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Lek Lagnu: Understanding HAPE and HACE at High Altitudes

Lek Lagnu

Lek lagnu (लेक लाग्नु) is a common term in Nepali, referring to the life-threatening effects people can experience at high altitudes. While it can describe general altitude sickness, medically it often points to two severe conditions: High-Altitude Pulmonary Edema (HAPE) and High-Altitude Cerebral Edema (HACE). Both are emergencies that require immediate attention.

What is HAPE (High-Altitude Pulmonary Edema)?

HAPE is a condition where fluid collects in the lungs, making it extremely difficult to breathe. It usually occurs above 2,500 meters (8,200 feet), but it can happen at lower altitudes if a person ascends too quickly.

Symptoms of HAPE:

• Difficulty breathing, even while resting

• Severe coughing, sometimes with frothy or blood-tinged sputum

• Chest tightness or congestion

• Extreme fatigue and weakness

• Blue or gray lips and fingernails (due to lack of oxygen)

Why does HAPE happen?
At high altitudes, the lower oxygen pressure causes the blood vessels in the lungs to constrict. In some people, this leads to leakage of fluid into the air spaces of the lungs, making breathing almost impossible.

What is HACE (High-Altitude Cerebral Edema)?

HACE is even more serious and involves swelling of the brain due to lack of oxygen. It typically happens at altitudes above 3,000 meters (about 10,000 feet) but can occur lower if ascent is too rapid.

Symptoms of HACE:

• Severe headache that does not improve with painkillers

• Loss of coordination (walking unsteadily)

• Confusion, irritability, or hallucinations

• Drowsiness that can progress to unconsciousness

• Seizures in extreme cases

Why does HACE happen?
Reduced oxygen at high elevations causes brain blood vessels to leak fluid, leading to dangerous swelling inside the skull.

Key Differences between HAPE and HACE

How to Prevent Lek Lagnu (HAPE and HACE)

• Ascend slowly: No more than 300–500 meters per day once above 3,000 meters.

• Acclimatize properly: Rest every few days to adjust to the altitude.

• Stay hydrated: But avoid alcohol and sleeping pills.

• Recognize early symptoms: Never ignore headaches, breathing problems, or confusion at high altitude.

• Descend immediately: The best and fastest treatment for HAPE and HACE is to move to a lower altitude as quickly as possible.

• Oxygen and medication: Supplemental oxygen, and medicines like nifedipine (for HAPE) or dexamethasone (for HACE), can save lives if available.

Conclusion

Lek lagnu is not just a minor inconvenience; it can be deadly if it progresses to HAPE or HACE. Anyone trekking, climbing, or traveling to high-altitude areas like the Himalayas must be aware of the risks and take preventive measures seriously. Quick recognition, proper acclimatization, and immediate descent are the best defenses against these life-threatening conditions.

Medical Notes: Face to Pubis delivery : What are the risk factors for it?

Which type of pelvis is associated with an increased incidence of face-to-pubis delivery?

a. Gynecoid pelvis
b. Anthropoid pelvis ✅ (Correct Answer)
c. Android pelvis
d. Platypelloid pelvis

Answer: b. Anthropoid pelvis

Solution:

Face-to-pubis delivery is most commonly associated with the Anthropoid pelvis.

Types of Pelvis:

1. Gynecoid Pelvis

• Normal female pelvis

• Most common type

• Transverse diameter > Anteroposterior (AP) diameter

2. Anthropoid Pelvis

• AP diameter > Transverse diameter

• Face-to-pubis delivery is common

3. Android Pelvis

• Male-type or wedge-shaped pelvis

• All diameters reduced

• Delayed engagement

• Deep transverse arrest

4. Platypelloid Pelvis

• Flat pelvis type

• Transverse diameter > AP diameter

• Least common type

• Shortest diameter of pelvic inlet = Obstetric conjugate

Additional Important Points:

• Most important diameter during labor: Interspinal diameter (of the pelvic outlet)

• Shortest diameter of the fetal skull: Bimastoid diameter

• Largest diameter of the fetal skull: Mento-vertical diameter

Rheumatoid Arthritis

Pathological Change

• In Rheumatoid Arthritis (RA), the synovium becomes edematous (↑ fluid content, ↓ viscosity), leading to:

  • Thickening, then hypertrophy, and finally

  • Pannus formation — hallmark of disease involving fibroblasts and small blood vessels.

General Characteristics

• RA is a non-suppurative chronic disease.

• Symmetrical inflammation of peripheral joints with progressive destruction of periarticular structures.

• Associated with HLA Class II genes: HLA-DR, HLA-DQ.

Most Common Joints Affected

• MCP of index finger > Wrist > PIP > MTP > Knee, Ankle, Shoulder, Elbow.

• DIP joints spared (DIP joints are involved in Osteoarthritis, not RA).

Important Autoantibodies

• Most specific: Anti-CCP antibodies.

• Rheumatoid factor (RF): IgM antibodies directed against Fc portion of IgG.

Common Complications

• Tendon rupture: Extensor digitorum communis (most common).

• Eye complication: Dry eye (Sicca syndrome) — seen in ~38%.

• Lung complication: Interstitial Lung Disease (ILD).

Characteristic Deformities

• Z-deviation of hand:

  • Radial deviation at the wrist.

  • Ulnar deviation of fingers.

• Swan neck deformity: Hyperextension of PIP, flexion of DIP.

• Hill’s hiker’s thumb:

  • Extension at 1st IP joint.

  • Flexion at 1st MCP joint.

  • Loss of thumb mobility and pinch.

• Hammer toes.

X-ray Findings

• Juxta-articular osteopenia.

• Bone erosions.

• ↓ Joint space due to cartilage loss.

Syndromic Associations

• Felty’s syndrome: Chronic RA + Splenomegaly + Neutropenia (<1500 cells/mm³).

• Caplan’s syndrome: Pulmonary nodules + Pneumoconiosis in RA patients.

Treatment

• First-line (DOC): Methotrexate (DMARD).

• Best analgesic: Naproxen.

• Biologics:

  • TNF inhibitors: Etanercept, Infliximab, Adalimumab.

  • Rituximab (anti-CD20 monoclonal antibody).

MCQ

Q. Which structure in the joint is affected earliest in Rheumatoid Arthritis?

a. Capsule
b. Articular cartilage
c. Synovium ✅
d. Subchondral bone

Here’s a list of antiemetic medications that can be used for nausea and vomiting in pregnancy (NVP), typically in order of preference and safety:

First-line

Second-line

Third-line

Others (used cautiously or in severe cases)

CBIMNCI (CB IMNCI) protocol Nepal for Health professionals

CBIMNCI protocol has been one of the driving guideline for treatment of neonatal and childhood illnesses in Nepal.

Here we have uploaded the latest CBIMNCI protocol book in pdf format for your reference. 

You can either refer it here or please download for future reference.

Download CBIMNCI (CB IMNCI) protocol

Community based integrated management of childhood and neonatal illness protocol has been developed by government of Nepal, child health division. This protocol has been the main guidelines for Nepal.

There are these protocols and guidelines developed for health care workers in Nepal.

1. CB-IMNCI (CBIMNCI) guidelines for FCHV pdf
2. FB-IMNCI (CBIMNCI) guidelines for Paramedics pdf
3. FB-IMNCI (CBIMNCI) guidelines for Medical officers pdf
4. CB IMNCI flipchart pdf
5. CBIMNCI remote area  guideline pdf
6. CBIMNCI program management module pdf

The complete guidelines can be downloaded below.

CBIMNCI remote area  guideline pdf (imnci chart booklet)

Here i CBIMNCI remote area guideline in pdf format to download and to read.

https://drive.google.com/file/d/1WMK9YeiYR0dIDPU9zaPvNEhZdRS2h5g0

CBIMNCI program management module pdf (imnci chart booklet)

Here is CBIMNCI program management module.

https://drive.google.com/file/d/11JiJMVooK7RVd2ER7O6yA5OMWdiOOF7O/preview

CB IMNCI flipchart pdf (imnci chart booklet)

Here is CBIMNCI flipchart for you to read and download.

https://drive.google.com/file/d/1cCVNF0ysFCYSYcKbwPCAlF8ZJ-cW1agS/preview

FB-IMNCI (CBIMNCI) guidelines for Paramedics pdf (imnci chart booklet)

https://drive.google.com/file/d/1z6XL030saQUPqacVJ4EKi5Euk7RwVDOj/preview

FB-IMNCI (CBIMNCI) guidelines for Medical officers pdf (imnci chart booklet)

https://drive.google.com/file/d/1S0ji6gsJyeSvbgdsV1hqVabhiSMkTkIj/preview

CB-IMNCI (CBIMNCI) guidelines for FCHV pdf (imnci chart booklet)

https://drive.google.com/file/d/1JE6Olq1Ko1oa8gs3jlpkEQeNq0_y9foA/preview

Download CBIMNCI (CB IMNCI) guideline (imnci chart booklet)

Please use this link for downloading the book in pdf format. These guidelines are updated accordingly to date of this post and updates will be posted subsequently.

Difference between CBIMNCI (CB IMNCI) and CB-IMCI

CBIMCI stands for community based integrated management of childhood illnesses. This guideline is the past form of CBIMNCI.

CBIMNCI was developed with addition of neonatal illnesses guidelines to the childhood illnesses. The main reason for this was that childhood illnesses cannot be separated from neonatal illnesses.

CBIMCI was also derived from IMCI (read below).

Definition of IMCI

IMCI stands for integrated management of childhood illnesses. As the childhood mortality rate in our country were relatively high this must have been addressed quickly and in a economic way. For this, healthcare workers like CMA, HA and volunteers like FCHV needed to be trained and upgraded to manage childhood illnesses. 

Gradually, this protocol was update to change into CBIMCI and subsequently into CBIMNCI and FBIMNCI.

IMCI vs IMNCI

The main difference between IMCI and IMNCI is that IMNCI includes neonatal ilnesses. 

Lately, IMNCI is updated into FB-IMNCI (Facility based integrated management of childhood and neonatal illnesses )

Timeline of CBIMNCI Nepal

IMCI-CBIMNCI-FCHV-PARAMEDICS-MEDICAL OFFICER-FBIMNCI

(See Picture below)

What are disease covered by CBIMNCI nepal?

Following diseases are covered by CBIMNCI and FBIMNCI Nepal.

1. Diarrhoea and AGE
2. Fever
3. Otitis media (ear infections)
4. Vomiting and dehydration
5. Feeding problems

Should doctors follow CBIMNCI protocol Nepal?

Yes. There is a separate FBIMNCI protocol for medical officers. 

The protocol is different for rural and urban area as well. 

When was latest CBIMNCI guideline updated in Nepal?

Latest guidelines was updated in 2021 AD. The exact date of patest protocol are mentioned in the guidelines books above. Please refer to pdfs above.

Is CBIMNCI Nepal approved by WHO?

YES . CBIMNCI guidelines are guided and developed with help of WHO.

These guidelines can also be downloaded by visiting WHO website. 

Where can I download CBIMNCI guideline Nepal?

Please download the guidelines from links above. 

If you want to download in bundle refer this link. 

Related links:

1. WHO
2. Child health division
3. Family welfare division
4. Dr Health Rx
5. Ministry of health and population 

Table of Contents(toc)

Tear gas, commonly used in crowd control, consists of chemical irritants such as chloroacetophenone (CN), chlorobenzylidene malononitrile (CS), and dibenzoxazepine (CR). While classified as a “riot control agent,” its effects on human health can be severe, particularly with prolonged or high-concentration exposure. 

Here are key risks supported by scientific and medical literature:

1. Respiratory Effects

• Acute Respiratory Distress Syndrome (ARDS): High exposure can lead to severe lung injury and ARDS, particularly in individuals with pre-existing conditions such as asthma or COPD.

• Bronchoconstriction & Asthma Exacerbation: CS gas can trigger acute bronchospasm, posing a significant risk for asthmatics.

• Lung Damage & Chronic Bronchitis: Prolonged exposure may result in chemical pneumonitis and chronic respiratory symptoms (Karagama et al., 2003).

2. Ocular Injuries & Blindness

• Severe Eye Irritation: Tear gas causes lacrimation, conjunctivitis, corneal abrasions, and in some cases, permanent vision impairment (Hu et al., 1989).

• Risk of Secondary Trauma: People often rub their eyes vigorously, leading to corneal damage and infection.

3. Skin Burns & Chemical Dermatitis

• Blister Formation & Irritation: CS and CN can cause second-degree burns, dermatitis, and allergic skin reactions (CDC, 2018).

• Delayed Hypersensitivity Reactions: Some individuals develop long-term skin sensitivity to tear gas chemicals.

4. Neurological & Psychological Effects

• Seizures & Nerve Damage: Reports suggest potential neurotoxicity with repeated exposure, including seizures in susceptible individuals (Papirmeister et al., 1991).

• PTSD & Anxiety Disorders: Tear gas exposure during stressful events has been linked to increased rates of PTSD, panic attacks, and acute stress reactions (Chorley et al., 2021).

5. Cardiovascular Risks

• Hypertension & Cardiac Events: Tear gas can increase blood pressure and heart rate, posing a risk for individuals with heart disease (Schep et al., 2015).

• Increased Risk of Heart Attacks: The sympathetic nervous system activation triggered by tear gas can induce myocardial infarction in vulnerable individuals.

6. Reproductive & Developmental Toxicity

• Increased Miscarriage Risk: Exposure to tear gas has been associated with miscarriages and menstrual irregularities in some studies (Karam et al., 2020).

• Potential Teratogenic Effects: Although data is limited, animal studies suggest possible fetal toxicity with prolonged exposure.

7. Long-Term Pulmonary & Systemic Effects

• Pulmonary Fibrosis & Chronic Lung Disease: Persistent exposure may lead to lung fibrosis, similar to occupational chemical exposures (Weisenburger et al., 2020).

• Potential Carcinogenicity: Some solvents used in tear gas formulations have been linked to DNA damage, though direct human studies are lacking.

Conclusion

Tear gas is not a harmless deterrent; it poses significant acute and chronic health risks, particularly for vulnerable populations (children, elderly, and those with pre-existing conditions). Its use in enclosed spaces or at high concentrations greatly increases risks of severe respiratory, ocular, and systemic effects.

Model MCQs for Nepal Government 8th Level Medical Officer Exam

General Medicine 

1. Which of the following is NOT a common cause of Chronic Obstructive Pulmonary Disease (COPD)?
   a) Smoking
   b) Air pollution
   c) Alpha-1 antitrypsin deficiency
   d) Tuberculosis
2. A patient presents with fever, murmur, and Janeway lesions. What is the most likely diagnosis?
   a) Myocardial infarction
   b) Rheumatic heart disease
   c) Infective endocarditis
   d) Pericarditis
3. Which investigation is most specific for diagnosing Hepatitis B infection?
   a) ALT/AST ratio
   b) HBsAg
   c) Anti-HBc IgM
   d) Anti-HAV IgM
4. What is the most common type of anemia worldwide?
   a) Megaloblastic anemia
   b) Iron deficiency anemia
   c) Aplastic anemia
   d) Sickle cell anemia
5. Which neurological condition is characterized by resting tremor, rigidity, and bradykinesia?
   a) Multiple sclerosis
   b) Parkinson’s disease
   c) Myasthenia gravis
   d) Guillain-Barré syndrome

   General Surgery
   

6. The most common cause of acute appendicitis is:
   a) Fecalith obstruction
   b) Intestinal tuberculosis
   c) Volvulus
   d) Hernia
7. Which is a common complication of deep vein thrombosis (DVT)?
   a) Pulmonary embolism
   b) Myocardial infarction
   c) Stroke
   d) Peripheral artery disease
8. The first-line management for pneumothorax in a hemodynamically stable patient is:
   a) Chest tube insertion
   b) Needle decompression
   c) Oxygen therapy
   d) Observation
9. Which condition is characterized by sudden onset of severe scrotal pain and absent cremasteric reflex?
   a) Testicular torsion
   b) Epididymitis
   c) Hydrocele
   d) Varicocele
10. Which of the following is the best initial investigation for breast carcinoma?
    a) Mammography
    b) FNAC
    c) MRI
    d) Ultrasound

     Obstetrics and Gynecology
    

11. A patient at 32 weeks gestation presents with painless vaginal bleeding. The most likely diagnosis is:
    a) Placenta previa
    b) Abruptio placentae
    c) Ectopic pregnancy
    d) Uterine rupture
12. Which of the following is NOT a risk factor for ectopic pregnancy?
    a) Pelvic inflammatory disease
    b) Previous ectopic pregnancy
    c) In vitro fertilization
    d) Multiparity

Answer Key:

1. d) Tuberculosis
2. c) Infective endocarditis
3. b) HBsAg
4. b) Iron deficiency anemia
5. b) Parkinson’s disease
6. a) Fecalith obstruction
7. a) Pulmonary embolism
8. c) Oxygen therapy
9. a) Testicular torsion
10. a) Mammography
11. a) Placenta previa
12. d) Multiparity

Definition: