Rhabdomyolysis in Emergency Medicine Clinical Presentation

  • Author: Sandy Craig, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Sep 21, 2011
 

History

[1]

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Physical

Focal or diffuse skeletal muscle swelling is rare. In Gabow's series, only 5% of the patients presented with muscle edema.

Tense and tender muscle compartments suggest compartment syndrome; peripheral pulses that are within reference range do not rule out compartment syndrome because loss of distal pulses is a very late sign.

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Causes

The etiologies may be subdivided into traumatic, exercise induced, toxicologic, environmental, metabolic, infectious, immunologic, and inherited classifications.

Rhabdomyolysis may occur after traumatic events, including the following:

  • Significant blunt trauma or crush injury[8]
  • High-voltage electrical injury
  • Extensive burns
  • Near drowning
  • Prolonged immobilization (eg, after excess alcohol or drug consumption, after an unwitnessed incapacitating stroke, following prolonged surgical procedures)

Rhabdomyolysis may occur after excessive muscular activity, such as the following:

  • Sporadic strenuous exercise (eg, marathons, squats, push-ups, sit-ups)[9]
  • Status epilepticus
  • Status asthmaticus[10]
  • Severe dystonia
  • Acute psychosis
  • Excessive computer keyboard use/gaming[11]

Toxin-mediated rhabdomyolysis may result from substance abuse, including abuse of the following:

  • Ethanol
  • Methanol
  • Ethylene glycol
  • Isopropanol
  • Heroin
  • Methadone
  • Barbiturates
  • Cocaine
  • Amphetamine
  • Phencyclidine
  • 3,4-methylenedioxymethamphetamine (MDMA, ecstasy)
  • Lysergic acid diethylamide (LSD)

Toxic-mediated rhabdomyolysis may result from prescription and nonprescription medications, including the following:

  • Antihistamines
  • Salicylates
  • Caffeine[12]
  • Fibric acid derivatives (eg, bezafibrate, clofibrate, fenofibrate, gemfibrozil)[13]
  • Neuroleptics/antipsychotics[14]
  • Anesthetic and paralytic agents (the malignant hyperthermia syndrome)
  • Amphotericin B
  • Quinine
  • Corticosteroids
  • Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors)[7]
  • Theophylline
  • Cyclic antidepressants
  • Selective serotonin reuptake inhibitors (the serotonin syndrome)
  • Aminocaproic acid
  • Phenylpropanolamine (recalled from US market)
  • Propofol (continuous infusion)[15]
  • Protease inhibitors

Rhabdomyolysis may be caused by other toxins, including the following:

  • Carbon monoxide[16]
  • Toluene
  • Hemlock herbs from quail (Rhabdomyolysis after the consumption of quail is well known in the Mediterranean region; it occurs as the result of intoxication by hemlock herbs that the quails consume.)
  • Snake, spider (eg, black widow spider), and massive envenomations of Africanized honey bees

Environmental causes of rhabdomyolysis include the following:

  • Hyperthermia
  • Hypothermia[17]

Metabolic causes of rhabdomyolysis include the following:

  • Hyponatremia[18] or hypernatremia
  • Hypokalemia[19]
  • Hypophosphatemia
  • Hypothyroidism or hyperthyroidism[20]
  • Diabetic ketoacidosis
  • Nonketotic hyperosmolar diabetic coma

Viral infectious disease agents may cause rhabdomyolysis, including the following:[21]

  • Influenza types A and B (most common)
  • HIV[22]
  • Coxsackievirus[23]
  • Ebstein-Barr virus
  • Echovirus
  • Cytomegalovirus
  • Adenovirus
  • Herpes simplex virus
  • Parainfluenza virus
  • Varicella-zoster virus[24]
  • West Nile virus[25]

Bacterial infectious agents may cause rhabdomyolysis, including the following:[26]

  • Francisella tularensis[27]
  • Streptococcus pneumoniae
  • Group B streptococci
  • Streptococcus pyogenes
  • Staphylococcus epidermidis
  • Escherichia coli
  • Borrelia burgdorferi
  • Clostridium perfringens
  • Clostridium tetani
  • Viridans streptococci
  • Plasmodium species
  • Rickettsia species
  • Salmonella species
  • Listeria species
  • Legionella species[28]
  • Mycoplasma species[29]
  • Vibrio species
  • Brucella species
  • Bacillus species
  • Leptospira species[30]

Fungal infectious agents may cause rhabdomyolysis, including the following:[26]

  • Candida species
  • Aspergillus species

Causative connective tissue diseases that can cause rhabdomyolysis include the following:

  • Polymyositis
  • Dermatomyositis

Inherited disorders may cause rhabdomyolysis, including the following:

  • Enzyme deficiencies of carbohydrate, lipid, or amino acid metabolism[31, 32]
  • Myopathies[33]

Rhabdomyolysis also has been reported in patients with sickle cell anemia and has mistakenly been identified as a pain crisis.

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Contributor Information and Disclosures
Author

Sandy Craig, MD  Residency Program Director, Carolinas Medical Center; Associate Professor, Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine

Sandy Craig, MD is a member of the following medical societies: Alpha Omega Alpha and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Lance W Kreplick, MD, FAAEM, MMM  Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC

Lance W Kreplick, MD, FAAEM, MMM, is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Tom Scaletta, MD  Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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