Rhabdomyolysis is a syndrome characterized by muscle necrosis and the release of intracellular muscle constituents into circulation. Common causes include drugs, medications, muscle diseases, trauma, infections, strenuous activity, and heat illness. Clinical manifestations range from asymptomatic enzyme elevations to life-threatening illness. Diagnosis is based on elevated creatine kinase levels and management focuses on aggressive IV fluid resuscitation to prevent acute kidney injury from electrolyte abnormalities that can result.

1. RHABDOMYOLYSIS
DR JAMSHEER V T MBBS MS MCh
SURGICAL ONCOLOGY

2. • Syndrome Characterized By Muscle Necrosis
And The Release Of Intracellular Muscle
Constituents Into The Circulation.

3. COMMON CAUSES
• Drugs Of Abuse And Alcohol
• Medications
• Muscle Diseases
• Trauma
• Neuroleptic Malignant Syndrome
• Seizures
• Immobility
• Infection
• Strenuous Physical Activity
• Heat-related Illness

4. CHILDREN
• Viral Myositis
• Trauma
• Connective Tissue Disease.
• Inherited Metabolic Disorders

5. DRUGS
• Cyclosporine
• Macrolide Antibiotics
• Warfarin
• Digoxin
• Statin Therapy

6. CLINICAL MANIFESTATIONS
• Asymptomatic elevations of Enzymes to Life-
threatening disease
• Creatine Kinase (CK)
• Most are nonspecific

7. TRIAD(1-10%)
• Myalgias
• Muscle weakness
• Red to brown urine

8. Muscle
• Pain - Thighs And Shoulders, and in the Lower
back and Calves
• Weakness –(12 - 70 %)
• Swelling –(8 to 52%) fluid repletion:

9. Urine
• Red to brown / Tea-colored /cola-colored
• 100 to 300 mg/Dl
• Orthotolidine/ dipstick - Only 0.5 to 1 mg/Dl

10. OTHER
Skin — discoloration / blisters
Systemic
• Malaise
• Fever
• Tachycardia
• Nausea & Vomiting
• Abdominal Pain

11. Fluid And Electrolyte Abnormalities
●Hypovolemia results from "third-spacing“
●Hyperkalemia and hyperphosphatemia
●Hypocalcemia
●Severe hyperuricemia
●Metabolic acidosis.

12. COMPARTMENT SYNDROME
• Excessive Fluid resuscitation
• Traumatic (eg, tibial fractures)
• Nontraumatic (eg, prolonged limb
compression)

13. DISSEMINATED INTRAVASCULAR COAGULATION
• Release of thromboplastin and other
prothrombotic substances

14. Other Organ Involvement
●Liver injury – Liver dysfunction, typically
reversible, occurs in up to 25 percent.
●Neurologic – Altered mental status due to
toxins, drugs, trauma
●Pulmonary – Respiratory failure or ARDS

15. History And Examination
●Recent trauma
●Prescription medications with attention to
myotoxic agents
●Alcohol and/or substance abuse
●Prolonged immobilization
●Strenuous or unaccustomed physical exertion or
exercise
●Heat exposure or hyperthermia of any cause
●History of myopathy or muscular dystrophy
●Prior episodes of rhabdomyolysis
●Electrocution/ Burn injury
●Convulsive seizure

16. Examination
• Including muscle weakness
• Tenderness
• Limb edema
• Evidence of trauma
• Compartment syndrome

17. MANAGEMENT
• INVESTIGATION
• TREATMENT

18. Initial laboratory studies
●CBC P.Smear for infection or hemolysis
● Urinalysis
●RFT
●Routine electrolytes plus calcium and
phosphate, for hyperkalemia, hypocalcemia,
and hyperphosphatemia
●Liver function tests

19. ● PT, aPTT ,D-dimer, and fibrinogen, for DIC
●ABG for metabolic acidosis
●Serum albumin
●ECG for cardiac dysrhythmias secondary to
hyperkalemia and hypocalcemia

20. Creatine Kinase Elevation
The standard biomarker
• Rise within 2 to 12 hours
• Maximum within 24 to 72 hours
• A decline within 3-5 days
NOT DECLINE AS EXPECTED
• Continued muscle injury
• Underlying muscle disease
• Compartment syndrome may be present

21. • Five times the upper limit of normal
• Range from approximately 1500 to over
100,000 units/L.
• Malignant Hyperthermia avg value 60,000
units/L.

22. PREHOSPITAL CARE
• Early and vigorous IV fluid resuscitation is the
most important treatment to prevent AKI
• Avoid potassium- or lactate-containing
solutions
• Preferred fluid is iv ns

23. EMERGENCY DEPARTMENT CARE
• Proper history
• Ask for co morbidities / medications
• Vitals
• ECG monitoring
• Catheterisation
• Basic investigation including electrolytes

24. • Continue aggressive IV rehydration.
• IV crystalloids infusion of 4 ml/kg/h
• Goal of maintaining a minimum urine output
of 200 to 300 ml/ hour.

25. • No Ideal fluid
• Urine alkalinization (sodium bicarbonate)
• Forced diuresis (mannitol or loop diuretics)
• CK >10000...Mannitol& Bicarbonates

26. • Hypocalcemia – no treatment needed
• IV-Calcium - hyperkalemia-induced
cardiotoxicity
Hyperkalemia
• Insulin - glucose therapy may not be effective.
• The use of ion-exchange resins (e.g., sodium
polystyrene sulfonate) may be effective.

27. • hyperphosphatemia - oral phosphate binders
when serum levels are >7 milligrams/Dl
• Avoid prostaglandin inhibitors such as NSAIDs
because of their vasoconstrictive effects on
the kidney.
• Treat the underlying cause