Rhabdomyolysis is a clinical syndrome resulting from skeletal muscle necrosis and the release of intracellular contents into circulation. Common causes in adults include trauma, excessive muscular activity, genetic disorders, infections, drugs/medications, and ischemic injury. Alcohol and drugs are associated with up to 80% of cases in adults. Clinical presentation includes muscle pain and weakness. Diagnosis is based on a significant elevation of creatine kinase levels in blood. Left untreated, rhabdomyolysis can lead to kidney injury or failure.

1. RHABDOMYOLYSIS IN ED
Dr. Xenia Klein
Rabin Medical Center,
Campus Beilinson

3. DEFINITION
 Rhabdomyolysis is a clinical and biochemical
syndrome that results from acute necrosis of
skeletal muscle fibers and the leakage of
cellular contents into the circulation.

6. COMMON CAUSES OF RHABDOMYOLYSIS IN ADULTS
 Trauma:
Crush injury and electrical or lightning injury
 Enviromental and excessive muscular activity:
Contact sports, delirium tremens, seizures, heat stroke,
psychosis, training, dystonia
 Genetic disorders:
Glycolysis and glycogenolysis disorders
Fatty acid oxidation disorders
Mitochondrial and respiratory chain metabolism
disorders

7. DRUGS:
Medications
Antypsychotics Neuroleptics
Barbiturates MAO inhibotors
Benzodiazepines Tricyclic
Lithium Narcotics
Clofibrate Statins
Phenothyazines Salicylates
Colchicine Corticosteroides
Isoniazide Zydovudine
SSRI Theophylline
+ Almost all drugs of abuse.

8. INFECTIONS
 Bacterial
Clostridium, Legionella*, Salmonella, Shigella, GABHS, S.
aureus, S. pneumoniae.
 Viral
Coxsackievirus, CMV, EBV, Enterovirus, Hepatitis, HSV, HIV,
Rotavirus, Influenza A,B*.

9.  Immunologic diseases involving muscle
Dermatomuositis
Polymyositis
 Ischemic injury
Compartment syndrome
Compression

10. EPIDEMIOLOGY
 Alcohol and drugs are thought to play a role in up to
80% of cases of rhabdomyolysis in adults.
 USA: The National Hospital Discharge Survey reports
26,000 cases annually.
 Rhabdomyolysis is found in 24% of adult patients who
present to emergency departments (EDs) with cocaine-
related conditions.
 The incidence of myoglobin-induced acute kidney injury
in adult rhabdomyolysis ranges from 17-35%.
 Mortality about 5%.
 About 30% of patients need RRT

12.  Rhabdomyolysis is a syndrome characterized by injury to
skeletal muscle with subsequent effects from the release of
intracellular contents. These contents include myoglobin,
CK, aldolase, lactate dehydrogenase, aspartate
aminotransferase, and potassium. Although numerous
causes of rhabdomyolysis have been described, the
common terminal event appears to involve the disruption of
the Na+K+ATPase pump and calcium transport, which
results in increased intracellular calcium and subsequent
muscle cell necrosis. In addition, calcium activates
phospholipase A2 and various vasoactive molecules and
proteases, and induces the production of free oxygen
radicals.

13. CLINICAL PRESENTATION

16. CPK
 Most investigators consider a fivefold or
greater increase above the upper threshold
of normal in serum CK level, in the absence
of cardiac or brain injury, as the requirement
for the diagnosis of rhabdomyolysis. In
general, serum CK level begins to rise
approximately 2 to 12 hours after the onset of
muscle injury, peaks within 24 to 72 hours, and
then declines at the relatively constant rate of
39% of the previous day's value. Ongoing
muscle necrosis should be suspected in
patients with elevated values that fail to
decrease in this manner.