Rhabdomyolysis: Difference between revisions

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==Background==
==Background==
[[File:PMC4065558 10.1177 1941738114522957-fig1.png|thumb|Intraoperative photograph of the left anterior compartment of the thigh. The quadriceps musculature can be seen bulging through the fascial defects.]]
*Muscle necrosis and release of intracellular muscle constituents into the circulation
*Muscle necrosis and release of intracellular muscle constituents into the circulation
*Recurrent episodes suggests inherited metabolic disorder
*Recurrent episodes suggests inherited metabolic disorder
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===Etiology===
===Etiology===
#Trauma or muscle compression
*[[Trauma]] or muscle compression
#*[[Crush Syndrome]]
**[[Crush Syndrome]]
#*Immobilization
**Immobilization
#*[[Compartment Syndrome]]
**[[Compartment Syndrome]]
#Nontraumatic Exertional
*Nontraumatic Exertional
#*Exercise + hot weather
**Exercise + hot weather
#*Exercise + sickle cell
**Exercise + [[sickle cell]]
#*Exercise + [[Hypokalemia]]
**Exercise + [[Hypokalemia]]
#*Hyperkinetic states
**Hyperkinetic states
#**[[Seizure]]
***[[Seizure]]
#**DTs
***[[delirium tremens|DTs]]
#**Stimulant / [[Sympathomimetic]]<ref> O'Connor AD et al. Prevalence of Rhabdomyolysis in Sympathomimetic Toxicity: A Comparison of Stimulants. J Med. Toxicol. 2015;11(2)195-200 </ref> overdose
***Stimulant / [[Sympathomimetic]]<ref> O'Connor AD et al. Prevalence of Rhabdomyolysis in Sympathomimetic Toxicity: A Comparison of Stimulants. J Med. Toxicol. 2015;11(2)195-200 </ref> overdose
#**[[Malignant Hyperthermia]]
***[[Malignant Hyperthermia]]
#**Neuroleptic malignant syndrome
***[[Neuroleptic malignant syndrome]]
#Nontraumatic Nonexertional
*Nontraumatic Nonexertional
#*Drugs and toxins
**Drugs and toxins
#**Coma induced by sedatives
***[[Coma]] induced by [[sedative/hypnotic toxicity|sedatives]]
#**Alcohol
***[[Alcohol]]
#***Coma-induced muscle compression
****Coma-induced muscle compression
#***Direct toxic effect
****Direct toxic effect
#***Nutritional compromise increases risk (hypoK, hypoMg, HypoPhos)
****Nutritional compromise increases risk ([[hypokalemia|hypoK]], [[hypomagnesemia|hypoMg]], [[hypophosphatemia|hypoPhos]])
#**Statins
***Statins
#**Colchicine   
***[[Colchicine]]  
#**[[CO Poisoning]]
***[[CO Poisoning]]
#*Infection
**[[Infection]]
#**Viral myositis - Influenza, Coxsackie, EBV, HSV, HIV, CMV
***Viral [[myositis]] - [[influenza]], [[coxsackie]], [[EBV]], [[HSV]], [[HIV]], [[CMV]]
#**Bacterial pyomyositis
***Bacterial pyomyositis
#**Septicemia
***[[Septicemia]]
#*Endocrine
**Endocrine
#**[[Hypothyroidism]]
***[[Hypothyroidism]]
#*Inflammatory myopathies
**Inflammatory myopathies
#**Moderate CK elevations only (rhabdo only described in case reports)
***Moderate CK elevations only (rhabdomyolysis only described in case reports)
#*Miscellaneous
**Miscellaneous
#**[[Status Asthmaticus]]
***[[Status Asthmaticus]]
#**TSS
***[[Toxic shock syndrome]]
#**Mushroom ingestion
***[[Mushroom]] ingestion


==Clinical Features==
==Clinical Features==
*Myalgia, stiffness, weakness, malaise, low-grade fever, dark urine
[[File:RhabdoUrine.jpg|thumb|Urine from a person with rhabdomyolysis showing the characteristic brown discoloration as a result of myoglobinuria]]
[[File:PMC2740115 1757-1626-0002-0000006479-001.png|thumb|Tea coloured with severe rhabdomyolysis]]
*[[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
*N/V, abd pain, tachycardia in severe 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]]


==Differential Diagnosis==
==Differential Diagnosis==
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{{Red urine DDX}}
{{Red urine DDX}}


==Diagnosis==
==Evaluation==
===Work-up===
===Work-up===
*Obtain immediate ECG (electrolyte abnormalities)
*Obtain immediate ECG (electrolyte abnormalities)
*Total CK
*Total CK
*UA
*[[Urinalysis]]
*CBC
*CBC
*Chemistry, including Mag, Phos
*Chemistry, including Mag, Phos
*Uric acid
*Uric acid
*LFTs
*[[LFTs]]
*DIC panel
*[[DIC]] panel
**Coags, FSP, fibrinogen
**Coags, FSP, fibrinogen


===Evaluation===
===Evaluation===
*Total CK
*Total CK
**Most consider rhabdo if 5x or greater increase above upper limit of normal (~2000)
**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
**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
**Degree of CK elevation correlates with muscle injury, but NOT renal failure
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*Uric Acid - elevates before CK
*Uric Acid - elevates before CK
*Myoglobinuria
*Myoglobinuria
**UA = +blood, no RBCs (Sn ~80%)  
**[[Urinalysis]] = +blood, no RBCs (Sn ~80%)  
**Myoglobin is cleared within 1-6hr (often see elevated CK with no myoglobinuria)
**Myoglobin is cleared within 1-6hr (often see elevated CK with no myoglobinuria)
*Acute renal failure
*Acute [[renal failure]]
**Creatinine increase
**Creatinine increase
*Electrolyte abnormalities
*Electrolyte abnormalities
**[[Hyperkalemia]]
**[[Hyperkalemia]]
**Hyperphosphatemia
**[[Hyperphosphatemia]]
**[[Hypocalcemia]]
**[[Hypocalcemia]]
**Hyperuricemia
**Hyperuricemia
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*Calcium, phosphorus
*Calcium, phosphorus


===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
*After rapid correction of fluid deficit, one method is infusing 2.5 mL/kg/hr with urine output goal of 200-300 ml/hr (2-3 cc/kg/hr)
*Frequently need ~10 L/day
*Frequently need ~10 L/day
===[[Urinary alkalinization]]===
===[[Urinary alkalinization]]===
*Admistered as bicarbonate drip
*Administered as [[bicarbonate]] drip
**Mix 150 mL [3 amps] of 8.4% sodium bicarbonate with 1 L D5W
**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
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*No RCT to date has demonstrated benefit
*No RCT to date has demonstrated benefit


===Intubation/RSI===
===[[Intubation]]/RSI===
*Use [[Rocuronium]] due to the potential elevations in potassium that result from the rhabdomyolysis
*Use [[Rocuronium]] due to the potential elevations in potassium that result from the rhabdomyolysis


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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 rhabdo with out presence of dehydration, heat stress, trauma
**Rare in exertional rhabdomyolysis with out presence of dehydration, heat stress, trauma
**Most commonly oliguric
**Most commonly oliguric
*[[Hyperkalemia]]
*[[Hyperkalemia]]

Revision as of 05:39, 10 December 2019

Background

Intraoperative photograph of the left anterior compartment of the thigh. The quadriceps musculature can be seen bulging through the fascial defects.
  • 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

Clinical Features

Urine from a person with rhabdomyolysis showing the characteristic brown discoloration as a result of myoglobinuria
Tea coloured with severe rhabdomyolysis

Differential Diagnosis

Extremity trauma

Red Urine

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

Management

Trend:

  • Volume status
  • Urine pH
  • Chemistry
  • CK
  • Calcium, phosphorus

IV Fluids

  • Start with NS 1-2 L/hr
  • After rapid correction of fluid deficit, one method is infusing 2.5 mL/kg/hr with urine output goal of 200-300 ml/hr (2-3 cc/kg/hr)
  • Frequently need ~10 L/day

Urinary alkalinization

  • Administered 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

  1. O'Connor AD et al. Prevalence of Rhabdomyolysis in Sympathomimetic Toxicity: A Comparison of Stimulants. J Med. Toxicol. 2015;11(2)195-200