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


Pathophisiology
PATHOPHISIOLOGY: skeletal muscle with subsequent release of intracellular contents.

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


Direct muscle injury: skeletal muscle with subsequent release of intracellular contents.

-Crush

- Electrical or lightning injury


Drugs of abuse skeletal muscle with subsequent release of intracellular contents.:

- Amphetamines (including Ecstasy)

- Caffeine

- Cocaine

- Ethanol

- Heroin

- Lysergic acid diethylamide

- Methamphetamines

- Opiates

- Phencyclidine


Excessive muscular activity: skeletal muscle with subsequent release of intracellular contents.

-Contact sports

-Delirium tremens

-Dystonia

-Psychosis

-Seizures

-Sports and basic training


Genetic disorders: skeletal muscle with subsequent release of intracellular contents.

-Glycolysis and glycogenolysis disorders

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


Immunologic diseases: skeletal muscle with subsequent release of intracellular contents.

-Dermatomyositis

-Polymyositis


Bacterial: skeletal muscle with subsequent release of intracellular contents.

-Clostridium

- Group A B-hemolytic Streptococcus

-Legionnaires' disease

-Salmonella

-Shigella

-Staphylococcus aureus

-Streptococcus pneumoniae


Viral: skeletal muscle with subsequent release of intracellular contents.

-Coxsackie virus

-Cytomegalovirus

-Epstein-Barr virus

-Entrovirus

-Hepatitis

-Herpes simplex virus

-Human immunodeficiency virus

-Influenza (A and B)

-Rotavirus


Ischemic injury: skeletal muscle with subsequent release of intracellular contents.

- Compartment syndrome

- Compression


Medications: skeletal muscle with subsequent release of intracellular contents.

-Barbiturates

- Benzodiazepines

- Clofibrate

- Colchicine

- Corticosteroids

- Isoniazid

- Lithium

- Monoamine oxidase inhibitors

- Narcotics

- Neuroleptic agents

- Phenothiazines

- Salicylates

- Serotonergic agents

- Statins

- Theophylline

- Tricyclic antidepressants


The skeletal muscle with subsequent release of intracellular contents.most common causes of rhabdomyolysis in adults appear to be:

Alcohol and drug abuse

Toxin ingestion

Trauma

Infection

Strenuous physical activity

Heat-related illness


In the skeletal muscle with subsequent release of intracellular contents.pediatric population, rhabdomyolysis is an uncommon disorder.


Influenza skeletal muscle with subsequent release of intracellular contents.virus is the most frequently cited infectious cause.


Legionella skeletal muscle with subsequent release of intracellular contents.is the most frequently reported bacterial cause of rhabdomyolysis.


CLINICAL FEATURES skeletal muscle with subsequent release of intracellular contents.

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



DIAGNOSIS in :

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


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.


Most investigators consider a muscle injury and the severity of illness, but not the development of renal failure or other morbidity.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


Serum CK begins to rise approximately muscle injury and the severity of illness, but not the development of renal failure or other morbidity.2 to 12 h after the onset of muscle injury.


Serum CK peaks within 24 to72 h muscle injury and the severity of illness, but not the development of renal failure or other morbidity.


Myoglobin muscle injury and the severity of illness, but not the development of renal failure or other morbidity.elevation occurs before CK elevation.



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


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.


suspect myoglobinuria the dipstick (which uses the orthotoluidine reaction) does not differentiate between hemoglobin, myoglobin, and red blood cells

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


myoglobin the dipstick (which uses the orthotoluidine reaction) does not differentiate between hemoglobin, myoglobin, and red blood cells levels may return to normal within 1 to 6 h after the onset of muscle necrosis.



COMPLICATIONS: not have myoglobinuria.


  • ARF not have myoglobinuria.

  • Metabolic derangements

  • DlC

  • Mechanial Complications

  • (e,g.,compartment syndrome or

  • peripheral neuropathy)


Acute renal failure not have myoglobinuria.is the most serious complication of rahabdomyolysis.


Ferrihemate not have myoglobinuria.:

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


Prehospital not have myoglobinuria. 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.


Emergency Department not have myoglobinuria.

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.


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.


Sodium bicarbonate, one minimum urine output of 2 m/kg per hour or

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.


Alkalinization minimum urine output of 2 m/kg per hour or is not without risks: It can exacerbate the hypocalcemia.


mannitol minimum urine output of 2 m/kg per hour or is 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.


The use of minimum urine output of 2 m/kg per hour or loop diuretics (e.g., furosemide) in rhabdomyolysis is controversial.


Dialysis minimum urine output of 2 m/kg per hour or may be necessary to treat rhabdomyolysis inducedARF


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.


Hypocalcemia 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.observed early in rhabdomyolysis usually requires no treatment.


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


hypercalcemia cardiotoxicity or profound signs and symptoms of hypocalcemiais frequently symptomatic and normally responds to saline diuresis and intravenous furosemide.


Hyperphosphatemia: cardiotoxicity or profound signs and symptoms of hypocalcemia

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


hypophosphatemia, cardiotoxicity or profound signs and symptoms of hypocalcemiawhich may occur late in rhabdomyolysis, requires treatment only when the serum level is below 1mg/dL.


Avoid the use of prostaglandin inhibitors such as cardiotoxicity or profound signs and symptoms of hypocalcemianonsteroidal anti inflammatory agents, because of their vasoconstrictive effects on the kidney.


For at least the initial cardiotoxicity or profound signs and symptoms of hypocalcemia24 to 48 h, these patients should be admitted to a monitored bed to identify dysrhythmias secondary to the metabolic complications.


THANK YOU cardiotoxicity or profound signs and symptoms of hypocalcemia


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