An overview of the management of Rhabdomyolysis, put together for the weekly Emergency Medicine registrar teaching session at Wollongong Hospital ED. Information in the presentation is from both the journals and medicine 2.0 (and in particular "FOAMed" -the free open access medical education network that aims to improve sharing of medical education resources through the web). Enjoy. @trainthetrainer

1. Rhabdomyolysis
Bishan Rajapakse – ED Registrar
Wollongong Hospital ED Reg teaching - 3/10/12
Image courtesy of Dr Carl Oller

2. Rhabdomyolysis - Overview
 Rhabdomyolysis in ACEM fellowship
curriculum
 Clinical Case – „teaser‟
 “Rhabdo facts”
 Epidemiology, causes, pathophys&management
 Clinical Cases – „pleaser‟
 Discussion
 Summary – take home points

3. ACEM fellowship syllabus
7-10% of
ARF is 2˚ to
Rhabdo

4. Case 1 – „Young crush‟
 26yo male
 Crush injury to R arm, 4x4 rolled back onto R arm
whilst under car
 Posterior compartment R Arm bruised and swollen
 Numbness and paraesthesia
 Suspected brachial plexus, CT Neck unremarkable
 Labs results in resus(16/9/12 19:36)
 Ph 6.92, Lactate 21, Cr 96
 CK 419
 Urine dipstick –
 Haematuria ++
 Urine myoglobinuria not ordered

5. What do you think?
 Is Rhabdomyolysis present?
 How do we make the diagnosis?
 What are the key features?
 If it is Rhabdomyolysis?
 What is the management?
 What are his risks of ARF & death?

6. Progress
 2nd CK 4 hours later
 CK 2,353 U/L
 Admitted under trauma surgery
 Aggressive fluids, good UO
 Serial CKs
 17/9/12
 03:11 – 3,999 U/L
 06:00 – 4,604 U/L
 14:30 – 6,275 U/L, Na 142, K 4.2, Ur 5.4, Cr 96
 Pain and paraesthesia improving day 2
 Patient discharged against medical advice!!

7. Rhabdomyolysis
 Rhabdmyolysis = „destruction of striated muscle‟
 Muscle breakdown and necrosis, Leaking of intracellular constituents into
Circulation & ECF
 Severity
 Ranges from Asymptomatic illness (with mild  CK) to life threatening condition
 extreme CK, Electrolyte imbalances, ARF & DIC
 Causes
 Most commonly – muscular trauma
 Less commonly – muscle enzyme deficiencies, electrolyte abnormalities
 Presentation
 Limb weakness, myalgia, swelling and tea coloured urine
 Commonly assoc with myoglobinuria, if severe can cause ARF
 Investigations - CK >5,000 indicates serious muscle injury
 Management
 ALS (airway breathing & circulation)
 Followed by measures to preserve renal function=vigorous hydration
 Use of alkalysing agents and osmotic diuretic – common by unproven benefit
Huerta-Alardin A, Varon J, Marik P. Bench-to-bedside review: Rhabdomyolysis -- an overview for
clinicians. Critical Care. 2005;9(15774072):158-169.

8. Rhabdomyolysis - epidemiology
 Seen in 85% of patients with traumatic injury
 Common in Earthquakes
 Acute Kidney injury in 10-50%
 7-80% mortality
 Outcome generally good, but…
 Co-existing valculopathy – mortality 32%
 In ICU patients – 22% mortality if RF absent, 59%
if RF present

9. Categories of cause
 Physical
 Trauma (Crush syndrome)
 Exertion (strenuous exercise, siezure, AWS)
 Muscle hypoxia (limb compression, prolonged immobilisation or
LOC, major artery occlusion)
 Non Physical
 Genetic defects (glycolysis or glyconeogenesis)
 Infections (legionella, malaria, herpes)
 Body temp changes
 Metabolic and electrolyte disorders (Na,K)
 Drugs and toxins (cocaine, statins)
 Endocrine/Autoimmune causes (polymyositis)
 Idiopathic

10. Clinical Illustrations
 Dengue viral myositis
 17 yo boy, fever and myalgia
 Day 4 developed oliguria, CK 60,000 (rpt 90,000)
 Reduced Calcium, elevated Phospate
 Oliguria and refractory hypotension – leading to
death
 Viral infections Rhabdomyolyis
Sunderalingam et al “Dengue viral myositis complicated with rhabdomyolyis and
super infection of methicillin resistant Staphylococcus aureus” awaiting
publication
 Young male, heroin OD
 Elevated CK, Hyperkalaemia, Hypocalcaemia,

11. Pathophysiology
 Method (and mechanism) of cellular
destruction
 Direct injury to cell membrane (crushing,
tearing, dissolving)
 Muscle cell hypoxialeading to depletion ATP
(Anaerobic conditions, shock states, vascular
occlusion and tissue compression)
 Electrolyte disturbance disrupting the Na/K pump (K
:vomiting diarrhoea, extensive diuresis, Na:
water intoxication)

12. Pathophysiology
Huerta-Alardin A, Varon J, Marik P. Bench-to-bedside review: Rhabdomyolysis -- an overview for
clinicians. Critical Care. 2005;9(15774072):158-169.

13. How does Myoglobin cause
ARF?
Myoglobin
Perutz (Hb), Kendrick
(Myoglobin)
Haemoglobin

14. Myoglobinuric ARF Pigmented Cast
formation
Cast formation
2 Cruicial Factors enhanced by
-Hypovolaemia/dehydration urine Ph
-Aciduria
ARF
Haem protein toxicity
-Renal vasoconstriction
-Diminished renal circulation
-Intraluminal cast formation &
direct haem protein-induced
cytotoxicity
It is suggested that
ARF is caused by
“in absence of hypovolaemia&aciduriaheme proteins tubular obstruction
have minimal nephrotoxic effects”

15. The New England journal of medicine. 2009;361(19571284):62-

16. Investigations
 CK levels
 >5000 U/L related to ARF (norm 45-260)
 Rises within 12 hrs, peak 1-3 days, declines 3-5days post muscle injury
 After peak drops by 40% per day (T ½ 1.5d)
 Myoglobinuria
 Urine dipstick positive for “blood” no red bood cells in urine sediment
 Electrolytes
 K+, PO4, Uric acid, LDH, ALT, AST, carbonic anhydrase III
 Ca++, (initially low as moves into cells, may increase later)
 Coagulation studies
 DIC may develop
 Tox screen
 Etoh commonly associated with diagnosis
 Heroin and other illicit drugs

17. Urinalysis

18. Management
 Advance Life Support
 Aggressive fluid therapy
Commonly used but controversial
 Urinary Alkalinisation -Little clinical evidence
 +/-Mannitol -Rationale “preserving urine flow
 Follow up CK and Electrolytes may reduce damage”
in ARF
 If suspect ARF -Useful if become fluid overloaded
whilst being treated for
 Cardiac monitoring Rhabdomyolysis
 Dialysis if necessary

19. Case 3 – Could it be renal colic
 65 year-old male presenting with right-sided
flank pain radiating to the groin. The following
CT scan was taken to confirm a
presumed diagnosis of renal colic:
http://lifeinthefastlane.com/2009/12/renal-riddle-001/

20. CT scan
-Right sided retro peritoneal
blood Patient went for
emergency AAA
- AAA repair

21. Routine post op biochemistry
• increased urea and creatinine (with urea-to-creatinineratio)
•hyperphosphataemia, hypocalcaemia, hyperkalaemia
• increased CK (usually to greater than 40,000)
http://lifeinthefastlane.com/2009/12/renal-riddle-001/

22. Rhabdomyolysis - treatment
 aggressively correct hypovolaemia
 Target UO 2-3ml/kg/hr
 Monitor K closely and treat hypokalaemia
 Alternate N/Saline with 1L litre of D5W
 Avoid K & lactate containing solutions
 100mmol of HCO3 if urine pH <6.5
 “Consider” mannitol, up to 200g/day, not > 800g
total dose.
 Consider haemodyalysis if resistant hyperkalemia
of more than 6.5mmol/L
Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. The New
England journal of medicine. 2009;361(19571284):62-72.

23. Hyperkalaemia (>5.5) in
Rhabdo
 Check K every 4 hours when CK>60,000
 Treat hyperkalaemia aggressively
 ECG
 CaCl or CaGluconate
 Consider cardiac monitoring if K>6
 Check plasma Calcium (aggravates hyperK)
 K>6
 1) Insulin and glucose, Salbutamol,
 2) NaHCO3 if acidaemia (may worsen HypoCa, not efficacious as
no1 above)
 Optional - Remove potassium
 Resins (sodium polystyrene sulfonate)
 Haemodialysis
 Loop diuretics (only once fluid level has been expanded
The New England journal of medicine. 2009;361(19571284):62-72.

24. Summary
 Rhabdomyolysis – muslce necrosis
 Limb weakness, myalgia, swelling and tea
coloured urine
 Can be life threatening, common cause of ARF (7-10%)
 Multiple causes – Physical and Non Physical
 Most commonly crush injury & immobility
 Can be drugs, tox
 CK rise >5,000
 Rx – Vigorous hydration – protect kidneys
 Monitor electrolytes & correct hyperkalaemia
 Alkalinisation if Urine ph<6.5, Mannitol if fluid overload

25. References/Acknowledgements
 Critical Care
 Huerta-Alardin A, Varon J, Marik P. Bench-to-bedside review: Rhabdomyolysis -- an
overview for clinicians. Critical Care. 2005;9(15774072):158-169.
 NEJM
 Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. The New
England journal of medicine. 2009;361(19571284):62-72.
 LTFL
 Paul Young (Intensivist Wellington, NZ) http://lifeinthefastlane.com/2009/12/renal-riddle-
001/
 Free EM talks (Joe Lex)
 Garry Gaddis (Orthopaedic Surgeon) – talk “Rabdomyolysis& compartment syndrome” Cancun
Trauma conference 2008 (http://freeemergencytalks.net/2010/04/gary-gaddis-rhabdomyolysis-and-
compartment-syndrome/)
 Personal discussion/case reports unpublished data
 Darren Roberts (Clinical Pharm and Tox, UK)
 VinothanSunderalingam (Physician Trainee, Sri Lanka)
 Jorge Sesperz (Trauma researcher)

26. Wollongong ED RegFacebook
group
Look it‟s a site just for us!
Please join up today!
http://www.facebook.com/gr
oups/131728460307304/
And do start commenting –
remember – it‟s only “us”

27. And don‟t forget “Free EM talks –
rock!!”
(http://freeemergencytalks.net/2010/04/gary-gaddis-rhabdomyolysis-and-
compartment-syndrome/)

28. Discussion:
…..Time for your thoughts!

29. Extra slides

30. BUN : Cr Ratio
BUN: Cr ratio is low in
Rhabdomyolysis
http://en.wikipedia.org/wiki/BUN-to-creatinine_ratio

31. Mannitol& Loop diuretics??
 Limited evidence for
 Diuretics preventing acute kidney injury
 Diuretics decreasing Mortality
 Diuretics are useful if become fluid overloaded
whilst being treated for Rhabdomyolysis
Gary Gaddis MD, Orthopaedist “Rhabdomyolysis& Compartment Syndrome
Talk at Orthopaedic Emergencies and Trauma (Cancun 2008)
Pod cast from Joe Lex @ http://freeemergencytalks.net/
Huerta-Alardin A, Varon J, Marik P. Bench-to-bedside review: Rhabdomyolysis --
an overview for clinicians. Critical Care. 2005;9(15774072):158-169.