RhabdomyolysisBishan Rajapakse – ED RegistrarWollongong Hospital ED Reg teaching - 3/10/12                               I...
Rhabdomyolysis - Overview   Rhabdomyolysis in ACEM fellowship    curriculum   Clinical Case – „teaser‟   “Rhabdo facts”...
ACEM fellowship syllabus                           7-10% of                           ARF is 2˚ to                        ...
Case 1 – „Young crush‟   26yo male   Crush injury to R arm, 4x4 rolled back onto R arm    whilst under car       Poster...
What do you think?   Is Rhabdomyolysis present?     How do we make the diagnosis?     What are the key features?   If ...
Progress   2nd CK 4 hours later       CK 2,353 U/L   Admitted under trauma surgery       Aggressive fluids, good UO  ...
Rhabdomyolysis     Rhabdmyolysis = „destruction of striated muscle‟          Muscle breakdown and necrosis, Leaking of i...
Rhabdomyolysis - epidemiology   Seen in 85% of patients with traumatic injury   Common in Earthquakes   Acute Kidney in...
Categories of cause   Physical       Trauma (Crush syndrome)       Exertion (strenuous exercise, siezure, AWS)       M...
Clinical Illustrations   Dengue viral myositis     17 yo boy, fever and myalgia     Day 4 developed oliguria, CK 60,000...
Pathophysiology   Method (and mechanism) of cellular    destruction     Direct injury to cell membrane (crushing,      t...
PathophysiologyHuerta-Alardin A, Varon J, Marik P. Bench-to-bedside review: Rhabdomyolysis -- an overview forclinicians. C...
How does Myoglobin causeARF?       Myoglobin                     Perutz (Hb), Kendrick                     (Myoglobin)    ...
Myoglobinuric ARF                                    Pigmented Cast                                                       ...
The New England journal of medicine. 2009;361(19571284):62-
Investigations   CK levels       >5000 U/L related to ARF (norm 45-260)       Rises within 12 hrs, peak 1-3 days, decli...
Urinalysis
Management   Advance Life Support   Aggressive fluid therapy                              Commonly used but controversia...
Case 3 – Could it be renal colic   65 year-old male presenting with right-sided    flank pain radiating to the groin. The...
CT scan   -Right sided retro peritoneal   blood                           Patient went for                                ...
Routine post op biochemistry  • increased urea and creatinine (with urea-to-creatinineratio)  •hyperphosphataemia, hypoca...
Rhabdomyolysis - treatment   aggressively correct hypovolaemia       Target UO 2-3ml/kg/hr   Monitor K closely and trea...
Hyperkalaemia (>5.5) inRhabdo   Check K every 4 hours when CK>60,000        Treat hyperkalaemia aggressively        ECG...
Summary   Rhabdomyolysis – muslce necrosis     Limb weakness, myalgia, swelling and tea      coloured urine       Can b...
References/Acknowledgements   Critical Care       Huerta-Alardin A, Varon J, Marik P. Bench-to-bedside review: Rhabdomyo...
Wollongong ED RegFacebookgroup                   Look it‟s a site just for us!                     Please join up today!  ...
And don‟t forget “Free EM talks –rock!!”  (http://freeemergencytalks.net/2010/04/gary-gaddis-rhabdomyolysis-and-  compartm...
Discussion:…..Time for your thoughts!
Extra slides
BUN : Cr Ratio                                                        BUN: Cr ratio is low in                             ...
Mannitol& Loop diuretics??   Limited evidence for      Diuretics preventing acute kidney injury      Diuretics decreasi...
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Rhabdomyolysis -Registar teaching (9-10-12)b

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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

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  • 85% in patients with traumatic injury NEJM (Acute Kidney injury ranges from 13-50%, or 10-50%)Earthquates
  • Max Perutz, Jon Kendrick
  • 3 main mechanisms influencing haem protein toxicity
  • Carbonic anydrase 3
  • aggressively correct hypovolaemia (a common problem due to sequestration of fluid in muscle)alternate each litre of saline with 1L litre of D5W plus 100mmol of bicarbonate if the urine pH is less than 6.5 (they suggest abandoning urinary alkalinisation if the urine pH does not rise after 4-6 hours of treatment or if symptomatic hypocalaemia develops)
  • Likely to indicateLow in Rhabdo
  • Rhabdomyolysis -Registar teaching (9-10-12)b

    1. 1. RhabdomyolysisBishan Rajapakse – ED RegistrarWollongong Hospital ED Reg teaching - 3/10/12 Image courtesy of Dr Carl Oller
    2. 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. 3. ACEM fellowship syllabus 7-10% of ARF is 2˚ to Rhabdo
    4. 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. 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. 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. 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 benefitHuerta-Alardin A, Varon J, Marik P. Bench-to-bedside review: Rhabdomyolysis -- an overview forclinicians. Critical Care. 2005;9(15774072):158-169.
    8. 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. 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. 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 RhabdomyolyisSunderalingam et al “Dengue viral myositis complicated with rhabdomyolyis andsuper infection of methicillin resistant Staphylococcus aureus” awaitingpublication Young male, heroin OD  Elevated CK, Hyperkalaemia, Hypocalcaemia,
    11. 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. 12. PathophysiologyHuerta-Alardin A, Varon J, Marik P. Bench-to-bedside review: Rhabdomyolysis -- an overview forclinicians. Critical Care. 2005;9(15774072):158-169.
    13. 13. How does Myoglobin causeARF? Myoglobin Perutz (Hb), Kendrick (Myoglobin) Haemoglobin
    14. 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 obstructionhave minimal nephrotoxic effects”
    15. 15. The New England journal of medicine. 2009;361(19571284):62-
    16. 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. 17. Urinalysis
    18. 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. 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. 20. CT scan -Right sided retro peritoneal blood Patient went for emergency AAA - AAA repair
    21. 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. 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/LBosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. The NewEngland journal of medicine. 2009;361(19571284):62-72.
    23. 23. Hyperkalaemia (>5.5) inRhabdo 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. 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. 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. 26. Wollongong ED RegFacebookgroup 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. 27. And don‟t forget “Free EM talks –rock!!” (http://freeemergencytalks.net/2010/04/gary-gaddis-rhabdomyolysis-and- compartment-syndrome/)
    28. 28. Discussion:…..Time for your thoughts!
    29. 29. Extra slides
    30. 30. BUN : Cr Ratio BUN: Cr ratio is low in Rhabdomyolysis http://en.wikipedia.org/wiki/BUN-to-creatinine_ratio
    31. 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 RhabdomyolysisGary 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.

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