Rhabdomyolysis is a topic covered in the 5-Minute Emergency Consult.

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Basics

Description

Abnormal systemic release of muscle contents—creatine phosphokinase (CPK), myoglobin, potassium, phosphate, urate—caused by trauma, poisoning, infection, primary muscle disorders, and many other disease states. Complications include:
  • Myoglobin-induced renal failure in 15–50% adults, only 5% in children
  • Hyperkalemia may lead to sudden death
  • Hypocalcemia and acidosis
  • Volume loss—fluid sequestration in injured muscle or result of underlying illness
  • Compartment syndrome of muscles in crush, worsened by IV fluid sequestration in damaged tissue
  • Hepatic dysfunction in 25%
  • DIC (Disseminated intravascular coagulation)

Epidemiology

Incidence
  • 26,000 per year in US
  • Disaster situations lead to 100s of cases of renal failure.

Risk Factors

  • Inherited myopathy
  • Alcohol or drug use
  • Medications as listed below
  • Overexertion with or without risk factors

Pathophysiology

  • Sarcolemma keeps intracellular calcium low.
  • Etiologies disrupt cell membrane and lead to following cascade.
  • Breakdown of sarcolemma Na–Ca pumps allows calcium to enter cell.
  • Calcium-dependent proteases cause destruction.
  • Ischemia and neutrophils cause damage.
  • Escape of cell contents: Myoglobin, potassium, phosphate, CPK, lactate, etc.
  • Myoglobin causes renal damage by direct toxicity in acidic urine.
  • Myoglobin 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 always.
Adults: Trauma, toxicity, 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
  • Prolonged immobile state without trauma
  • Drugs/toxins: Alcohols, cocaine, amphetamines, and analogs (methamphetamine and ecstasy), toluene, opiates, LSD, phencyclidine (PCP), caffeine, 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) and other cholesterol-lowering agents, antihistamines, selective serotonin receptor inhibitors (SSRIs).
  • 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, diabetic ketoacidosis, 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, salmonellosis, shigellosis, Staphylococcus, Streptococcus, Listeria, tetanus, toxic shock syndrome, tularemia, gas gangrene, Bacillus cereus
    • Parasitic (Plasmodium falciparum), protozoan (leptospirosis), rickettsial
    • Inherited myopathic disorders: McArdle disease, Tarui disease, CPT deficiency.
  • Immunologic disorders: Dermatomyositis, polymyositis
  • Idiopathic

Commonly Associated Conditions

  • Crush syndrome
  • Compartment syndrome
  • Alcohol and drug abuse
  • Elderly and acutely immobile (found on floor)

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Citation

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TY - ELEC T1 - Rhabdomyolysis ID - 307217 Y1 - 2016 PB - 5-Minute Emergency Consult UR - https://emergency.unboundmedicine.com/emergency/view/5-Minute_Emergency_Consult/307217/all/Rhabdomyolysis ER -