Rhabdomyolysis

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Definition/Description

Rhabdomyolysis is the breakdown of skeletal muscle tissue that occurs quickly due to a large release of creatinine phosphokinase enzymes due to mechanical, physical, or chemical traumatic injuries.^Patho  Due to the quick breakdown of the skeletal muscle there is a big accumulation of the breakdown products which can cause renal failure.^patho

Historical Background

The first known report

of rhabdomyolysis occurred in Sicily in 1908 after an earthquake, this was also the first case of crush syndrome as well and was found in German military literature.^AE   While this was the first report there has been some speculation that there are references in the bible about rhabdomyolysis during the Jews exodus from Egypt. It was described as a plague that occurred after a large intake of quail.^A   A similar incident occurred in 1930 in the Baltic sea area where there was a large consumption of intoxicated fish.^E  

Military

The focus of rhabdomyolysis really came about during World War II, especially during the bombing that occurred in London, where crush victims developed acute renal failure.^AE  Reports were also present during the Korean War as well as during Vietnam.  During Vietnam the incidence actually decreased which is thought to be due to the faster evacuation techniques and improved fluid resuscitation to victims.^A

Natural Disasters

As seen through history the most common incidence of rhabdomyolyisis occurs during natural disasters where there are less resources available to helped trapped victims, making their time under rubble longer increasing their chances of developing rhabdomyolysis.  On August 17, 1999 in Marmara, a region of Turkey, an earthquake with a 7.4 magnitude devastated the area.  This earthquake caused 17,480 deaths.  Many victims were sent to hospitals, 9,843 patients were hospitalized with 425 of them dying.  Of those 9,843 patients, 639 patients developed renal failure, this was 12% of the patients that were hospitalized.  The victims average time spent under rubble was 11.7 hours. ^A

Collapse of World Trade Center

On September 11, 2001 in New York City the twin towers collapsed trapping many victims under rubble.  Hospitals were prepared to have dialysis ready the days following the attacks to treat the many victims to prevent renal failure.  Fortunately very few victims had crush injuries and only victim developed rhabdomyolysis, a 38 year-old police officer who had been trapped under rubble for 24 hours.^A

Causes

Causes for rhabdomyolysis can be broken down into 2 categories, hereditary causes and acquired causes.

Hereditary Causes

Those that are at risk for rhabdomyolysis have a family history of disorders dealing with carbohydrate metabolism as well as disorders of lipid metabolism.  Disorders of lipid metabolism include malignant hyperthermia, mitochondrial disorders, as well as other genetic disorders.

Acquired Causes

Some of the most common acquired causes include trauma or crush injury, toxic, sever muscle exertion, seizures, shaking chills, delerium tremors, ischemia or muscle necrosis, metabolic disorders, bacterial and viral infections, heat-induced (malignant hyperthermia, heat intolerance, heat stroke), inflammatory, certain drugs (overuse or overdose) such as cocaine, amphetamines, statins, heroin, PCP, as well as low phosphate levels.

Below is a chart that describes the risk factors for rhabdomyolysis as well as examples of the risk factors and associated signs and symptoms.   

Risk Factors For Postoperative Rhabdomyolysis

Preoperative

• Male
• Age > 10 years
• BMI > 55 kg/m2
• History of

hypertension, diabetes mellitus, or peripheral vascular disease

• History of statin use
• Elevated preoperative

serum CPK level

Intraoperative

• Operation duration

> 5hours

• Anesthesia time >

6 hours

• Inadequate hydration
• Urine output <

1.5ml/kg/h

• Bleeding and/or

hypotension

• Use of propofol

and/or succinylcholine

Postoperative

• Complaints of muscle

pain and weakness

• Delayed ambulation
• Urine output <1.5mL/kg/h

• Serum CPK >

1,000IU/L

• Urine myoglobin >

250m g/L

Characteristics/Clinical Presentation

The signs and symptoms of rhabdomyolyis vary from person to person. The three most common signs and symptoms are muscle pain, weakness, and dark urine.^AE  Muscle pain as well as weakness and tenderness may be general or specific to muscle groups.  The calves and low back are the most general muscle groups that are affected.^A   According to the author Efstratiadis, back pain and limb pain are the most frequent sites in patients with rhabdomyolysis.^E  However, over 50% of the patients with rhabdomyolysis may not complain of muscle pain or weakness.^A   The initial sign of rhabdomyolysis is discolored urine which can range from  pink to dark black.^AE Other signs and symptoms include, local edema, cramps, hypotension, malaise, fever, tachycardia, nausea and vomiting.^AE  Often during the early stages of rhabdomyolysis the following conditions may also be present:  hyperkalemia, hypocalcemia, elevated liver enzymes, cardiac dysrrhythmias and cardiac arrest.^A  Some late complications include acute renal failure and disseminated intravascular coagulation.^A<o:p></o:p>

Associated Co-morbidities

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Diagnostic Tests/Lab Tests/Lab Values

File:Table 2.1.png

Blood samples are taken

from the patient to look at various serum values, one of the most important serum indicators of myocyte injury is creatinine kinase.^ef

Creatinine Kinase

“ Under normal conditions, CK levels are 45-260 U/L. After rhabdomyolysis, the levels of CK can be raised to 10.000-200.000 U/L or even 3.000.000.000 U/L.  No other condition except rhabdomyolysis can cause such extreme CK elevation.”^Ef   Creatine Kinase has several forms that include the muscles, heart, brain and kidneys, as well as mitochndria so it is important to look at all values.

Uric Acid

Uric Acid is important to check due to the fact that rhabdomyolysis breaks down skeletal muscle creating more creatinine, which then becomes creatinine which can then lead to acute renal failure, therefore causing the levels of uric acid to rise.

 Urinalysis

File:Table 3.png

Urine analysis can be very helpful in diagnosing rhabdomyolysis.  Urinalysis will be able to detect changes in the body’s waste, such as increases in uric acid, albumin, as well as myoglobin.^ef  Often patients that are positive for rhabdomyolysis have brown tinted urine.  Table 3 has a description of common findings in urinalysis.

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