Rhabdomyolysis: Difference between revisions
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#**[[Hypothyroidism]] | #**[[Hypothyroidism]] | ||
#*Inflammatory myopathies | #*Inflammatory myopathies | ||
#**Moderate CK elevations only ( | #**Moderate CK elevations only (rhabdomyolysis only described in case reports) | ||
#*Miscellaneous | #*Miscellaneous | ||
#**[[Status Asthmaticus]] | #**[[Status Asthmaticus]] | ||
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*Myalgia, stiffness, weakness, malaise, low-grade fever, dark urine | *Myalgia, stiffness, weakness, malaise, low-grade fever, dark urine | ||
**Musculoskeletal symptoms may be present in only half of cases | **Musculoskeletal symptoms may be present in only half of cases | ||
* | *Nausea and vomiting, abdominal pain, tachycardia in severe cases | ||
*Mental status changes secondary to urea-induced encephalopathy | *Mental status changes secondary to urea-induced encephalopathy | ||
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{{Red urine DDX}} | {{Red urine DDX}} | ||
== | ==Evaluation== | ||
===Work-up=== | ===Work-up=== | ||
*Obtain immediate ECG (electrolyte abnormalities) | *Obtain immediate ECG (electrolyte abnormalities) | ||
*Total CK | *Total CK | ||
* | *[[Urinalysis]] | ||
*CBC | *CBC | ||
*Chemistry, including Mag, Phos | *Chemistry, including Mag, Phos | ||
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===Evaluation=== | ===Evaluation=== | ||
*Total CK | *Total CK | ||
**Most consider | **Most consider rhabdomyolysis if 5x or greater increase above upper limit of normal (~2000) | ||
**Serum CK begins to rise 2-12hr after injury, peaks | **Serum CK begins to rise 2-12hr after injury, peaks within 24-72hr | ||
**Degree of CK elevation correlates | **Degree of CK elevation correlates with muscle injury, but NOT renal failure | ||
*CK-MB | *CK-MB | ||
**May be normal or mildly elevated (<5% of total) | **May be normal or mildly elevated (<5% of total) | ||
*Uric Acid - elevates before CK | *Uric Acid - elevates before CK | ||
*Myoglobinuria | *Myoglobinuria | ||
** | **[[Urinalysis]] = +blood, no RBCs (Sn ~80%) | ||
**Myoglobin is cleared | **Myoglobin is cleared within 1-6hr (often see elevated CK with no myoglobinuria) | ||
*Acute renal failure | *Acute renal failure | ||
**Creatinine increase | **Creatinine increase | ||
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===IV Fluids=== | ===IV Fluids=== | ||
*Start with NS 1-2 L/hr | *Start with NS 1-2 L/hr | ||
*Once urination occurs maintain urine output of 200-300 mL/hr | *Once urination occurs maintain urine output of 200-300 mL/hr (3 cc/kg/hr) | ||
*Frequently need ~10 L/day | *Frequently need ~10 L/day | ||
===[[Urinary alkalinization]]=== | ===[[Urinary alkalinization]]=== | ||
*Admistered as bicarbonate drip | *Admistered as bicarbonate drip | ||
**Mix 150 mL [3 amps] of 8.4% sodium bicarbonate | **Mix 150 mL [3 amps] of 8.4% sodium bicarbonate with 1 L D5W | ||
**Infuse at 200 mL/hour; rate is adjusted to achieve urine pH of >6.5 | **Infuse at 200 mL/hour; rate is adjusted to achieve urine pH of >6.5 | ||
*Controversial; no RCT to date have demonstrated benefit | *Controversial; no RCT to date have demonstrated benefit | ||
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*[[Acute Renal Failure]] | *[[Acute Renal Failure]] | ||
**Neither presence of myoglobinuria nor degree of CK rise is predictive of ARF | **Neither presence of myoglobinuria nor degree of CK rise is predictive of ARF | ||
**Rare in exertional | **Rare in exertional rhabdomyolysis with out presence of dehydration, heat stress, trauma | ||
**Most commonly oliguric | **Most commonly oliguric | ||
*[[Hyperkalemia]] | *[[Hyperkalemia]] | ||
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**Consider oral phosphate binders when level >7 | **Consider oral phosphate binders when level >7 | ||
*[[DIC]] | *[[DIC]] | ||
**Usually resolves spontaneously | **Usually resolves spontaneously within several days | ||
*[[Compartment Syndrome]] | *[[Compartment Syndrome]] | ||
*Peripheral nerve injury | *Peripheral nerve injury | ||
**Usually resolves | **Usually resolves within few days-weeks | ||
==See Also== | ==See Also== |
Revision as of 02:22, 18 September 2018
Background
- Muscle necrosis and release of intracellular muscle constituents into the circulation
- Recurrent episodes suggests inherited metabolic disorder
- Alcohol and drugs play a role in up to 80% of cases
Etiology
- Trauma or muscle compression
- Crush Syndrome
- Immobilization
- Compartment Syndrome
- Nontraumatic Exertional
- Exercise + hot weather
- Exercise + sickle cell
- Exercise + Hypokalemia
- Hyperkinetic states
- Seizure
- DTs
- Stimulant / Sympathomimetic[1] overdose
- Malignant Hyperthermia
- Neuroleptic malignant syndrome
- Nontraumatic Nonexertional
- Drugs and toxins
- Coma induced by sedatives
- Alcohol
- Coma-induced muscle compression
- Direct toxic effect
- Nutritional compromise increases risk (hypoK, hypoMg, HypoPhos)
- Statins
- Colchicine
- CO Poisoning
- Infection
- Viral myositis - Influenza, Coxsackie, EBV, HSV, HIV, CMV
- Bacterial pyomyositis
- Septicemia
- Endocrine
- Inflammatory myopathies
- Moderate CK elevations only (rhabdomyolysis only described in case reports)
- Miscellaneous
- Status Asthmaticus
- TSS
- Mushroom ingestion
- Drugs and toxins
Clinical Features
- Myalgia, stiffness, weakness, malaise, low-grade fever, dark urine
- Musculoskeletal symptoms may be present in only half of cases
- Nausea and vomiting, abdominal pain, tachycardia in severe cases
- Mental status changes secondary to urea-induced encephalopathy
Differential Diagnosis
Extremity trauma
- Compartment syndrome
- Contusion
- Crush syndrome
- Degloving injury
- Fracture
- Laceration
- Myositis ossificans
- Open joint injury
- Peripheral nerve injury
- Rhabdomyolysis
- Tendon injury
- Vascular injury
Red Urine
- Hematuria
- Hemoglobinuria
- Porphyria
- Myoglobinuria (rhabdomyolysis)
- Foods
- Blackberries
- Beets
- Blackberries
- Rhubarb
- Food coloring
- Fava beans
- Drugs
- Uric acid crystalluria (neonates)
Evaluation
Work-up
- Obtain immediate ECG (electrolyte abnormalities)
- Total CK
- Urinalysis
- CBC
- Chemistry, including Mag, Phos
- Uric acid
- LFTs
- DIC panel
- Coags, FSP, fibrinogen
Evaluation
- Total CK
- Most consider rhabdomyolysis if 5x or greater increase above upper limit of normal (~2000)
- Serum CK begins to rise 2-12hr after injury, peaks within 24-72hr
- Degree of CK elevation correlates with muscle injury, but NOT renal failure
- CK-MB
- May be normal or mildly elevated (<5% of total)
- Uric Acid - elevates before CK
- Myoglobinuria
- Urinalysis = +blood, no RBCs (Sn ~80%)
- Myoglobin is cleared within 1-6hr (often see elevated CK with no myoglobinuria)
- Acute renal failure
- Creatinine increase
- Electrolyte abnormalities
- Hyperkalemia
- Hyperphosphatemia
- Hypocalcemia
- Hyperuricemia
Management
Trend:
- Volume status
- Urine pH
- Chemistry
- CK
- Calcium, phosphorus
IV Fluids
- Start with NS 1-2 L/hr
- Once urination occurs maintain urine output of 200-300 mL/hr (3 cc/kg/hr)
- Frequently need ~10 L/day
Urinary alkalinization
- Admistered as bicarbonate drip
- Mix 150 mL [3 amps] of 8.4% sodium bicarbonate with 1 L D5W
- Infuse at 200 mL/hour; rate is adjusted to achieve urine pH of >6.5
- Controversial; no RCT to date have demonstrated benefit
- Consider if CK >5000, severe muscle injury (crush injury), rising CK AND urine pH <6.5
- Contraindications:
- Severe hypocalcemia
- Arterial pH > 7.50
- Serum bicarbonate > 30 meq/L
- Arterial pH and serum calcium should be monitored q2hr
- Discontinue alkalinization:
- Urine pH does not rise above 6.5 after 3-4hr
- Patient develops symptomatic hypocalcemia
- Arterial pH > 7.5
- Serum bicarbonate >30 meq/L
Mannitol
- Mannitol administration can worsen dehydration and oliguria and although used in the past should generally be avoided
- No RCT to date has demonstrated benefit
Intubation/RSI
- Use Rocuronium due to the potential elevations in potassium that result from the rhabdomyolysis
Disposition
- Discharge if:
- Exertional rhabdo
- Otherwise healthy
- No comorbidities (heat stress, dehydration, trauma)
- Downtrending total CK
- Consider admission for CK >30,000
- Otherwise admit to monitored bed
Complications
- Acute Renal Failure
- Neither presence of myoglobinuria nor degree of CK rise is predictive of ARF
- Rare in exertional rhabdomyolysis with out presence of dehydration, heat stress, trauma
- Most commonly oliguric
- Hyperkalemia
- Renal function, not release of K+, is most important determinant
- Treat aggressively; insulin may be ineffective; may require dialysis
- Hypocalcemia (initial phase)
- Treat only if symptomatic or severely hyperkalemic (often have rebound hypercalcemia)
- Hypercalcemia (recovery phase)
- Hyperphosphatemia
- Treat cautiously (treatment may worsen calcium precipitation in muscle)
- Consider oral phosphate binders when level >7
- DIC
- Usually resolves spontaneously within several days
- Compartment Syndrome
- Peripheral nerve injury
- Usually resolves within few days-weeks
See Also
References
- ↑ O'Connor AD et al. Prevalence of Rhabdomyolysis in Sympathomimetic Toxicity: A Comparison of Stimulants. J Med. Toxicol. 2015;11(2)195-200