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!

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Jay Khadpe MD

  • Editor in Chief of "The Original Kings of County"
  • Assistant Professor of Emergency Medicine
  • Assistant Residency Director
  • SUNY Downstate / Kings County Hospital

Latest posts by Jay Khadpe MD (see all)


Jay Khadpe MD

  • Editor in Chief of “The Original Kings of County”
  • Assistant Professor of Emergency Medicine
  • Assistant Residency Director
  • SUNY Downstate / Kings County Hospital

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