severe headache (not relieved by medication), nausea, vomiting, increasing weakness and fatigue, shortness of breath, and decreased coordination.[medicinenet.com]
    • “my guts are really bad” to “my guts are fine”), fatigue (1.[journals.plos.org]
    • […] and/or weakness Not tired or weak Mild fatigue/weakness Moderate fatigue/weakness Severe fatigue/weakness 0 1 2 3 Dizziness/light-headedness Not dizzy Mild dizziness Moderate dizziness Severe dizziness 0 1 2 3 Difficulty sleeping Slept as well as usual[patient.info]
    Malaise
    • Symptoms of mild AMS include mild headaches, increased breathing, rapid pulse, nausea, loss of appetite, lack of energy, and general malaise.[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]
    • It includes a constellation of symptoms, such as headache, loss of appetite, nausea, lightheadedness, a general feeling of malaise and difficulty sleeping.[sfgate.com]
    • At first the symptoms of acute mountain sickness are mild : the patient complains of headache, fatigue, loss of appetite, nausea, insomnia, dizziness and general malaise.[climbeverest.jimdo.com]
    • They must also demonstrate one of the following signs and symptoms: lack of appetite, nausea, or vomiting exhaustion or weakness dizziness insomnia pins and needles shortness of breath upon exertion feeling sleepy general malaise swelling of the hands[medicalnewstoday.com]
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  • 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].

    Laboratory

    Serum
    Hypocapnia
    • The hypoxic ventilatory drive causes hypocapnia and a reduction in respiratory drive [11] .[journals.plos.org]
    • Changes in sleep state, as well as conflicting effects of hypocapnia and hypoxia on the peripheral chemoreceptors, lead to a destabilization of the respiratory control system, which is responsible for the periodic breathing observed at high altitude.[emedicine.medscape.com]
    • Severe altitude illness occurs most commonly in this range. [9] Extreme altitude [ edit ] Above 5,500 metres (18,000 ft), marked hypoxemia, hypocapnia , and alkalosis are characteristic of extreme altitudes.[en.wikipedia.org]
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  • ECG

    Rhythm
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  • Axis
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  • T Wave
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  • QT, RR, ST Intervals
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  • P Wave
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  • Treatment

    Prognosis

    Complications

    Pulmonary Hypertension
    • Reversal of high altitude pulmonary hypertension.[emedicine.medscape.com]
    • Sildenafil citrate for the prevention of high altitude hypoxic pulmonary hypertension: double blind, randomized, placebo-controlled trial.[journals.lww.com]
    • It can lead to hypertension, blood coagulation disorders (intravascular blood coagulation, thrombo-embolism) and pulmonary hypertension.[ratnavoyages.com]
    • Bates MG, Thompson AA, Baillie JK, Sutherland AI, Irving JB, et al. (2011) Sildenafil citrate for the prevention of high altitude hypoxic pulmonary hypertension: double blind, randomized, placebo-controlled trial.[journals.plos.org]
    • Even if N.M.S.U. tested all of the nearly one million cows grazing in the Rockies for pulmonary hypertension—high blood pressure in the lungs—it wouldn't solve the brisket problem.[livescience.com]
    Hypoxia
    • Thus people going to high altitude, above 2500m, develop hypoxia, which is a reduced content of O2 in the blood and tissues.[sciencedaily.com]
    • A time lag of six to 96 hours between arrival and onset of symptoms ruled out any direct relation between hypoxia and acute mountain sickness.[nejm.org]
    • What are the general considerations for acute mountain sickness (AMS) AMS is due to hypobaric hypoxia at high altitudes (greater than 6560 feet), usually as a result of increased physical activity with insufficient acclimatization, inaequate education[quizlet.com]
    • Thesaurus Antonyms Related Words Synonyms Legend: Noun 1. altitude sickness - effects (as nosebleed or nausea) of oxygen deficiency in the blood and tissues at high altitudes hypoxia - oxygen deficiency causing a very strong drive to correct the deficiency[thefreedictionary.com]
    • Hypoxia: The Adaptations .[emedicine.medscape.com]
    Respiratory Alkalosis
    • In response to hypoxia, control subjects hyperventilated and developed mild respiratory alkalosis with increased blood pH and reduced carbon dioxide tension and bicarbonate within eight hours after arrival at altitude.[nejm.org]
    High Altitude Cerebral Edema
    • However, Shah et al have described potential drugs for management of high-altitude illnesses, such as acute mountain sickness (AMS), high altitude cerebral edema, and high altitude pulmonary edema (HAPE) as one group under the section “Novel drug treatment[dovepress.com]
    • AMS is generally benign though may progress to high-altitude cerebral edema (HACE) in more severe cases or during continued ascent when symptoms of AMS are present.[link.springer.com]
    • Further ascent can result in HACE (High Altitude Cerebral Edema), which includes encephalopathic symptoms and signs, including ataxic gait, severe lassitude, and progressive decline of mental function and consciousness.[openanesthesia.org]
    • These extremely dangerous symptoms are called high altitude cerebral edema (or HACE).[mallatreknepal.com]
    Cor Pulmonale
    • They concluded that patients with mild or moderate COPD without cor pulmonale tolerate altitude exposure quite well.[emedicine.medscape.com]
    Alkalosis
    • Alkalosis was prevented in the acetazolamide-treated group, with a greater increase in ventilation and alveolar oxygen tension and a greater decrease in carbon dioxide tension and bicarbonate than in controls.[nejm.org]
    • Severe altitude illness occurs most commonly in this range. [9] Extreme altitude [ edit ] Above 5,500 metres (18,000 ft), marked hypoxemia, hypocapnia , and alkalosis are characteristic of extreme altitudes.[en.wikipedia.org]
    Cerebral Edema
    • In one biopsy and two autopsy studies there was evidence of cerebral edema.[nejm.org]
    • However, Shah et al have described potential drugs for management of high-altitude illnesses, such as acute mountain sickness (AMS), high altitude cerebral edema, and high altitude pulmonary edema (HAPE) as one group under the section “Novel drug treatment[dovepress.com]
    • AMS is generally benign though may progress to high-altitude cerebral edema (HACE) in more severe cases or during continued ascent when symptoms of AMS are present.[link.springer.com]
    • Severe cases may result in death due to lung problems or brain swelling, called cerebral edema.[nlm.nih.gov]
    High Altitude Pulmonary Edema
    • High altitude pulmonary edema.[emedicine.medscape.com]
    • However, Shah et al have described potential drugs for management of high-altitude illnesses, such as acute mountain sickness (AMS), high altitude cerebral edema, and high altitude pulmonary edema (HAPE) as one group under the section “Novel drug treatment[dovepress.com]
    • Sildenafil (Viagra) has been shown to be useful for the prevention and treatment of high-altitude pulmonary edema associated with altitude sickness such as that suffered by mountain climbers.[climbeverest.jimdo.com]
    • Increasing shortness of breath, cough and tiredness may also be signs of high altitude pulmonary edema or HAPE.[mallatreknepal.com]
    Pulmonary Edema
    • High altitude pulmonary edema.[emedicine.medscape.com]
    • [Acute mountain sickness and high altitude cerebral and pulmonary edema].[dovemed.com]
    • Sildenafil (Viagra) has been shown to be useful for the prevention and treatment of high-altitude pulmonary edema associated with altitude sickness such as that suffered by mountain climbers.[climbeverest.jimdo.com]
    • High altitude cerebral edema; Altitude anoxia; Altitude sickness; Mountain sickness; High altitude pulmonary edema Harris NS.[nlm.nih.gov]
    Central Sleep Apnea
    Hypocapnia
    • The hypoxic ventilatory drive causes hypocapnia and a reduction in respiratory drive [11] .[journals.plos.org]
    • Changes in sleep state, as well as conflicting effects of hypocapnia and hypoxia on the peripheral chemoreceptors, lead to a destabilization of the respiratory control system, which is responsible for the periodic breathing observed at high altitude.[emedicine.medscape.com]
    • Severe altitude illness occurs most commonly in this range. [9] Extreme altitude [ edit ] Above 5,500 metres (18,000 ft), marked hypoxemia, hypocapnia , and alkalosis are characteristic of extreme altitudes.[en.wikipedia.org]
    Apnea
    • Sleep Apnea Syndromes .[emedicine.medscape.com]
    • Preexisting Medical Problems Travelers with medical conditions, such as heart failure, myocardial ischemia (angina), sickle cell disease, any form of pulmonary insufficiency or preexisting hypoxemia, or obstructive sleep apnea (OSA) should consult a physician[wwwnc.cdc.gov]

    Etiology

    Causes

    Alkalosis
    • Alkalosis was prevented in the acetazolamide-treated group, with a greater increase in ventilation and alveolar oxygen tension and a greater decrease in carbon dioxide tension and bicarbonate than in controls.[nejm.org]
    • Severe altitude illness occurs most commonly in this range. [9] Extreme altitude [ edit ] Above 5,500 metres (18,000 ft), marked hypoxemia, hypocapnia , and alkalosis are characteristic of extreme altitudes.[en.wikipedia.org]

    Epidemiology

    Sex distribution
    Age distribution

    Pathophysiology

    Prevention

    Summary

    Patient Information

    Self-assessment

    Ask Question


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    References

    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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    33. Acetazolamide in prevention of acute mountain sickness: a double-blind controlled cross-over study. - MK Greene, AM Kerr, IB McIntosh - British medical journal ( , 1981 - ncbi.nlm.nih.gov

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