1. Rhabdomyolysis By: Kevin Cummo

2. What is Rhabdomyolysis Rhabdomyolysis is the breakdown of muscle fibers, specifically of the sarcolemma of skeletal muscle, resulting in the release of muscle fiber contents (myoglobin) into the bloodstream.

3. Skeletal Muscle Cell The sarcolemma is the cell membrane of a muscle cell. The membrane is designed to receive and conduct stimuli Source: (Muscle Anatomy & Structure, 2007)

4. Why all the worry? When muscle is damaged, a protein pigment called myoglobin is released into the bloodstream and filtered out of the body by the kidneys. The broken down myoglobin may block the structures of the kidney, causing damage such as acute tubular necrosis or kidney failure. Dead muscle tissue may cause a large amount of fluid to move from the blood into the muscle, leading to hypovolemic shock. Causing reduced blood flow to the kidneys.

5. What causes Rhabdomyolysis? May result from a large variety of diseases, TRAUMA, or toxic insults to skeletal muscle Hereditary Risk Factors – Alcoholism – Crush Injuries – Heat intolerance – Heatstroke – Ischemia or necrosis of the muscles – Low phosphate levels – Seizures – Severe exertion – Shaking chills – Trauma – Use or overdose of drugs

6. What are the symptoms of Rhabdomyolysis? Muscle tenderness Weakness of the affected muscles General weakness Muscle stiffness or aching Abnormal urine color Additionally some possible symptoms include Overall fatigue Joint pain Seizures Weight gain

7. What are the possible complications of Rhabdomyolysis? Kidney damage Acute tubular necrosis Acute renal failure Hyperkalaemia Cardiac arrest Disseminated Intravascular Coagulation Compartment syndrome

8. How do you test for Rhabdomyolysis? An examination reveals tender or damaged skeletal muscles. Creatine Phosphokinase levels are very high. Serum myoglobin test is positive Serum potassium may be very high Urinalysis may reveal protein and be positive for hemoglobin without evidence of red blood cells on microscopic examination. Urine myoglobin test is positive.

9. How do you test for Rhabdomyolysis? (cont.) This disease may also alter the results of the following tests: – Creatine Phosphokinase isoenzymes – Urine creatinine – Serum creatinine  Creatinine is a product of metabolized creatine. If kidney function is abnormal, creatinine levels will increase in the blood.

10. EMS Treatment 1.Immediately obtain intravenous access with a large-bore catheter. 2.Administer isotonic crystalloid 500 mL/h and then titrate to maintain a urine output of 200-300 mL/h.

11. Treatment (Cont.) Early and aggressive fluids (hydration) may prevent complications by rapidly remove myoglobin out of the kidneys. Administer isotonic crystalloid fluids (Normal Saline or Lactated Ringer’s). Give as much fluid as you would give a severely burned patient. Studies of patients with severe crush injuries resulting in Rhabdomyolysis suggest that the prognosis is better when prehospital personnel provide FLUID RESUCITATION!

12. Treatment (Cont.) Medicines that may be prescribed include diuretics and sodium bicarbonate. Hyperkalemia should be treated if present. Kidney failure should be treated as appropriate.

13. Prognosis of Rhabdomyolysis The outcome varies depending on the extent of kidney damage. Source: Silberber, 2007

14. How can I prevent Rhabdomyolysis? Drink plenty of fluids after strenous exercise to dilute the urine and flush the myoglobin out of the kidney. Proper hydration is also necessary after any condition or event that may involve damage to skeletal muscle.

15. Now that you know…CHECK THIS OUT Rhabdomyolysis accounts for an estimated 8- 15% of cases of acute renal failure. The overall mortality rate for patients with Rhabdomyolysis is approximately 5% Rhabdomyolysis is more common in Males than in Females May occur in infants, toddlers, and adolescents

16. Hmmm…That’s weird... “Rhabdomyolysis was first reported in 1881, in the German literature” (Abbeele, Parker, 1985). “Rhabdomyolysis was first described in the victims of crush injury during the 1940-1941 London, England, bombing raids of World War II” (Craig, 2006).

17. Bibliography Abbeele M.D., A.D. Van den, and J. Anthony Parker, M.D. (April 9, 1985). Rhabdomyolysis. Retrieved Nov. 15, 2007. http://www.med.harvard.edu/JPNM/BoneTF/Case18/WriteUp18.html Baggaley, DR. Paul. (1997). Rhabdomyolysis. Retrieved Nov. 15, 2007. http://members.tripod.com/~baggas/rhabdo.html Craig M.D., Sandy. (Nov. 30, 2006). Rhabdomyolysis. Retrieved Nov. 15, 2007. http://www.emedicine.com/emerg/topic508.htm Definition of Rhabdomyolysis. (March 14, 2003). Retrieved Nov. 15, 2007. http://www.medterms.com/script/main/art.asp?articlekey=5352 http://www.medterms.com/script/main/art.asp?articlekey=5352 Handler M.D., Jonathan A. (2000) Rhabdomyolysis: Taking it one day at a time. Retrieved Nov. 15, 2007. http://www.spiralnotebook.org/rhabdomyolysis/ Mayo Clinic Staff. (Aug. 16, 2006). Rhabdomyolysis from statin use: What are the symptoms? Nov. 15, 2007. http://www.mayoclinic.com/health/rhabdomyolysis/AN01413 Muscal M.D.,Eyal. (Apr.13, 2007). Rhabdomyolysis. Retrieved Nov. 15, 2007. http://www.emedicine.com/ped/topic2003.htm Muscle Anatomy & Structure. (2007) Retrieved Nov. 20, 2007. www.sport-fitness-advisor.com Rhabdomyolysis: Kidney Failure and Damage. (2007). Retrieved Nov. 15, 2007. http://www.rhabdomyolysis.org/ http://www.rhabdomyolysis.org/ Silberber, Charles. (Aug. 14, 2007). MedlinePlus Medical Encyclopedia: Rhabdomyolysis. Retrieved Nov. 15, 2007. http://www.nlm.nih.gov/medlineplus/ency/article/000473.htm http://www.nlm.nih.gov/medlineplus/ency/article/000473.htm