1.
RHABDOMYOLYSIS
DR JAMSHEER V T MBBS MS MCh
SURGICAL ONCOLOGY

2.
• Syndrome Characterized By Muscle Necrosis
And The Release Of Intracellular Muscle
Constituents Into The Circulation.

3.
COMMON CAUSES
• Drugs Of Abuse And Alcohol
• Medications
• Muscle Diseases
• Trauma
• Neuroleptic Malignant Syndrome
• Seizures
• Immobility
• Infection
• Strenuous Physical Activity
• Heat-related Illness

4.
CHILDREN
• Viral Myositis
• Trauma
• Connective Tissue Disease.
• Inherited Metabolic Disorders

5.
DRUGS
• Cyclosporine
• Macrolide Antibiotics
• Warfarin
• Digoxin
• Statin Therapy

6.
CLINICAL MANIFESTATIONS
• Asymptomatic elevations of Enzymes to Life-
threatening disease
• Creatine Kinase (CK)
• Most are nonspecific

7.
TRIAD(1-10%)
• Myalgias
• Muscle weakness
• Red to brown urine

8.
Muscle
• Pain - Thighs And Shoulders, and in the Lower
back and Calves
• Weakness –(12 - 70 %)
• Swelling –(8 to 52%) fluid repletion:

9.
Urine
• Red to brown / Tea-colored /cola-colored
• 100 to 300 mg/Dl
• Orthotolidine/ dipstick - Only 0.5 to 1 mg/Dl

10.
OTHER
Skin — discoloration / blisters
Systemic
• Malaise
• Fever
• Tachycardia
• Nausea & Vomiting
• Abdominal Pain

11.
Fluid And Electrolyte Abnormalities
●Hypovolemia results from "third-spacing“
●Hyperkalemia and hyperphosphatemia
●Hypocalcemia
●Severe hyperuricemia
●Metabolic acidosis.

12.
COMPARTMENT SYNDROME
• Excessive Fluid resuscitation
• Traumatic (eg, tibial fractures)
• Nontraumatic (eg, prolonged limb
compression)

13.
DISSEMINATED INTRAVASCULAR COAGULATION
• Release of thromboplastin and other
prothrombotic substances

14.
Other Organ Involvement
●Liver injury – Liver dysfunction, typically
reversible, occurs in up to 25 percent.
●Neurologic – Altered mental status due to
toxins, drugs, trauma
●Pulmonary – Respiratory failure or ARDS

15.
History And Examination
●Recent trauma
●Prescription medications with attention to
myotoxic agents
●Alcohol and/or substance abuse
●Prolonged immobilization
●Strenuous or unaccustomed physical exertion or
exercise
●Heat exposure or hyperthermia of any cause
●History of myopathy or muscular dystrophy
●Prior episodes of rhabdomyolysis
●Electrocution/ Burn injury
●Convulsive seizure

16.
Examination
• Including muscle weakness
• Tenderness
• Limb edema
• Evidence of trauma
• Compartment syndrome

17.
MANAGEMENT
• INVESTIGATION
• TREATMENT

18.
Initial laboratory studies
●CBC P.Smear for infection or hemolysis
● Urinalysis
●RFT
●Routine electrolytes plus calcium and
phosphate, for hyperkalemia, hypocalcemia,
and hyperphosphatemia
●Liver function tests

19.
● PT, aPTT ,D-dimer, and fibrinogen, for DIC
●ABG for metabolic acidosis
●Serum albumin
●ECG for cardiac dysrhythmias secondary to
hyperkalemia and hypocalcemia

20.
Creatine Kinase Elevation
The standard biomarker
• Rise within 2 to 12 hours
• Maximum within 24 to 72 hours
• A decline within 3-5 days
NOT DECLINE AS EXPECTED
• Continued muscle injury
• Underlying muscle disease
• Compartment syndrome may be present

21.
• Five times the upper limit of normal
• Range from approximately 1500 to over
100,000 units/L.
• Malignant Hyperthermia avg value 60,000
units/L.

22.
PREHOSPITAL CARE
• Early and vigorous IV fluid resuscitation is the
most important treatment to prevent AKI
• Avoid potassium- or lactate-containing
solutions
• Preferred fluid is iv ns

23.
EMERGENCY DEPARTMENT CARE
• Proper history
• Ask for co morbidities / medications
• Vitals
• ECG monitoring
• Catheterisation
• Basic investigation including electrolytes

24.
• Continue aggressive IV rehydration.
• IV crystalloids infusion of 4 ml/kg/h
• Goal of maintaining a minimum urine output
of 200 to 300 ml/ hour.

25.
• No Ideal fluid
• Urine alkalinization (sodium bicarbonate)
• Forced diuresis (mannitol or loop diuretics)
• CK >10000...Mannitol& Bicarbonates

26.
• Hypocalcemia – no treatment needed
• IV-Calcium - hyperkalemia-induced
cardiotoxicity
Hyperkalemia
• Insulin - glucose therapy may not be effective.
• The use of ion-exchange resins (e.g., sodium
polystyrene sulfonate) may be effective.

27.
• hyperphosphatemia - oral phosphate binders
when serum levels are >7 milligrams/Dl
• Avoid prostaglandin inhibitors such as NSAIDs
because of their vasoconstrictive effects on
the kidney.
• Treat the underlying cause