Today’s morning report comes courtesy of Dr. Lau.
It begins with the following case presentation:
22 yo m with no pmh BIBEMS for syncope c/o nausea, fatigue, and generalized myalgias.
Pt states just returned from a trip to Miami where he was enrolled at a training bootcamp for 2 days and was sunburnt on the beach.
Exam:
Vitals stable, afebrile
Alert and oriented
Mostly 1st degree burns on chest wall
Any thoughts so far?
Keep reading below for lab results and the conclusion:
Labs:
CK: 26000
UA: +myoglobin
K, Cr normal
Dx: Rhabdomyolysis
– Disruption of calcium homeostasis of muscle cell
- Direct cell membrane damage
- Trauma, hereditary, biochemical -> direct Ca influx
- ATP depletion
- Increased intracell Ca by disrupting Na/K ATPase -> triggers apoptosis, cell death
– Most common presentations
- Prolonged immobilization e.g. old people who fall at home
- Intoxication esp. sympathomimetics, alcohol
- Altered mental status esp. agitated delirium
– Less common
- Also remember that many pharmaceuticals, eg. Statins, neuroleptics, antihistamines…
- Crush injuries, compartment syndrome
- Excessive muscular activity (marathon runners, prisoners wanting a hospital vacation does 2000 squats to get rhabdo, now boon of “boot camps” and crossfit)
- ….
– Labs
- Elevated CK
- Myoglobin in urine
- HyperK, Hyperphos, early hypoCa, late hyperCa
- Increased BUN and Cr but decreased BUN:Cr due to release of Cr from muscle, normal 10:1, can be 5:1 in rhabdo
– EKG – look for signs of hyper K
– Early complications
- Electrolyte abnormalities -> dysrhymias
- Hypovolemia – likely already dehydrated, but damaged muscle -> fluid sequestration -> intravasc volume depletion
– Late
- Renal due to myoglobin cast and direct cytotoxic effects of myoglobin
– Treat
- Aggressive volume expansion
- Delayed fluid resus -> develop acute renal failure (in fact, pts in mass casualty events – initiate fluid resus before complete extrication)
- Urine alkalinization controversial
- Based on animal data that myoglobin precipitation increased in acidic urine
- Not shown to impact outcomes in humans
- NS with 1 amp sodium bicarb at 100 ml/h – but look out for hypoCa
- Mannitol controversial, no benefits shown – osmotic diuretic thought to increase urine flow therefore reduce myoglobin cast obstruction of renal tubules
- Furosemide if pt is oliguric but must only do so after assuring adequate intravasc volume
- Renal replacement therapy if uncorrectable metabolic acidosis, life-threatening hyperK, renal failure
Thanks Dr. Lau!
Jay Khadpe MD
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