Rhabdomyolysis is a condition characterized by the breakdown of striated muscle, leading to the release of intracellular contents into circulation, which can cause acute kidney injury and be life-threatening. It commonly arises from muscular trauma, with symptoms such as limb weakness, myalgia, swelling, and tea-colored urine. Management involves aggressive hydration, monitoring electrolytes, and possibly alkalinization and dialysis in severe cases.

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.