Rhabdomyolysis in Emergency Medicine Workup

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

Laboratory Studies

Preliminary diagnosis of rhabdomyolysis requires a high index of suspicion. Definitive diagnosis is made by laboratory evaluation.

The most useful measurement is for serum creatine kinase (CK). This assay is widely available and 100% sensitive. Rhabdomyolysis has been variously defined as total CK levels 5-10 times above normal in a patient with typical symptoms and/or risk factors.

Total CK elevation is a sensitive but nonspecific marker for rhabdomyolysis. Suspect early rhabdomyolysis in patients with serum CK levels in excess of 2-3 times the reference range and risk factors for rhabdomyolysis; initiate a full laboratory workup. Remember that the total CK may increase from the initial values, and repeat total CK levels should be drawn every 6-12 hours until a peak level is established. Patients with other disorders, such as acute myocardial infarction and acute stroke, may have high CK levels. CK levels have a wide range of distribution among patients with rhabdomyolysis (several hundred to hundreds of thousands of units per liter). Serum CK levels peak within 24 hours and should decrease by approximately 30-40% per day after the initial insult.[34] Persistent elevation suggests continuing muscle injury or development of a compartment syndrome.[35]

A urine dipstick test for blood has positive results in the presence of hemoglobin or myoglobin. A urine dipstick test for blood that has positive findings in the absence of red blood cells suggests myoglobinuria. Myoglobinuria may be sporadic or resolve early in the course of rhabdomyolysis. Urine dipstick findings are positive in fewer than 50% of patients with rhabdomyolysis; therefore, a normal urine dipstick test result does not rule out this condition.[36]

Aldolase, lactate dehydrogenase (LDH), and serum glutamic-oxaloacetic transaminase (SGOT) are nonspecific enzyme markers that are elevated in patients with rhabdomyolysis.

One series of 109 emergency department patients with rhabdomyolysis found that 50% had an elevated cardiac troponin I level. Of these, 58% were ultimately found (based on ECG and echocardiography) to be true positives, 33% were false positives, and 9% were indeterminate.[37]

Hyperkalemia, an immediate threat to life in the hours immediately after injury, occurs in 10-40% of cases. Liberated potassium can cause life-threatening dysrhythmias and death. Measure and closely monitor serum potassium levels.

Acute renal failure develops in 30-40% of patients and is the most serious complication in the days after initial presentation. Measure and closely monitor blood urea nitrogen (BUN) and creatinine levels. The BUN-creatinine ratio can be decreased because of the conversion of liberated muscle creatine to creatinine. In one emergency department – based study of 97 adults with rhabdomyolysis, no patient with an initial creatinine level of less than 1.7 mg/dL developed acute renal failure.[38]

Hyperphosphatemia does not require specific therapy. Hypocalcemia occurs early in the course of rhabdomyolysis. Supplemental calcium is not recommended. Increased purine metabolism causes hyperuricemia. Specific therapy with uricosuric agents or allopurinol is not indicated.

Obtain the prothrombin time, activated partial thromboplastin time, and platelet count in all patients with rhabdomyolysis. Thromboplastin released from injured myocytes can cause DIC.

Next

Imaging Studies

Imaging studies generally play little role in the initial diagnosis of rhabdomyolysis.

MRI may be useful in distinguishing various etiologies of myopathy.

One study suggests that bacterial myositis, focal myositis, and idiopathic rhabdomyolysis show a characteristic gadolinium enhancement on MRI. Abscesses were found only in bacterial myositis.

Polymyositis and dermatomyositis have a characteristic uniform distribution pattern with emphasis on the quadriceps muscles.

MRI is the imaging modality of choice to evaluate the distribution and extent of injury of affected muscles, especially when fasciotomy or involvement of deep compartments is considered.[39]

Previous
Next

Other Tests

Obtain an electrocardiogram (ECG) early in the course of ED evaluation.

ECG may reveal changes of acute hyperkalemia, including peaked T waves, prolongation of the PR and QRS intervals, and loss of the P wave or the sine wave.

Previous
Next

Procedures

Measure the compartment pressures in any patient with severe focal muscle tenderness and a firm muscle compartment.

Perform a fasciotomy if compartment pressures are sustained in excess of 25-30 mm Hg.

Previous
Proceed to Treatment & Management
 
 
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

References

  1. Better OS. The crush syndrome revisited (1940-1990). Nephron. 1990;55(2):97-103. [Medline].

  2. Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med. Jul 2 2009;361(1):62-72. [Medline].

  3. Gabow PA, Kaehny WD, Kelleher SP. The spectrum of rhabdomyolysis. Medicine (Baltimore). May 1982;61(3):141-52. [Medline].

  4. Ward MM. Factors predictive of acute renal failure in rhabdomyolysis. Arch Intern Med. Jul 1988;148(7):1553-7. [Medline].

  5. Melli G, Chaudhry V, Cornblath DR. Rhabdomyolysis: an evaluation of 475 hospitalized patients. Medicine (Baltimore). Nov 2005;84(6):377-85. [Medline].

  6. Mannix R, Tan ML, Wright R, Baskin M. Acute pediatric rhabdomyolysis: causes and rates of renal failure. Pediatrics. Nov 2006;118(5):2119-25. [Medline].

  7. Ahn SC. Neuromuscular complications of statins. Phys Med Rehabil Clin N Am. Feb 2008;19(1):47-59, vi. [Medline].

  8. Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin. Jan 2004;20(1):171-92. [Medline].

  9. Lin AC, Lin CM, Wang TL, Leu JG. Rhabdomyolysis in 119 students after repetitive exercise. Br J Sports Med. Jan 2005;39(1):e3. [Medline].

  10. Chen YJ, Chang SH, Yuan A, Huang CH, Lee CC. Rhabdomyolysis after successful resuscitation of a patient with near-fatal asthma. Am J Emerg Med. Jul 2007;25(6):736.e3-4. [Medline].

  11. Song SH, Lee DW, Lee SB, Kwak IS. Rhabdomyolysis caused by strenuous computer gaming. Nephrol Dial Transplant. Apr 2007;22(4):1263-4. [Medline].

  12. Wrenn KD, Oschner I. Rhabdomyolysis induced by a caffeine overdose. Ann Emerg Med. Jan 1989;18(1):94-7. [Medline].

  13. Holoshitz N, Alsheikh-Ali AA, Karas RH. Relative safety of gemfibrozil and fenofibrate in the absence of concomitant cerivastatin use. Am J Cardiol. Jan 1 2008;101(1):95-7. [Medline].

  14. Hung CF, Huang TY, Lin PY. Hypothermia and rhabdomyolysis following olanzapine injection in an adolescent with schizophreniform disorder. Gen Hosp Psychiatry. Jul-Aug 2009;31(4):376-8. [Medline].

  15. Wysowski DK, Pollock ML. Reports of death with use of propofol (Diprivan) for nonprocedural (long-term) sedation and literature review. Anesthesiology. Nov 2006;105(5):1047-51. [Medline].

  16. Kao LW, Nañagas KA. Toxicity associated with carbon monoxide. Clin Lab Med. Mar 2006;26(1):99-125. [Medline].

  17. Aslam AF, Aslam AK, Vasavada BC, Khan IA. Hypothermia: evaluation, electrocardiographic manifestations, and management. Am J Med. Apr 2006;119(4):297-301. [Medline].

  18. Strachan P, Prisco D, Multz AS. Recurrent rhabdomyolysis associated with polydipsia-induced hyponatremia - a case report and review of the literature. Gen Hosp Psychiatry. Mar-Apr 2007;29(2):172-4. [Medline].

  19. Agrawal S, Agrawal V, Taneja A. Hypokalemia causing rhabdomyolysis resulting in life-threatening hyperkalemia. Pediatr Nephrol. Feb 2006;21(2):289-91. [Medline].

  20. Lichtstein DM, Arteaga RB. Rhabdomyolysis associated with hyperthyroidism. Am J Med Sci. Aug 2006;332(2):103-5. [Medline].

  21. Nauss MD, Schmidt EL, Pancioli AM. Viral myositis leading to rhabdomyolysis: a case report and literature review. Am J Emerg Med. Mar 2009;27(3):372.e5-372.e6. [Medline].

  22. Patel N, Patel N, Espinoza LR. HIV infection and rheumatic diseases: the changing spectrum of clinical enigma. Rheum Dis Clin North Am. Feb 2009;35(1):139-61. [Medline].

  23. Wang YM, Zhang Y, Ye ZB. Rhabdomyolysis following recent severe coxsackie virus infection in patient with chronic renal failure: one case report and a review of the literature. Ren Fail. 2006;28(1):89-93. [Medline].

  24. Pirounaki M, Liatsos G, Elefsiniotis I, Skounakis M, Moulakakis A. Unusual onset of varicella zoster reactivation with meningoencephalitis, followed by rhabdomyolysis and renal failure in a young, immunocompetent patient. Scand J Infect Dis. 2007;39(1):90-3. [Medline].

  25. Gupta M, Ghaffari M, Freire AX. Rhabdomyolysis in a patient with West Nile encephalitis and flaccid paralysis. Tenn Med. Apr 2008;101(4):45-7. [Medline].

  26. Singh U, Scheld WM. Infectious etiologies of rhabdomyolysis: three case reports and review. Clin Infect Dis. Apr 1996;22(4):642-9. [Medline].

  27. Eliasson H, Broman T, Forsman M, Bäck E. Tularemia: current epidemiology and disease management. Infect Dis Clin North Am. Jun 2006;20(2):289-311, ix. [Medline].

  28. Antonarakis ES, Wung PK, Durand DJ, Leyngold I, Meyerson DA. An atypical complication of atypical pneumonia. Am J Med. Oct 2006;119(10):824-7. [Medline].

  29. Weng WC, Peng SS, Wang SB, Chou YT, Lee WT. Mycoplasma pneumoniae--associated transverse myelitis and rhabdomyolysis. Pediatr Neurol. Feb 2009;40(2):128-30. [Medline].

  30. Turhan V, Atasoyu EM, Kucukardali Y, Polat E, Cesur T, Cavuslu S. Leptospirosis presenting as severe rhabdomyolysis and pulmonary haemorrhage. J Infect. Jan 2006;52(1):e1-2. [Medline].

  31. Scheuerman O, Wanders RJ, Waterham HR, Dubnov-Raz G, Garty BZ. Mitochondrial trifunctional protein deficiency with recurrent rhabdomyolysis. Pediatr Neurol. Jun 2009;40(6):465-7. [Medline].

  32. Korematsu S, Kosugi Y, Kumamoto T, Yamaguchi S, Izumi T. Novel mutation of early, perinatal-onset, myopathic-type very-long-chain acyl-CoA dehydrogenase deficiency. Pediatr Neurol. Aug 2009;41(2):151-3. [Medline].

  33. Brumback RA, Feeback DL, Leech RW. Rhabdomyolysis in childhood. A primer on normal muscle function and selected metabolic myopathies characterized by disordered energy production. Pediatr Clin North Am. Aug 1992;39(4):821-58. [Medline].

  34. Lappalainen H, Tiula E, Uotila L. Elimination kinetics of myoglobin and creatine kinase in rhabdomyolysis: implications for follow-up. Crit Care Med. Oct 2002;30(10):2212-5. [Medline].

  35. Minnema BJ, Neligan PC, Quraishi NA, Fehlings MG, Prakash S. A case of occult compartment syndrome and nonresolving rhabdomyolysis. J Gen Intern Med. Jun 2008;23(6):871-4. [Medline].

  36. Young SE, Miller MA, Docherty M. Urine dipstick testing to rule out rhabdomyolysis in patients with suspected heat injury. Am J Emerg Med. Sep 2009;27(7):875-7. [Medline].

  37. Li SF, Zapata J, Tillem E. The prevalence of false-positive cardiac troponin I in ED patients with rhabdomyolysis. Am J Emerg Med. Nov 2005;23(7):860-3. [Medline].

  38. Fernandez WG, Hung O, Bruno GR, Galea S, Chiang WK. Factors predictive of acute renal failure and need for hemodialysis among ED patients with rhabdomyolysis. Am J Emerg Med. Jan 2005;23(1):1-7. [Medline].

  39. Moratalla MB, Braun P, Fornas GM. Importance of MRI in the diagnosis and treatment of rhabdomyolysis. Eur J Radiol. Feb 2008;65(2):311-5. [Medline].

  40. Better OS, Stein JH. Early management of shock and prophylaxis of acute renal failure in traumatic rhabdomyolysis. N Engl J Med. Mar 22 1990;322(12):825-9. [Medline].

  41. Iraj N, Saeed S, Mostafa H, Houshang S, Ali S, Farin RF, et al. Prophylactic fluid therapy in crushed victims of Bam earthquake. Am J Emerg Med. Sep 2011;29(7):738-42. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.