Rhabdomyolysis

Causes

Anything that causes breakdown of skeletal muscle.

Trauma: crush injuries, over-exertion,

Medications: statins, antipsychotics, propofol

Seizures, infections, hypo/hyperthermia

Alcohol, cocaine, amphetamines

Infections, stings/bites

Low P04, low K.

McArdle's syndrome.

Pathophysiology

Increase intracellular calcium leads to

lysis
Intracellular contents released (K, Ca,
CK, LDH, myoglobin)
Myoglobin primarily responsible for
renal injury: directly toxic, precipitates
in tubules and causes vasoconstriction.
Responsible for approx 10% of AKI.

Diagnosis

Assess risk factors

Triad of weakness, myalgia and dark urine (50% sens).

CK: 5-10x upper normal limit.

Magnitude of CK rise poor predictor of risk of kidney injury.

Peaks 24-36 hours, decrease 30%/day.

Urine/plasma myoglobin not sens or spec (T 1/2 1.5hours)

High K, high phos, raised Cr, anion gap. Ca can be low initially
(deposition in muscles) then high.
Monitor electrolytes, pH, CK, renal function, coags

Management

1. Prevent further muscle damage

2. Prevent renal injury

3. Identify life-threatening complications

Lack of high quality evidence. No RCTs. Some

animal models and retrospective studies.

Preventing muscle damage

Vary with the cause: control agitation, stop

medications, treat infection, correct metabolic
abnormalities, cooling/warming, surgery.

Prevent AKI

Early and aggressive volume resuscitation

Want to restore renal perfusion and increase UO

Aim 300ml/hr for 24 hours (Scharman, 2013)

Normal saline (no extra K)

Urine alkalinisation (pH>6) to prevent myoglobin precipitation

(uncertain benefit). Requires large volumes bicarbonate.
Diuresis (mannitol and loop diuretics). Only anecdotal
evidence.

Dialysis if severely acidotic/hyperkalaemic/CCF.

In general, don't treat hypocalcaemia.

Complications

Hyperkalaemia

Fluid overload

Compartment syndrome

DIC

References

Scharman and Troutman, Prevention of kidney injury

following rhabdomyolysis: a systematic review. Ann
Pharmacother. 2013 Jan;47(1):90-105
Zimmerman and Chen. Rhabdomyolysis. Chest. 2013
Sep;144(3):1058-65
Desjardins, Strange. Pre-hospital treatment of traumatic
rhabdomyolysis BEmerg Nurse. 2013 Dec;21(8):28-33
BMJs Best Practice.