questions 4

Rhabdomyolysis

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Topic updated on 08/12/17 10:27am

Snapshot
  • HyperK-ECGA 26-year-old woman has just finished running a full marathon. She did not stop as often as she would have liked for water to rehydrate during her 26.2 mile run. She reports feeling lightheaded and has mild muscle soreness. When she went to use the restroom, she noticed that her urine was dark – almost like tea. At an urgent care clinic, her serum creatine kinase is found to be elevated. An ECG is shown here.
Introduction
  • Clinical definition
    • skeletal muscle breakdown and necrosis
      • releases intracellular contents of the cells into circulation
      • causes severe complications including acute kidney injury, compartment syndrome, cardiac arrest, or respiratory failure
  • Epidemiology
    • risk factors
      • intense physical exercise under heat or humidity
      • diuretic abuse
      • marathon running
  • Etiology
    • trauma
    • crush injury
    • alcohol abuse
    • cocaine abuse
    • statins and fibrates together
    • neuroleptic malignant syndrome
  • Pathogenesis
    • mechanism
      • muscle cell injury causes intracellular contents to be released including:
        • potassium
        • myoglobin
        • uric acid
        • sarcoplasmic contents
          • creatine kinase
          • alanine aminotransferase (ALT)
          • aspartate aminotransferase (AST)
    • cocaine-induced rhabdomyolysis
      • prolonged vasoconstriction can lead to ischemia and necrosis of muscle cells
    • acute kidney injury
      • high levels of myoglobin precipitates in kidneys and cause tubular obstruction
      • metabolites of myoglobin also directly causes damage to tubules
  • Prognosis
    • generally good with early detection, supportive care, and careful monitoring
Presentation
  • Symptoms
    • primary symptoms
      • classic triad
        • muscle pain
        • weakness and swelling of muscle
        • tea-colored urine (myoglobinuria)
    • nausea
    • emesis
    • oliguria or anuria
    • may be asymptomatic
  • Physical exam
    • fever
    • tachycardia
    • muscle weakness
Studies
  • Labs
    • ↑ serum creatine kinase (CK)
    • ↑ serum myoglobin
      • because of its short half-life they are not as sensitive as CK
    • ↑ serum creatinine
    • electrolyte abnormalities
      • ↑ potassium
      • ↑ phosphate
      • ↓ calcium
      • ↑ uric acid
    • ↑ liver function tests
  • Urine dipstick
    • myoglobinuria
  • Urinalysis
    • protein
    • brown casts
    • uric acid crystals
    • red blood cells
  • Electrocardiogram (ECG)
    • monitor for cardiac arrhythmias from electrolyte abnormalities
    • first step in evaluating a patient with suspected rhabdomyolysis
  • Diagnostic criteria
    • elevated serum CK
Differential
  • Hemolysis causing hemoglobinuria (dark urine)
    • normal CK
Treatment
  • Conservative
    • fluid hydration
      • indications
        • for all patients to help treat or prevent acute kidney injury
  • Medical
    • sodium bicarbonate
      • indications
        • to alkalinize the urine
    • insulin and glucose
      • indications
        • if rhabdomyolysis causes hyperkalemia
Complications
  • Acute kidney injury
  • Cardiac arrest from hyperkalemia



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Qbank (2 Questions)

TAG
(M2.RL.49) A patient arrives in the ED following a motor vehicle accident in which his legs were compressed for 5 hours before he was finally freed. He complains of intense pain in his legs, but vital signs are within normal limits. His EKG is shown in Figure A. Blood work will likely show: Topic Review Topic
FIGURES: A          

1. Elevated serum creatine kinase (CK), elevated serum potassium, elevated lactate dehydrogenase (LDH), decreased serum calcium
2. Elevated serum CK, elevated serum potassium, decreased LDH, decreased serum calcium
3. Elevated serum CK, decreased serum potassium, elevated LDH, elevated serum calcium
4. Elevated serum CK, decreased serum potassium, decreased LDH, elevated serum calcium
5. Decreased serum CK, elevated serum potassium, elevated LDH, elevated serum calcium

PREFERRED RESPONSE ▶
TAG
(M2.RL.87) A 32-year-old male is brought in by EMS after his friends found him passed out in his apartment. According to EMS accounts, there was drug paraphernalia near his body, most likely heroin. Currently, he is alert and oriented only to self. Urinalysis is pending, but an image of the collected urine is shown in Image A. What is the next step in the management of this patient? Topic Review Topic
FIGURES: A          

1. Mannitol administration
2. Calcium gluconate administration
3. Furosemide administration
4. CPK Level
5. Electrocardiogram

PREFERRED RESPONSE ▶
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