Rhabdomyolysis Diagnosis and Treatment
VBMC TRAUMA CARE SERVICES GUIDELINE
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.