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Traumatic rhabdomyolysis: causes, pathophysiology and management strategies

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A crush injury is direct injury resulting from a crush ... Oda, Jun MD; Tanaka, Hiroshi MD; Analysis of 372 Patients with Crush Syndrome ... – PowerPoint PPT presentation

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Title: Traumatic rhabdomyolysis: causes, pathophysiology and management strategies


1
Traumatic rhabdomyolysis causes, pathophysiology
and management strategies
  • By Sharon Fish

2
Overview
  • Definitions
  • Historically
  • Causes
  • Pathophysiology
  • Clinical
  • Management

3
Definitions
  • Rhabdomyolysis - destruction of striated muscle
  • A crush injury is direct injury resulting from a
    crush
  • A crush syndrome is the systemic manifestation of
    muscle cell damage, resulting from pressure or
    crushing.
  • Also known as traumatic rhabdomyolysis

4
  • Based on 3 criteria
  • Involvement of a muscle mass
  • Prolonged compression
  • Compromised local circular

5
History
  • In 1910 Myer-Betz Syndrome, German physician.
  • Triad Muscle Pain, Weakness, Brown Urine.
  • World War II
  • Dr Bywaters described patients during London
    Bombings (Battle of Britain 1941).
  • Oliguria, pigmented casts, limb oedema, shock and
    death.
  • In 1943, in animal models, Bywaters Stead
    identified myoglobin as the offending agent, and
    formulated the first treatment plan.

6
History
  • In 1950 Korean War, dialysis reduces mortality
    rate from 84 to 53.
  • Natural Disasters Earthquakes
  • 1976 Tangshan (near Beijing) 20 of 242,000
    deaths due to crush syndrome.
  • 1988 Spitak (Armenia)
  • In 1995, British nephrologists introduced the
    Disaster Relief Task Force with the goal to
    prevent acute renal failure.
  • 1999 Marmara (Turkey) 7.2 Richter scale
    earthquake. 12 hospitalised patients had renal
    failure, 76 received dialysis, 19 fatality rate.

7
Causes - Traumatic
  • Trauma and compression
  • Crush injuries
  • MVA
  • Long-term confinement without changing position
  • Physical torture and abuse
  • Prolonged hours of surgery without changing
    position

8
Causes Non-traumatic
  • Strainful muscle exercise
  • Electrical current
  • Lightning
  • Cardioversion
  • Electric shock
  • Hyperthermia
  • Neuromuscular malignant syndrome
  • Heat stroke
  • Metabolic disorders
  • Mcardles disease
  • Palmitoyotransferase def
  • Drugs
  • Cocaine
  • statins
  • Sepsis

9
(No Transcript)
10
pathogenesis
  • Compressive forces leads to cellular
    hypoperfusion and hypoxia
  • Decrease in ATPase?failure of ATPase pump and
    sacrolemma leakage
  • Lysed cell release inflammatory mediators
  • platelet aggregation
  • vasoconstriction
  • inc vasc permeability

11
  • Lysed cell release
  • Potassium
  • Phospate
  • Creatine kinase
  • Myoglobin
  • Electrolyte disturbances
  • Hyperkalaemia
  • Hypocalcaemia
  • Hyperphosphatemia
  • Hyperuricaemia
  • Metabolic acidosis

12
  • Revascularization
  • Fluids trapped in damaged tissue
  • Oedema of affected limb
  • Haemoconcentration and shock
  • Myoglobin, potassium, phosphate enter venous
    circulation

13
Mechanisms of ARF in rhabdomyolysis
  • Renal vasoconstriction with diminished renal
    perfusion
  • Cast formation leads to tubular obstruction
  • Direct Myoglobin nephrotoxicity- Haeme produced
    free radicles

14
Clinical manifestations
  • Range from asymptomatic to acute renal failure
    and DIC
  • Triad muscle pain weakness ,dark urine
  • Musculoskeletal signs
  • General manifestations
  • Complications
  • early
  • late

15
Musculoskeletal signs
  • Pain
  • Weakness
  • Swelling

16
General manifestation
  • Malaise
  • Fever
  • Tachycardia
  • Nausea
  • vomiting

17
Complications
  • Early
  • Hypovolaemia
  • Hyperkalaemia
  • Hypocalcaemia
  • Cardiac arrhythmias
  • Cardiac arrest
  • Compartment syndrome
  • Late(12-72hrs)
  • Acute renal failure
  • DIC
  • ARDS
  • sepsis

18
Lab findings
  • CK n 45-260U/L
  • Rises within 12hours
  • Peaks 1-3 days
  • Declines 3-5days after cessation of muscle injury

19
CK-peak
  • Huerta-Alardin et al CKgt5000U/L serious muscle
    injury, related to renal failure
  • Gonzales et algt10000U/L related to ARF
  • Brown et al 2083 trauma ICUadmission,85abn CK
    (gt520)
  • 74 of 382 lt5000U/L developed RF(8)
  • 143 of 1701 gt5000U/L developed RF(19)
  • Renal failure defined peak creatinine gt2mg/dl

20
CK-peak
  • Oda et al 372 crush injury pts at Hanshin
    earthquake
  • CK lt 75000 45 of 115 (39) developed RF
    requiring dialysis
  • CK gt 75000 43 of 51 (84.3) developed renal
    failure requiring dialysis
  • Note different definitions of renal failure

21
Other muscle markers
  • Measuring myoglobin level in serum or urine
  • Appears in urine when plasma concentration
    exceeds 1.5mg/dl
  • Urine becomes dark red brown colour gt100mg/dl
  • Myoglobin has short T1/2 (2-3hours)
  • Serum level return to normal after 6-8hours

22
  • Carbonic anhydrase 3
  • Aldolase
  • Trop T I

23
Lab tests
  • Raised UE
  • Hyperkalaemia
  • hypocalcaemia
  • hyperphosphataemia
  • uric acid

24
Treatment
  • A B C
  • Fluids
  • Treat hyperkalaemia

25
Fluids
  • When
  • if possible before the crush is relieved
  • What
  • isotonic crystalloids are favoured normal saline
    preferred (consensus meeting crush syndrome
    2001-Edinburgh) (R/L have 4 mEq K )
  • How much
  • Gonzalez et aladult
  • extrication 1.5l/hr
  • postextrication .5l/hr alternating with D5W
  • Children 10-20ml/kg/hr
  • Urine output -.50ml/hr -200mls/hr
  • Children 2mls/kg/hr
  • CVP Smith et al suggest fluid bolus until a
    sustained increase in CVP (gt3mmhg after 15 min )
  • Stop fluids if patient oliguric, fluid
    overloaded, consider dialysis

26
Alkalinisation of urine
  • Alkalinisation increases the solubility of
    myoglobin and promotes its excretion .
  • Bicarbonate is used to raise the urine pH to 6.5
    thereby increasing solubility of Haeme pigments
  • Add 50 ml 8.5sodium bicarbonate to each litre
  • HOWEVER little clinical evidence to support use
  • Brown and colleagues CK gt5000U/L
  • 154(40) received mannitol and bicarbonate
  • 228 (60) didnt
  • No significant difference in renal failure
    ,dialysis,or mortality between the groups.

27
Mannitol
28
  • It was postulated that treatment with mannitol
    was more efficacious than isotonic volume
    expansion alone.
  • It is argued that it forces an osmotic diuresis,
    thereby diluting nephrotoxic agents and
    encouraging their excretion.
  • little evidence to prove mannitol alone
  • Brown et al Failed to show benefit of bic/man

29
Dialysis
  • Despite optimal treatment ,daily haemodialysis or
    haemofiltration may be necessary
  • Remove urea and potassium

30
Free radical scavengers and antioxidants
  • The magnitude of muscle necrosis caused by
    ischemia-reperfusion injury has been reduced in
    experimental models by the administration of
    free-radical scavengers .
  • Many of these agents have been used in the early
    treatment of crush syndrome to minimize the
    amount of nephrotoxic material released from the
    muscle
  • Pentoxyphylline is a xanthine derivative used to
    improve microvascular blood flow. In addition,
    pentoxyphylline acts to decrease neutrophil
    adhesion and cytokine release
  • Vitamin E , vitamin C , lazaroids
    (21-aminosteroids) and minerals such as zinc,
    manganese and selenium all have antioxidant
    activity and may have a role in the treatment of
    the patient with rhabdomyolysis

31
Summary
  • High index of suspicion
  • On scene treatment important
  • Aggressive fluid treatment
  • Adequate monitoring
  • Recognition and early treatment of complications

32
Compartment syndrome
  • Increased interstitial pressure in a close
    fascial compartment leading to microvascular
    compromise and cellular death
  • Pressures measuring gt30mmhg surgical assessment
  • DBP-compartment lt 30 fasciotomy

33
References
  • Oda, Jun MD Tanaka, Hiroshi MD Analysis of 372
    Patients with Crush Syndrome Caused by the
    Hanshin-Awaji Earthquake,J of traumaVolume
    42(3), March 1997, pp 470-476
  • Gonzalez, Dario MD ,Crush syndrome,J of critical
    careVolume 33(1) Supplement, January 2005, pp
    S34-S41
  • Ana L Huerta-Alardín1, Joseph Varon2 and Paul E
    Marik .Bench-to-bedside review Rhabdomyolysis
    an overview for clinicians Critical Care 2005,
    9158-169Crush Injury and Crush Syndrome A
    Review
  • Smith, Jason MD Greaves, Ian Crush Injury and
    Crush Syndrome A Review .J of traumaVolume
    54(5) Supplement, May 2003, pp S226-S230
  • Brown,carlos V MDRhee,Peter MD Preventing Renal
    Failure in Patients with Rhabdomyolysis Do
    Bicarbonate and Mannitol Make a difference . J of
    Trauma Vol 56 ,June2004,pp1191-1196

34
Also Check
  • San Fran crush protocol
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