#EMConf: Rhabdomyolysis
General: Skeletal muscle breakdown with release of intracellular contents.
Classic Triad: Myalgias + muscle weakness + myoglobinuria; present in 10% of cases.
Gold Standard for Diagnosis --> CK --> generally accepted 5x the upper limit of normal (>1000 U/L).
Complications: Acute Renal Failure + Electrolyte abnormalities/ Cardiac arrhythmias + Compartment syndrome.
-Electrolyte Abnormalities - Hyperkalemia + Hypocalcemia (may be followed by rebound hypercalcemia) + Hyperuricemia + Hyperphosphatemia
Treatment:
-Aggressive IV Fluids - normal saline is recommended ~ 1.5L/hr and titrated to urine output (200-300 cc/h)
-Monitor for signs of AKI and EKG for cardiac changes from electrolyte abnormalities.
-Monitor for treatment of hyperkalemia - may be refractor to traditional treatments and may require dialysis
-if patient requires intubation, avoid succinylcholine.
-do not correct early hypocalcemia unless there are signs of cardiac instability (rebound hypercalcemia)
-consider bicarbonate - controversial, no RCT demonstrated beneift; little evidence to support its use but some retrospective studies suggest it may decrease rates of AKI especially if peak CKs > 10,000 U/L.
-consider mannitol - controversial, no RCT demonstrated benefit.
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Take Home Points
CK for diagnosis, levels > 5x upper limit of normal (~1000 U/L)
Monitor for AKI, treat with aggressive fluids, titrate to urine output
Traditional treatments of hyperkalemia may not work, consider dialysis
Don’t correct hypocalcemia unless signs of cardiac instability or severe hyperkalemia
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References:
1. Cervellin G, Comelli I, Benatti M, Sanchis-Gomar F, Bassi A, Lippi G. Non-traumatic rhabdomyolysis: Background, laboratory features, and acute clinical management. Clin Biochem. 2017;50(12):656-662.
2. Chavez LO, Leon M, Einav S, Varon J. Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice. Crit Care. 2016;20(1):135.
3. Nielsen JS, Sally M, Mullins RJ, et al. Bicarbonate and mannitol treatment for traumatic rhabdomyolysis revisited. Am J Surg. 2017;213(1):73-79.
4. Wang S, Zhang C, Li J, et al. Erythropoietin protects against rhabdomyolysis-induced acute kidney injury by modulating macrophage polarization. Cell Death Dis. 2017;8(4):e2725.