Saturday, September 5, 2015

Rhabdomyolysis (Rhabdo) Diagnosis and Treatment



Background: Rhabdomyolysis is defined as injury of the skeletal muscle, which results in the release of intracellular components into the circulation.1 The most common causes of rhabdomyolysis are reviewed in Tables 1 and 2. Rhabdomyolysis in critically ill patients can result in significant morbidity, including need for fasciotomy (52%), amputation (24%), renal insufficiency (29%), and dialysis (9.5%).2

 
 
 
CO – carbon monoxide; CN – cyanide; DTs – delirium tremens; NMS – neuroleptic malignant syndrome; MH – malignant hyperthermia; OTC – over the counter; DKA – diabetic ketoacidosis

 

Table 2. Drugs Associated with Rhabdomyolysis
Drug Class
Examples
Lipid-lowering agents
Statins, Fibrates
Psychiatric medications
Haloperidol, atypical antipsychotics, SSRIs, lithium, valproic acid
Antimicrobial agents
Protease inhibitors, trimethoprim-sulfamethoxazole, daptomycin, quinolones, macrolides, amphotericin B
Anesthetics
Propofol
Paralytics
Succinylcholine
Antihistamines
Doxylamine, diphenhydramine
Appetite suppressants
Phentermine, ephedra
Chemotherapy
Sunitinib, erlotinib
Antiarrhythmics
Amiodarone
Miscellaneous
Colchicine, narcotics, aminocaproic acid, vasopressin
Illicit drugs
Cocaine, amphetamines/methamphetamines, hallucinogens, heroin, bath salts (methlenedioxypyrovalerone, mephedrone), phencyclidine

This list should not be considered comprehensive. Consult with a pharmacist is recommended for all potential medication-induced cases of rhabdomyolysis. SSRIs – selective serotonin reuptake inhibitors

 

 
Diagnosis: Obtain serum creatinine, base deficit, and creatine kinase (CK) on admission.  No utility in obtaining urine myoglobin. 3   If CK > 1250, continue to trend (every 8 hrs) until peak usually within 48hrs followed by decline.  CK < 20,000 is unlikely to be associated with a risk of renal impairment.  No standard CK level otherwise exists.


Treatment: There are no well-done randomized controlled trials of treatments for rhabdomyolysis. Treatment is based around three core components: prevention of further skeletal muscle damage, prevention of acute kidney injury (AKI), and rapid identification of potentially life-threatening complications.

References:

1)      Zimmerman JL, Shen MC. Rhabdomyolysis. CHEST. 2013; 144: 1058-65.

2)      Sharp LS, Rozychi GS, Feliciano DV. Rhabdomyloysis and secondary renal failure in critically ill surgical patients. Am J Surg. 2004; 801-6.

3)      Bhavsar P, Rathod KJ, Rathod D, Chamania CS.  Utility of Serum Creatinine, Creatinine Kinase, and Urinary Myoglobin in Detecting Acute Renal Failure due to Rahabdomyolysis in Trauma and Electrical Burns Patients.  Indian J Surg.   (jan-feb 2013) 75 (1): 17-21.

4)      Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin. 2004; 20: 171-92.
 

Trauma Service: Severe Rhabdomyolysis Algorithm
                This is a guideline only and not to be substituted for individual clinical judgment.          
 
(Adapted from reference 3)