questions 4


Topic updated on 02/15/17 9:59am

  • HyperK-ECGA 35-year-old marathon runner is brought in by EMS after collapsing during a race on a hot day. En route to the hospital he began seizing. Fluids are started and an EKG is shown.
  • Result of the acute breakdown of skeletal muscle and leakage into the circulation
  • Causes include
    • crush injuries
    • seizures
    • overexertion
    • burns
    • immobility
    • alcohol abuse
    • certain medications
    • toxic substances
      • cocaine
    • snake bites
    • genetic conditions
      • McArdle's disease and Duchenne's muscular dystrophy
  • This is a medical emergency requiring early recognition of and prompt management
  • Symptoms
    • non-specific
      • based on presenting cause of muscle breakdown
  • Physical exam
    • non-specific
      • based on presenting cause of muscle breakdown
  •  ECG
    • essential to detect cardiac arrhythmias resulting from hyperkalemia
    • should be the first step in evaluating a patient with suspected rhabdomyolysis
    • as seen in Snap Shot peak T-waves are early sign of hyperkalemic cardiac changes
  • Urinalysis
    • Myoglobinuria - dipstick is positive for blood; however urine microscopy does not show RBCs 
  • Serology 
    • creatine phosphkinase (CPK)
      • values > 20,000 are diagnostic
    • hyperkalemia
    • hypocalcemia
      • result of calcium binding to damaged muscle
      • does not require intervention
    • hyperuricemia
  •  Medical
    • saline hydration 
    • mannitol
      • for induction of osmotic diuresis
    • bicarbonate
    • calcium gluconate
      • if abnormalities seen on ECG for cardiac stabilization
Prognosis, Prevention, and Complications
  • Complications
    • acute renal failure (ARF)
      • result of muscle degradation products (myoglobin) plugging the renal filtration system


Qbank (3 Questions)

(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

(M2.RL.62) A 24-year-old male presents to the emergency department with complaints of severe pain in his right thigh and generalized weakness. He also reports that his urine appeared darker than normal. These symptoms have only been present since he woke up this morning on his kitchen floor after drinking heavily and taking "a few prescription pain-killers" yesterday evening. He does not recall any events of the prior evening after he began drinking in the early afternoon. Physical examination reveals extreme tenderness to palpation of the right anterolateral thigh as well as weakness in flexion and extension of the right hip. The area of the anterolateral portion of the right thigh appears moderately swollen with darkening of the overlying skin. An ECG is obtained and is shown in Figure A. CBC, BMP, and creatine phosphokinase levels have been drawn and results are pending. A urine sample is obtained, which appears reddish-brown in color. Which of the following findings would be expected on this patient's urine dipstick and microscopy? Topic Review Topic
FIGURES: A          

1. Dipstick: normal; Micro: normal
2. Dipstick: normal; Micro: small 1+ blood
3. Dipstick: large 3+ blood; Micro: 30 RBCs/hpf
4. Dipstick: large 3+ blood; Micro: normal except for occasional pigmented casts
5. Dipstick: 2+ protein, 2+ leukocytes, + nitrite; Micro: 25 WBCs/hpf, 3 RBCs/hpf

(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

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