Rhabdomyolysis
Basics
Description
Literally “dissolution of skeletal contents.” Defined as pathologic release of muscle contents – creatine phosphokinase (CPK), myoglobin, potassium, phosphate, urate – with systemic complications. Caused by trauma, direct compression of muscle, poisoning, infection, primary muscle disorders, and many other disease states. Complications include:Description
- Myoglobinuric renal failure in 15–50% adults, only 5% in children
- Hyperkalemia may lead to sudden death
- Hypocalcemia and acidosis
- Intravascular hypovolemia – fluid sequestration in injured muscle or result of underlying illness
- Hepatic dysfunction in 25%
- Disseminated intravascular coagulation (DIC)
Epidemiology
IncidenceEpidemiology
- 26,000 per year in the U.S.
- Disaster situations lead to 100s of cases of renal failure
Risk Factors
Risk Factors
- Trauma, particularly crush injuries
- Sepsis
- Prolonged immobilization
- Inherited myopathy
- Alcohol or drug use
- Medications as listed below
- Overexertion with or without risk factors
Pathophysiology
Pathophysiology
- Ion pumps in sarcolemma normally keep intracellular Ca, Na low, and K high via ATP-dependent processes
- Myocyte damage reduces ATP availability which disrupts ion channel activity
- Prolonged intracellular Ca causes sustained myofibrillar contraction and further ATP depletion leads to ischemia
- Ca-dependent proteases cause cell membrane lysis
- Escape of cell contents: Myoglobin, potassium, phosphate, CPK, lactate, AST, ALT
- Myoglobin causes direct renal toxicity and precipitates with other proteins to obstruct renal tubular flow
- Volume depletion also leads to renal vasoconstriction and failure
- Hyperkalemia can lead to arrhythmias
- Calcium precipitates with phosphate, leading to systemic hypocalcemia
Etiology
Cause usually obvious, but not alwaysEtiology
Adults: Trauma, drug toxicity, seizure, infection
Children: Viral myositis, trauma
- Muscle injury – due to trauma/crush, burn, electrical shock – most common cause overall
- Muscle exertion: Strenuous exercise, marathon running; exercise in hot, humid conditions; exercise in individuals with an inherited myopathy or with poor physical training; status epilepticus; delirium tremens; tetanus; psychotic agitation
- Muscle ischemia: Extensive thrombosis, multiple embolism, generalized shock, sickle cell crisis
- Surgery: Immobilization, hypotension, ischemia due to vessel clamping
- Massive blood transfusion
- Hypothermia, hyperthermia (NMS, MH)
- Prolonged immobilization without trauma
- Drugs/toxins: Alcohols, cocaine, amphetamines, and analogs (methamphetamine and ecstasy), toluene, opiates, LSD, phencyclidine (PCP), carbon monoxide, snake venom, bee/hornet venom, hemlock, buffalo fish, tetanus toxin, mushroom poisoning (Tricholoma equestre)
- Medications: Most common – haloperidol, phenothiazines, HMG–CoA reductase inhibitors (statins) especially in combination with fibrates (gemfibrozil)
- Sports supplements including ephedra, caffeine, androgenic steroids, creatine, diuretics
- Neuroleptic malignant syndrome (idiosyncratic and not dose-related)
- Metabolic disorders: Hypokalemia, hypophosphatemia, hypocalcemia, hyper- and hyponatremia, metabolic acidosis, hyperosmolar state, hypoxia, hyperthyroid state (rare), pheochromocytoma (rare)
- Infections:
- Viral: Coxsackievirus, herpesviruses, HIV, influenza B, cytomegalovirus, Epstein–Barr virus, adeno/echovirus
- Bacterial: Legionnaires disease, pyomyositis, sepsis
- Parasitic (Plasmodium falciparum), protozoan (leptospirosis), rickettsial
- Inherited myopathic disorders: McArdle disease, Tarui disease, CPT deficiency
- Immunologic disorders: Dermatomyositis, polymyositis
- Idiopathic
Commonly Associated Conditions
Commonly Associated Conditions
- Crush syndrome
- Compartment syndrome
- Alcohol and drug abuse
- Elderly and acutely immobile (found on floor)
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Citation
Schaider, Jeffrey J., et al., editors. "Rhabdomyolysis." 5-Minute Emergency Consult, 6th ed., Lippincott Williams & Wilkins, 2020. Emergency Central, emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307217/all/Rhabdomyolysis.
Rhabdomyolysis. In: Schaider JJJ, Barkin RMR, Hayden SRS, et al, eds. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307217/all/Rhabdomyolysis. Accessed October 15, 2024.
Rhabdomyolysis. (2020). In Schaider, J. J., Barkin, R. M., Hayden, S. R., Wolfe, R. E., Barkin, A. Z., Shayne, P., & Rosen, P. (Eds.), 5-Minute Emergency Consult (6th ed.). Lippincott Williams & Wilkins. https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307217/all/Rhabdomyolysis
Rhabdomyolysis [Internet]. In: Schaider JJJ, Barkin RMR, Hayden SRS, Wolfe RER, Barkin AZA, Shayne PP, Rosen PP, editors. 5-Minute Emergency Consult. Lippincott Williams & Wilkins; 2020. [cited 2024 October 15]. Available from: https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307217/all/Rhabdomyolysis.
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