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.