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Diagnose on Sight: Rhabdomyolysis

A very useful and rapid screening test for rhabdomyolysis is the urinalysis, which will often show large blood but few or no RBCs on microscopy. Both myoglobin and hemoglobin contain heme, which is recognized by the urine dipstick as “blood”; however free myoglobin (from rhabdomyolysis) or free hemoglobin (from hemolysis) do not appear in the urine as RBCs. The test can be done in under 30 minutes and allow for rapid diagnosis and initiation of therapy. Urine myoglobin can also be checked, but has a longer turnaround time. Prompt treatment of the patient with aggressive (1-2L per hour to start) IV crystalloid resuscitation is critical to the management of rhabdomyolysis. I can’t overstate enough…

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Featured

 Recovering from Leg Day: Rhabdomyolysis in the Emergency Department

Much like “golden hour” for trauma, there is a “golden 6 hours” for time to treatment of rhabdomyolysis to prevent the development of severe AKI. The mainstay of management is aggressive IV hydration. Start with at least 1-2 liter boluses of normal saline in the emergency department, depending on the patient’s volume status.

 Rhabdomyolysis - Pediatric EM Morsels

So the child who has had an antecedent “viral” illness who now presents with a limp and you naturally consider joint pathology (ex, toxic synovitis) you should also entertain the potential for Rhabdomyolysis (viral symptoms and LE pain +/- refusing to walk).

 Rhabdomyolysis in the Urgent Care: An Unexpected Case of Myalgias

Rhabdomyolysis has a wide range of presentations, from asymptomatic to life-threatening. The most dramatic presentation can result in acute renal failure, electrolyte imbalances, and/or disseminated intravascular coagulation (DIC). Treatment of rhabdomyolysis includes aggressive fluid administration to prevent renal injury. Most data indicate that acute kidney injury doesn’t increase until the CK level exceeds 5,000 units/L.

 Rhabdomyolysis – Go big or go home

The term rhabdomyolysis comes from the Greek words rhabdo, meaning “rod or spindle like”, myo meaning “muscle”, and lysis “dissolution or destruction”. Rhabdomyolysis is the breakdown of skeletal muscle with the release of its cellular contents into the systemic circulation. The etiologies of skeletal muscle insult leading to rhabdomyolysis are varied and often multifactorial.

 Rhabdomyolysis: Evidence-Based Management in the Emergency Department

There have been few prospective studies or randomized controlled trials to establish a gold standard for the treatment of rhabdomyolysis, and evidence for treatment modalities tends to be sourced from retrospective studies. To some extent, treatment is driven by dogma and tradition.3 A substantial portion of the research upon which clinicians base their management of rhabdomyolysis was published prior to 2000. This creates a somewhat mixed and outdated picture, with no formalized guidelines on standard of care.

Articles of Interest

Episode 150 AKI – A Simple ED Approach

Safe discharge considerations for patients with rhabdomyolysis Patients are likely safe to be discharged home according to our experts if the underlying cause is identified and reversed, their CK is <1000 and down-trending, their creatinine has normalized and the patient is reliable to continue fluids orally at home.

Exertional rhabdomyolysis: clinical features, management, complications and prediction of acute kidney injury

Managing exertional rhabdomyolysis and identifying those at risk of complications is a clinical challenge. It is important to identify the few who will develop AKI without admitting otherwise healthy adults.

Podcast 660: Rhabdomyolysis

Causes include elevated temperature, excessive exercise, toxins, infection, muscle ischemia, crush injury, and prolonged immobilization. Can also be caused by medications, like antipsychotics, statins, SSRIs, colchicine, lithium.

Recognizing Rhabdomyolysis in the ED

Clinical history that may raise suspicion for this illness includes recent immobilization with prolonged muscle compression, increased muscle activity (seizures, drug intoxication, strenuous exercise), electrical/lightning injury, traumatic crush injury, heat stroke and comorbid diseases such as sickle cell, dermatomyositis, and polymyositis.

Rhabdomyolysis CCC

Complications... Hyperkalemia (early). Hypocalcemia (secondary to increased phosphate). Myoglobin release leading to acute renal failure (late). DIC due to release of thromboplastins (rare). Shock, due to “third space” losses from extravasation of fluid from extensively damaged muscle (if severe).

Rhabdomyolysis: A Big Problem with a Big Name

In the transport environment, rhabdomyolysis remains an often underappreciated phenomenon. As a consequence, the causes are treated while the syndrome remains overlooked. It can become challenging to put all of the pieces of the clinical puzzle together, especially in the critical care transport environment.

Rhabdomyolysis: Advances In Diagnosis And Treatment

The evidence for therapeutic measures in rhabdomyolysis is limited. Intravascular volume expansion with crystalloids, with or without urine alkalinization, has been the hallmark of treatment for several decades. While outcome data on specific agents such as acetazolamide, furosemide, mannitol, and even urine alkalinization are still lacking, immediate and rapid volume expansion remain the evidence-based, first-line therapeutic regimen to mitigate adverse complications of rhabdomyolysis.

Rhabdomyolysis—Signs, Symptoms, and Management

There are no definitive criteria for the diagnosis of rhabdomyolysis; however, most clinicians utilize the elevated CK or myoglobin, because it seems the most sensitive marker for muscle breakdown. It is often easiest to use five times the upper limit of normal for the CK level as positive for a diagnosis of rhabdomyolysis (~1,000 IU/L). This is typically true for both adult and pediatric populations. The CK level starts rising about 2–12 hours after the insult occurs, peaks 24–72 hours later, and declines over the next 5–10 days.

Resources

EmCrit

Rhabdomyolysis is extremely difficult to define precisely. Despite decades of research on this disease, there is no single consensus definition! Rhabdomyolysis rarely occurs alone (e.g., it’s usually accompanied with traumatic injuries, shock, or hypoperfusion). This makes it extremely difficult to sort out the independent contribution of rhabdomyolysis to kidney failure. It is generally believed that administration of fluid to flush myoglobin out of the renal tubules is beneficial treatment in rhabdomyolysis. There is probably some truth to this, but unfortunately the concept hasn’t been studied prospectively. Most texts and review articles contain strong recommendations regarding precise volumes of fluid, which are completely arbitrary.

Geeky Medics

IV fluid resuscitation is the most important aspect of management, aiming to reduce the rate of myoglobin precipitation and kidney toxicity.5 Prompt administration of IV fluid alone is often the only specific management required, with the rate adjusted to maintain high urine output.

StatPearls

Rhabdomyolysis is a clinical syndrome characterized by skeletal muscle breakdown and the release of intracellular components such as myoglobin, creatine phosphokinase (CPK), electrolytes, and sarcoplasmic proteins into the bloodstream. This process can lead to systemic complications, including acute kidney injury (AKI), electrolyte disturbances, and disseminated intravascular coagulation.