Diferencia entre revisiones de «Rhabdomyolysis»

(Created page with "==Background == Insert ==Diagnosis== Total CK > 10,000 (although may occur at different levels)Urine +heme without RBC ~80% sensitive ==Work-Up== Total CKCBCChem 10 ==D...")
 
(Strip excess bold)
 
(No se muestran 107 ediciones intermedias de 14 usuarios)
Línea 1: Línea 1:
==Background ==
==Background==
*Breakdown of skeletal muscle releasing intracellular contents into the circulation
*Key toxins: myoglobin (nephrotoxic), creatine kinase (CK), potassium, phosphate, uric acid
*Acute kidney injury (AKI) occurs in 15-40% of cases<ref name="bosch">Bosch X, et al. Rhabdomyolysis and acute kidney injury. ''N Engl J Med''. 2009;361(1):62-72. PMID 19571284.</ref>
*Overall mortality ~5%; higher with AKI, DIC, or [[Compartment syndrome|compartment syndrome]]


==Etiology==
*Trauma / Crush injury (most common worldwide)
*'''Exertional''' (exercise, seizures, agitation, status epilepticus)
*Drug/toxin-induced
**Statins (especially with interacting drugs)
**[[Cocaine toxicity|Cocaine]], [[Amphetamine toxicity|amphetamines]], MDMA, [[Ethanol toxicity|alcohol]]
**[[Neuroleptic malignant syndrome|NMS]], [[Serotonin syndrome]], [[Malignant hyperthermia]]
*Prolonged immobilization (found down, intraoperative)
*[[Hypokalemia]], [[Hypophosphatemia]], [[Hyponatremia]]
*[[Heat stroke]]
*Infections (influenza, COVID-19, Legionella)
*Hypothermia, [[Electrical injury|electrical injuries]]


Insert
==Clinical Features==
*Classic triad: myalgias, weakness, dark urine (tea/cola-colored)
**Full triad present in <10% of cases
*Muscle tenderness, swelling, and stiffness
*May be asymptomatic with only lab abnormalities
*Complications:
**[[Hyperkalemia]] (can cause [[Cardiac dysrhythmia|cardiac dysrhythmias]]) — '''life-threatening'''
**[[Acute kidney injury]] (oliguria, anuria)
**[[Compartment syndrome]]
**[[DIC]]
**Hypocalcemia (early), hypercalcemia (recovery phase)
**Metabolic acidosis


==Evaluation==
*Creatine kinase (CK) — diagnostic marker
**CK >5x upper limit of normal (typically >1,000 U/L) diagnostic
**CK >5,000 U/L: significant risk of AKI
**Peak CK at 24-72 hours; monitor serial levels
*Urinalysis: urine dipstick positive for "blood" but no RBCs on microscopy (myoglobinuria)
*BMP: potassium (may be severely elevated), creatinine, BUN, calcium, phosphate, bicarbonate
*CBC, LDH, uric acid, coagulation studies
*ECG — evaluate for [[Hyperkalemia|hyperkalemia]] changes (peaked T waves, wide QRS)
*Consider compartment pressures if clinical concern


==Diagnosis==
==Management==
===Aggressive IV Fluid Resuscitation===
*Cornerstone of treatment
*Normal saline at 200-300 mL/hr (or 1-2 L/hr initially if severely hypovolemic)<ref name="scharman">Scharman EJ, et al. Prevention of kidney injury following rhabdomyolysis: a systematic review. ''Ann Pharmacother''. 2013;47(1):90-105. PMID 23324509.</ref>
*Target urine output 200-300 mL/hr until CK trending down and urine clears
*Monitor for fluid overload, especially in elderly and those with cardiac/renal disease
*Bicarbonate drip (150 mEq NaHCO3 in 1 L D5W) may be considered to alkalinize urine (target urine pH >6.5) — evidence is limited


===Treat Hyperkalemia===
*See [[Hyperkalemia]] for detailed management
*Calcium gluconate 10% 10 mL IV for cardiac membrane stabilization if ECG changes
*Insulin 10 units regular IV + D50W 50 mL IV
*[[Sodium bicarbonate]], [[Albuterol]] nebulizer, [[Kayexalate]] or patiromer
*Emergent [[Hemodialysis|dialysis]] if refractory


Total CK > 10,000 (although may occur at different levels)Urine +heme without RBC ~80% sensitive ==Work-Up==
===Other===
*Treat underlying cause (cool if [[Heat stroke|hyperthermic]], correct electrolytes)
*Avoid nephrotoxins (NSAIDs, contrast dye, aminoglycosides)
*[[Compartment syndrome]]: emergent fasciotomy if pressures >30 mmHg or clinical diagnosis
*Monitor for and treat [[DIC]] if present


 
==Disposition==
Total CKCBCChem 10 ==DDx==
*Admit patients with:
 
**CK >5,000 U/L
 
**AKI (elevated creatinine)
Insert ==Treatment==
**[[Hyperkalemia]] or other electrolyte derangements
 
**Ongoing symptoms or rising CK
 
*Discharge may be considered for mild rhabdomyolysis (CK <5,000, normal renal function, normal K) with close follow-up and oral hydration
1) Aggressive IVF (often up to 10L per day)    -type of fluid = controversial    -NaBicarb (to alkalize urine)          -may exacerbate the symptoms of the initial hypocalcemic phase of rhabdomyolysis.          -urine pH and serum bicarbonate, calcium, and potassium levels should be monitored          -if urine pH does not rise after 4 to 6 hours of treatment or if symptomatic hypocalcemia develops, alkalinization should be discontinued and hydration continued with NS2) Monitor electrolytes    -correct hyperkalemia    -early hypocalcemia should NOT be treated unless symptomatic or severe hyperkalemia present    -Calcium-containing chelators should be used with caution to treat hyperphosphatemia, since the calcium load could increase the precipitation of calcium phosphate in injured muscle.==Disposition==
 
 
Insert
 
 
==Evidence Based Questions==
 
 
No randomized, controlled trial has supported the evidence-based use of mannitol, and some clinical studies suggest no beneficial effects. In addition, high accumulated doses of mannitol (>200 g per day or accumulated doses of >800 g) have been associated with acute kidney injury due to renal vasoconstriction and tubular toxicity, a condition known as osmotic nephrosis. However, many experts continue to suggest that mannitol should be used to prevent and treat rhabdomyolysis-induced acute kidney injury and relieve compartmental pressure. During the time mannitol is being administered, plasma osmolality and the osmolal gap (i.e., the difference between the measured and calculated serum osmolality) should be monitored frequently and therapy discontinued if adequate diuresis is not achieved or if the osmolal gap rises above 55 mOsm per kilogram.
 
A. Bozch X et al. Rhabdomyolysis and Acute Kidney Injury. NEJM 2009; 361: 62-72
 


==See Also==
==See Also==
*[[Hyperkalemia]]
*[[Acute kidney injury]]
*[[Compartment syndrome]]
*[[Crush injury]]
*[[Heat stroke]]


==References==
<references/>


Insert
[[Category:Renal]]
 
[[Category:Orthopedics]]
 
==Source==
 
 
KajQuestions
 
 
 
 
[[Category:GU]]

Revisión actual - 09:31 22 mar 2026

Background

  • Breakdown of skeletal muscle releasing intracellular contents into the circulation
  • Key toxins: myoglobin (nephrotoxic), creatine kinase (CK), potassium, phosphate, uric acid
  • Acute kidney injury (AKI) occurs in 15-40% of cases[1]
  • Overall mortality ~5%; higher with AKI, DIC, or compartment syndrome

Etiology

Clinical Features

  • Classic triad: myalgias, weakness, dark urine (tea/cola-colored)
    • Full triad present in <10% of cases
  • Muscle tenderness, swelling, and stiffness
  • May be asymptomatic with only lab abnormalities
  • Complications:

Evaluation

  • Creatine kinase (CK) — diagnostic marker
    • CK >5x upper limit of normal (typically >1,000 U/L) diagnostic
    • CK >5,000 U/L: significant risk of AKI
    • Peak CK at 24-72 hours; monitor serial levels
  • Urinalysis: urine dipstick positive for "blood" but no RBCs on microscopy (myoglobinuria)
  • BMP: potassium (may be severely elevated), creatinine, BUN, calcium, phosphate, bicarbonate
  • CBC, LDH, uric acid, coagulation studies
  • ECG — evaluate for hyperkalemia changes (peaked T waves, wide QRS)
  • Consider compartment pressures if clinical concern

Management

Aggressive IV Fluid Resuscitation

  • Cornerstone of treatment
  • Normal saline at 200-300 mL/hr (or 1-2 L/hr initially if severely hypovolemic)[2]
  • Target urine output 200-300 mL/hr until CK trending down and urine clears
  • Monitor for fluid overload, especially in elderly and those with cardiac/renal disease
  • Bicarbonate drip (150 mEq NaHCO3 in 1 L D5W) may be considered to alkalinize urine (target urine pH >6.5) — evidence is limited

Treat Hyperkalemia

Other

  • Treat underlying cause (cool if hyperthermic, correct electrolytes)
  • Avoid nephrotoxins (NSAIDs, contrast dye, aminoglycosides)
  • Compartment syndrome: emergent fasciotomy if pressures >30 mmHg or clinical diagnosis
  • Monitor for and treat DIC if present

Disposition

  • Admit patients with:
    • CK >5,000 U/L
    • AKI (elevated creatinine)
    • Hyperkalemia or other electrolyte derangements
    • Ongoing symptoms or rising CK
  • Discharge may be considered for mild rhabdomyolysis (CK <5,000, normal renal function, normal K) with close follow-up and oral hydration

See Also

References

  1. ↑ Bosch X, et al. Rhabdomyolysis and acute kidney injury. N Engl J Med. 2009;361(1):62-72. PMID 19571284.
  2. ↑ Scharman EJ, et al. Prevention of kidney injury following rhabdomyolysis: a systematic review. Ann Pharmacother. 2013;47(1):90-105. PMID 23324509.
Obtenido de «https://www.wikem.org/w/index.php?title=Rhabdomyolysis&oldid=389287»