Rhabdomyolysis
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RHABDOMYOLYSIS. O. Ahmadi MD. Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital. Rhabdomyolysis is a syndrome characterized by injury to skeletal muscle with subsequent release of intracellular contents. PATHOPHISIOLOGY:.

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Rhabdomyolysis

RHABDOMYOLYSIS

O. Ahmadi MD.

Professor Assistant of Esfahan medical School, Emergency Department of Al-Zahra Hospital


Rhabdomyolysis

Rhabdomyolysis is a syndrome characterized by injury to skeletal muscle with subsequent release of intracellular contents.


Pathophisiology

PATHOPHISIOLOGY:

Disruption of Na+K +ATPase pump and calcium transport.


Rhabdomyolysis

Direct muscle injury:

-Crush

- Electrical or lightning injury


Rhabdomyolysis

Drugs of abuse:

- Amphetamines (including Ecstasy)

- Caffeine

- Cocaine

- Ethanol

- Heroin

- Lysergic acid diethylamide

- Methamphetamines

- Opiates

- Phencyclidine


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Excessive muscular activity:

-Contact sports

-Delirium tremens

-Dystonia

-Psychosis

-Seizures

-Sports and basic training


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Genetic disorders:

-Glycolysis and glycogenolysis disorders

- Fatty acid oxidation disorders - Mitochondrial and respiratory chain metabolism disorders


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Immunologic diseases:

-Dermatomyositis

-Polymyositis


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Bacterial:

-Clostridium

- Group A B-hemolytic Streptococcus

-Legionnaires' disease

-Salmonella

-Shigella

-Staphylococcus aureus

-Streptococcus pneumoniae


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Viral:

-Coxsackie virus

-Cytomegalovirus

-Epstein-Barr virus

-Entrovirus

-Hepatitis

-Herpes simplex virus

-Human immunodeficiency virus

-Influenza (A and B)

-Rotavirus


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Ischemic injury:

- Compartment syndrome

- Compression


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Medications:

-Barbiturates

- Benzodiazepines

- Clofibrate

- Colchicine

- Corticosteroids

- Isoniazid

- Lithium

- Monoamine oxidase inhibitors

- Narcotics

- Neuroleptic agents

- Phenothiazines

- Salicylates

- Serotonergic agents

- Statins

- Theophylline

- Tricyclic antidepressants


Rhabdomyolysis

The most common causes of rhabdomyolysis in adults appear to be:

Alcohol and drug abuse

Toxin ingestion

Trauma

Infection

Strenuous physical activity

Heat-related illness


Rhabdomyolysis

In the pediatric population, rhabdomyolysis is an uncommon disorder.


Rhabdomyolysis

Influenza virus is the most frequently cited infectious cause.


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Legionella is the most frequently reported bacterial cause of rhabdomyolysis.


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CLINICAL FEATURES

Myalgias, stiffness, weakness, malaise, low-grade fever, and dark (usually brown) urine.


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Nausea, vomiting, abdominal pain, and tachycardia can occur in Severe rhabdomyolysis.


Rhabdomyolysis

DIAGNOSIS:

An elevated serum CKlevel is themost sensitive and reliable indicator of muscle injury.


Rhabdomyolysis

The degree of CK elevation correlates with the amount of muscle injury and the severity of illness, but not the development of renal failure or other morbidity.


Rhabdomyolysis

Most investigators consider a fivefold or greater increase above the upper threshold of normal in serum CK level, in the absence of cardiac or brain injury, as the requirement for the diagnosis of rhabdomyolysis


Rhabdomyolysis

Serum CK begins to rise approximately2 to 12 h after the onset of muscle injury.


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Serum CK peaks within 24 to72 h


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Myoglobin elevation occurs before CK elevation.


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Myoglobin enters the urine when the plasma concentration exceeds>5mg/dl.


Rhabdomyolysis

Myoglobin causes the typical reddish brown discoloration when urine myoglobin exceeds 100 mg/dL.


Rhabdomyolysis

Because myoglobin contains heme, qualitative tests such as the dipstick (which uses the orthotoluidine reaction) does not differentiate between hemoglobin, myoglobin, and red blood cells.


Rhabdomyolysis

suspect myoglobinuria

when the urine dipstick is positive for blood, but no red blood cells are present on microscopic examination.


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myoglobin levels may return to normal within 1 to 6 h after the onset of muscle necrosis.


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In one study, 26 percent of patients with rhabdomyolysis did not have myoglobinuria.


Rhabdomyolysis

COMPLICATIONS:


Rhabdomyolysis

  • ARF

  • Metabolic derangements

  • DlC

  • Mechanial Complications

  • (e,g.,compartment syndrome or

  • peripheral neuropathy)


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Acute renal failureis the most serious complication of rahabdomyolysis.


Rhabdomyolysis

Ferrihemate:

the breakdown product of myoglobin, is responsible for the direct toxic effect on the kidneys.


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Prehospital Care

Once a limb is extricated, intravenous NS should be initiated at 1 Lit/h. After extrication, continue intravenous NS at 500 mL, alternating with D5NS, at 1 Lit/h. Potassium or lactate-containing solutions should be avoided.


Rhabdomyolysis

Emergency Department

Once in the emergency department, aggressive intravenous rehydration remains the mainstay of therapy. This treatment should be continued for the first 24 to 72 h.


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Infusion of 2.5 ml/kg per h, with the goal of maintaining a minimum urine output of 2 m/kg per hour or 200 – 300 ml/h.


Rhabdomyolysis

Sodium bicarbonate, one

ampule (44 mEq) added to 1 L of NS or two to three ampules (88 to 132 mEq) in D5W to run at a rate of 100 mL/h, has been recommended to maintain a urine pH of 6.5 or above to prevent the development of ARF.


Rhabdomyolysis

Alkalinizationis not without risks: It can exacerbate the hypocalcemia.


Rhabdomyolysis

mannitolis commonly recommended, although there are no prospective studies on its benefit. This solution may be given as 1 g/kg IV over 30 min, or as 25 g IV initially, followed by 5 g/h IV, for a total of 120 g/day.


Rhabdomyolysis

The use of loop diuretics (e.g., furosemide) in rhabdomyolysis is controversial.


Rhabdomyolysis

Dialysismay be necessary to treat rhabdomyolysis inducedARF


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Foley catheter cardiac monitor, hemodynamic monitoring may be necessary to avoid fluid overload. Serial measurements of urine pH, artenal pH, electrolytes, CK, calcium, phosphorus, blood urea nitrogen, and creatinine should be performed.


Rhabdomyolysis

Hypocalcemia observed early in rhabdomyolysis usually requires no treatment.


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Calcium should be given only to treat hyperkalemia induced cardiotoxicity or profound signs and symptoms of hypocalcemia.


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hypercalcemiais frequently symptomatic and normally responds to saline diuresis and intravenous furosemide.


Rhabdomyolysis

Hyperphosphatemia:

should be treated with oral phosphate binders when serum levels exceed 7 mg/dL.


Rhabdomyolysis

hypophosphatemia, which may occur late in rhabdomyolysis, requires treatment only when the serum level is below 1mg/dL.


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Avoid the use of prostaglandin inhibitors such asnonsteroidal anti inflammatory agents, because of their vasoconstrictive effects on the kidney.


Rhabdomyolysis

For at least the initial 24 to 48 h, these patients should be admitted to a monitored bed to identify dysrhythmias secondary to the metabolic complications.


Rhabdomyolysis

THANK YOU


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