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 | |||
**[[Crush Syndrome]] | |||
**Immobilization | |||
**[[Compartment Syndrome]] | |||
*Nontraumatic Exertional | |||
**Exercise + hot weather | |||
**Exercise + [[sickle cell]] | |||
**Exercise + [[Hypokalemia]] | |||
**Hyperkinetic states | |||
***[[Seizure]] | |||
***[[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 | |||
***[[Malignant Hyperthermia]] | |||
***[[Neuroleptic malignant syndrome]] | |||
*Nontraumatic Nonexertional | |||
**Drugs and toxins | |||
***[[Coma]] induced by [[sedative/hypnotic toxicity|sedatives]] | |||
***[[Alcohol]] | |||
****Coma-induced muscle compression | |||
****Direct toxic effect | |||
****Nutritional compromise increases risk ([[hypokalemia|hypoK]], [[hypomagnesemia|hypoMg]], [[hypophosphatemia|hypoPhos]]) | |||
***Statins | |||
***[[Colchicine]] | |||
***[[CO Poisoning]] | |||
**[[Infection]] | |||
***Viral [[myositis]] - [[influenza]], [[coxsackie]], [[EBV]], [[HSV]], [[HIV]], [[CMV]] | |||
***Bacterial pyomyositis | |||
***[[Septicemia]] | |||
**Endocrine | |||
***[[Hypothyroidism]] | |||
**Inflammatory myopathies | |||
***Moderate CK elevations only (rhabdomyolysis only described in case reports) | |||
**Miscellaneous | |||
***[[Status Asthmaticus]] | |||
***[[Toxic shock syndrome]] | |||
***[[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 | ||
*Nausea and vomiting, abdominal 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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*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 | ||
*Uric acid | *Uric acid | ||
*LFTs | *[[LFTs]] | ||
*DIC panel | *[[DIC]] panel | ||
**Coags, FSP, fibrinogen | **Coags, FSP, fibrinogen | ||
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*Uric Acid - elevates before CK | *Uric Acid - elevates before CK | ||
*Myoglobinuria | *Myoglobinuria | ||
** | **[[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 | ||
* | *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]]=== | ||
* | *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 | ||
Revision as of 05:39, 10 December 2019
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
- Statins
- Colchicine
- CO Poisoning
- Infection
- Endocrine
- Inflammatory myopathies
- Moderate CK elevations only (rhabdomyolysis only described in case reports)
- Miscellaneous
- Status Asthmaticus
- Toxic shock syndrome
- 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
- 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
- ↑ O'Connor AD et al. Prevalence of Rhabdomyolysis in Sympathomimetic Toxicity: A Comparison of Stimulants. J Med. Toxicol. 2015;11(2)195-200