Rhabdomyolysis
The Resus Room
Simon Laing
4.8 • 678 Ratings
🗓️ 21 February 2017
⏱️ 12 minutes
🧾️ Download transcript
Summary
Think of rhabdomyolysis and you'll think of an elevated creatine kinase (CK). The condition ranges from an asymptomatic period to a life-threatening condition with a hugely associated rise in CK which can also be accompanied by electrolyte disturbance, renal failure and disseminated intravascular coagulation.
Rhabdomyolysis is caused by a breakdown in skeletal muscle and occurs most commonly following trauma, very often that can be due to a 'long-lie' when a patient is unable to get off a floor until help arrives after a prolonged period. There are other causes including drugs, muscle enzyme deficiencies, electrolyte abnormalities and more.
The presentation itself is pretty vague and suspicion of the disease needs to be pretty high. Patients can experience weakness, myalgia and the dark'coca-cola urine', the diagnosis is then confirmed with a serum elevation in CK.
The big concern with Rhabdomyolysis is the hit the kidneys take. Acute kidney injury is due to the heme pigment that is released from myoglobin and haemoglobin and is nephrotoxic. Early aggressive fluid rehydration aims to minimise ischaemic injury, increase urinary flow rates and thus limit intratubular cast formation. Fluids also help eliminate excess K+ that may be associated. But have a think about the management in your ED, how high does that CK need to be to require i.v. fluids and admission to hospital?
Here's a few facts we need to know:
- Normal CK enzyme levels are 45–260 U/l.
- CK rises in rhabdomyolysis within 12hours of the onset of muscle injury
- CK levels peak at 1–3 days, and declines 3–5 days after muscle injury
- The peak CK level may be predictive of the development of renal failure
- A CK level of 5000 U/l or greater is related to renal failure
- Optimal fluid rate administration is unclear, some papers suggest replacement of isotonic saline at rates of 1-2L per hour. , adjusted to 200-300mL per hour to maintain a diuresis.
- Attention needs to be paid to urine output serum markers and fluid status.
A lot of the evidence and knowledge surrounding rhabdomyolysis is from humanitarian disasters; earthquakes, terrorism along with observational cohorts, but at the end of the day we need to work with what we've got.
Have a listen to the podcast and see what you think, the application of the evidence base may change your practice.
Enjoy!
References
Creatine kinase MB isoenzyme in dermatomyositis: a noncardiac source. Larca LJ. Ann Intern Med. 1981
Transcript
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| 0:00.0 | Welcome to the Recess Room podcast. |
| 0:03.9 | Five, four, three, two, one, fire. |
| 0:12.3 | So hi, and welcome back to the Recess Room podcast. I'm Simon Lang. |
| 0:16.4 | And I'm Rob Fenwick. |
| 0:17.8 | And today we're going to be talking about rhabdomyalysis. |
| 0:22.0 | Rabdo what am Ilysis? |
| 0:23.4 | No, I do know. |
| 0:24.1 | I do. |
| 0:24.6 | So big thanks before we start to our sponsors, Abpract, for making this all possible. |
| 0:29.2 | Right. |
| 0:29.9 | So this is actually a really important topic to think about. |
| 0:34.4 | And it's important because if you've got a real understanding of rhabdomyelysis, |
| 0:38.7 | it's probably going to make a difference to how you treat patients and also to the number |
| 0:43.1 | of patients that actually need to come into hospital. But I'll reveal that little secret a little bit |
| 0:48.2 | later when we get into it. So before we get started, Simon, just tell us again and remind us what exactly is |
| 0:56.3 | rhabdomyalysis. So you think of rabdomyalysis and you'll think of an elevated creatine |
| 1:01.3 | kines or k. So the condition ranges from an asymptomatic period to a hugely significant, |
| 1:09.4 | life-threatening condition which has a huge associated rise in |
| 1:13.6 | CK. It can be accompanied by some nasty stuff like electrolyte disturbance, renal failure and DIC. |
| 1:21.5 | Okay, so it is caused, as you probably know, by a breakdown in skeletal muscle and occurs most frequently following trauma, |
| 1:30.2 | although there are loads and loads of other causes, which includes the flight drugs, muscle |
| 1:35.3 | enzyme deficiencies, electrolyte abnormalities, and the list goes on and on and on. |
... |
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