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Rhabdomyolysis in adults: Rapid overview of emergency management

Rhabdomyolysis in adults: Rapid overview of emergency management
Clinical features
  • Classic triad: Muscle pain, weakness, and dark urine (triad seen in <10% of cases)
  • Muscle swelling, tenderness, firm compartments
  • Systemic (mainly in severe cases): Malaise, fever, tachycardia, nausea, vomiting, abdominal pain
  • Symptoms may be vague or absent in many patients
  • Potential complications: Fluid and electrolyte abnormalities (eg, hyperkalemia, hypocalcemia, hyperphosphatemia, hyperuricemia), acute kidney injury, liver injury, disseminated intravascular coagulation, dysrhythmias (mainly from hyperkalemia and hypocalcemia)
Evaluation
  • History should focus on factors that may cause or predispose to rhabdomyolysis. Potential etiologies include:
    • Trauma (crush injury, burn, electrical injury)
    • Infection/sepsis
    • Prolonged immobilization (eg, surgery, sedative-hypnotic intoxication)
    • Toxins (eg, cocaine)
    • Exercise/physical exertion with or without environmental heat exposure
    • Inherited muscle disorders (eg, metabolic myopathy or muscular dystrophy) – Should be considered if initial evaluation unrevealing or rhabdomyolysis is recurrent
    • Excessive neuromuscular activity (eg, withdrawal syndromes, malignant hyperthermia, serotonin syndrome, convulsive seizure, neuroleptic malignant syndrome)
  • Examination should focus on signs that suggest muscle injury, palpation of all muscle compartments for firmness (especially back, gluteals, lower extremities).
  • Obtain following testing:
    • Serum CK, CBC, BUN, creatinine, sodium, potassium, calcium, phosphate, serum aminotransferases, albumin
    • PT, aPTT, INR, D-dimer, fibrinogen
    • Both routine urine dipstick evaluation and microscopic examination of the urinary sediment from a fresh urine specimen
    • ECG
    • Other studies focused on suspected etiology: Blood cultures, serum ethanol concentration, urine drug of abuse screen
Diagnosis
  • Marked acute elevation in serum CK (no absolute cutoff value is defined, but usually >5000 units/L*) and
  • At least one of the following:
    • One or more causative or triggering factors
    • Characteristic symptoms and signs, particularly muscle weakness and brown or tea-colored urine
    • Urinalysis consistent with myoglobinuria: Heme positive by dipstick with <3 red blood cells per HPF on microscopic examination
Early management
  • Prevent any ongoing muscle breakdown (eg, compartment syndrome is a surgical emergency)
  • Administer isotonic IV fluids to prevent acute kidney injury if CK >5000 units/L or if CK values are increasing
    • Initial rate of IV fluids (eg, normal saline [0.9% sodium chloride]) is 1 to 2 L/hour
    • Adjust rate to goal urine output of 200 to 300 mL/hour while avoiding volume overload
  • Treat hyperkalemia, if present
Continued management
  • Monitor serial serum CK, BUN, creatinine, routine electrolytes, calcium every 6 to 12 hours depending on severity.
  • Fluid management:
    • For patients without volume overload, continue IV fluids until serial serum CK levels are ≤5000 units/L and are not increasing.
    • For patients with intravascular volume overload, stop fluids and treat with loop diuretics (eg, furosemide 20 mg IV).
  • Urinary alkalinization for select patients:
    • For patients with severe rhabdomyolysis in whom a diuresis has been established with IV fluids, start IV sodium bicarbonate infusion and decrease rate of concurrent isotonic IV fluids by an equivalent amount. (Do not administer sodium bicarbonate to patients with hypocalcemia, alkalemia, or volume overload.)
    • If sodium bicarbonate is given, the arterial pH and serum calcium should be monitored every 2 hours during the infusion.
    • Discontinue sodium bicarbonate if urine pH does not rise above 6.5 after 3 to 4 hours.
  • Give calcium supplementation only for symptomatic hypocalcemia or severe hyperkalemia (eg, serum potassium >6.5 mEq/L and/or hyperkalemia associated with characteristic ECG abnormalities).Δ

aPTT: activated partial thromboplastin time; BUN: blood urea nitrogen; CBC: complete blood count; CK: creatine kinase; D5W: 5% dextrose in water; ECG: electrocardiogram; HPF: high-powered field; INR: international normalized ratio; IV: intravenous; NS: normal saline (0.9% sodium chloride); PT: prothrombin time.

* Serum CK is usually >5000 units/L with non-exertional rhabdomyolysis and >10,000 units/L with exertional rhabdomyolysis. The serum CK begins to rise within 2 to 12 hours following the onset of muscle injury and reaches its maximum within 24 to 72 hours. The degree of CK elevation should be interpreted in the clinical context of the history and examination findings, including premorbid CK values when available. As an example, an asymptomatic CK elevation of >2000 units/L can occur as a transient physiologic response to vigorous exercise.

¶ Rhabdomyolysis is generally considered severe if the serum CK level is >5000 units/L or if there is clinical evidence of severe muscle injury and a rising serum CK level.

Δ For symptomatic hypocalcemia, IV calcium can be infused over 10 to 20 minutes (1 or 2 g of calcium gluconate, equivalent to approximately 90 or 180 mg elemental calcium [approximately 2.25 or 4.5 mmol elemental calcium], in 50 mL of D5W or NS). May repeat after 10 to 60 minutes if needed to resolve symptoms. For hyperkalemia associated with characteristic ECG abnormalities and/or serum potassium >6.5 mEq/L, give calcium gluconate 1 g (10 mL of 10% solution) or calcium chloride 0.5 to 1 g (5 to 10 mL of a 10% solution) IV over 2 to 3 minutes to stabilize cardiac membranes.
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