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Definition of Rhabdomyolysis Rhabdomyolysis is a condition or syndrome of skeletal muscle breakdown with release of myocyte contents into the circulation which may arise from a variety of stresses that cause injury to muscle tissue. It is characterized by laboratory findings of myonecrosis with clinical spectrum dependent upon amount of muscle injury and associated comorbid factors.
Definition of Exertional Rhabdomyolysis " Exertional rhabdomyolysis " is the term applied to rhabdomyolysis arising from exercise or exertion. It is most frequently ascribed to running activity and often associated with exertional heat illness (heat stroke). However any extreme muscle overload activity may precipitate rhabdomyolysis . It is a spectrum illness ranging from insignificant asymptomatic muscle injury with minor laboratory alterations to fulminant immediate life threatening syndrome with severe metabolic alterations and cardiac dysrythmias.
Subclinical rhabdo common in vigorous exercisers and collision sports
(how common ?)
More serious cases seen in endurance athletes and military personnel
May be low initially or falsely high in asymptomatic patient
Greater than 5 times normal is considered + …maybe!
> 16,000 U/L (renal damage)
+ dipstick for blood. But no RBC’s on micro exam
AST/ALT/LDH: marker for more severe muscle damage in exertional rhabdo; and for liver injury when exertional and heat related
Chem 7, Phos, Calcium, ABG
Uric acid: sensitive but not specific; normal is somewhat reassuring
Toxic effects on distal tubule
Sludging and obstruction with renal failure; “muddy casts”
Dehydration worsens toxic effects on kidneys
Load and duration of exposure = toxicity
Urine frothy when agitated
Making the Diagnosis
Compartment pressure testing
Nuclear medicine scan for limited rhabdo
Muscle biopsy: not acutely
Severe, recurrent, or unusual precipitators
Muscle enzyme or neuromuscular disease
Special stains and techniques (specialty center is best)
Making the Diagnosis
Ischemic Forearm Test
Forearm exercise with BP cuff inflated > 200 mm Hg
Serial lactate and ammonia levels from antecubital vein
Muscle enzyme deficiencies
Low lactate production = disorder of carbo metabolism (McArdle’s)
Low ammonia production = myoadenylate deficiency
Normal rise in ammonia and lactate = disorder of lipid metabolism
Guillan-Barre Syndrome (post viral)
Periodic Paralysis (follows sleep or rest)
Intrinisic renal disease
Beets, phenytoin, rifampin, vitamin B 12
Algorithm for Treatment of Acute Exertional Rhabdomyolosis Service-member presents with severe muscle pain Screen with spot UA for blood, visualize color of urine Heat stroke panel * Screen for compartment syndrome (Also follow Exertional Heat Injury Algorithm) CPK > 5X nl Or Positive urine dipstick- blood (YES) (BOTH NO) Limited indoor duty for remainder of day Medical re-evaluation on following day Home oral re-hydration ACUTE EXERTIONAL RHABDOMYOLYSIS -Admit to ICU -Urine myoglobin, serum calcium, phosphate, uric acid -ABG if lactic acidosis suspected -Foley catheter -IV hydration with NS to maintain urine output >200cc/hr (consider mannitol or furosemide) - Monitor for development of compartment syndrome Positive urine myoglobin OR Metabolic acidosis Alkalinize urine if lactate <4 or pH < 7.2: * Moderate: Add 1 amp bicarb to 1 bag ½ NS Severe: Add 2 amps bicarb to 1 bag ¼ NS *D/C when myoglobin negative or pH>7.2 Hyperkalemia D50 -Insulin -Inhaled B -agonist Phos > 7mg/dl Or SYMPTOMATIC hypocalcemia Or Acute Renal Failure Or Refractory hyperkalemia Consult nephrologist for possible dialysis Uric acid Consider uricosuric agents
Questions: Prognosis, Return to Duty, Medical Board ?
23 year old African American E-3 with exertional rhabdo after 12 mile road march
CPK peaked at 20,000
Sickle trait positive
Fully recovered after 7 days with no sequelae, now what?
What are the chances that this will happen again? Further eval needed?