Rhabdomyolysis
BACKGROUND
JD is 34
year-old male who presents to the Emergency Department with a CC
of
headache. He
recalls being involved in
an altercation several months ago and was recently incarcerated
for public
intoxication. He
admits to using PCP (phenylcyclohexylpiperidine
, a.k.a. angel dust) on a daily basis.
SUBJECTIVE (Pertinent
Positives from ROS)
·
Admits
to + illicit use (PCP) almost daily and most recently 1 day
prior.
·
Reports
that he went to the gym 1 day prior and engaged in heavy
weightlifting x 2
hours and drank only 1 liter of water after his workout.
·
Complains
of neck pain/back pain and generalized myalgia, +visual
disturbances.
·
PMH/PSH:
None reported
OBJECTIVE
(Abbreviated PE)
·
HEENT:
Normocephalic/atraumatic; oropharynx clear and moist;
Conjunctivae are normal;
PERRL; +Nystagmus
·
CV:
RRR (regular rate & rhythm); S1, S2, no murmur, gallop or
friction rub
·
PULM:
Regular/unlabored respirations, bilat equal chest excursion,
CTAB
·
ABD:
SNTND, + BS
·
MS:
·
NEURO:
AAOx3; 5/5 Strength BUE/BLE, no pronator drift, normal gait,
sensation intact,
CN II-VII grossly intact
LABS/RAD
Total CK: >7800 (nml
20-543 U/L)
CK-MB: 5.0 (nml
0-5 ng/ml)
PCP: Positive
Troponin: <0.06 (nml 0-0.78
ng/ml)
Urine:
+ Protein +RBC
CBC: H/H=15.7/45.7, PLT=
81,
WBC=7.33
CMP:
NA=144 K=4.1 Cl= 104
BUN=11 HCO3=28 Cr=1.0
CT/MRI: Negative for acute process
ASSESSMENT
34 year-old male
with CC of headache with no significant PMH and admits to + PCP
use and
extensive weightlifting in the past 24 hours.
He reports neck/back pain as well myalgia, +visual
disturbances.
Physical exam is
significant for nystagmus and tenderness to deep muscle
palpation BUE/BLE. Labs
are significant for +PCP on tox screen
and elevated CK.
PLAN and
OUTCOME
JD was admitted
to medical surgical unit for IV hydration and monitoring of
renal
function. He was
hospitalized for four
days, recovered completely, and had no long-term sequelae from
his self-induced
case of rhabdomyolysis.
MORE ON
RHABDOMYLOYSIS
Some Possible
Causes: Trauma,
crush injuries,
burns, seizures, physical torture, prolonged coma, extreme
physical activity,
illicit drugs, alcohol intoxication, prolonged drowning,
hypothermia, viral
infections, venom from certain snakebites, prolonged immobility
(i.e. I’ve
fallen and I can’t get up or get help!!!)
Hyperkalemia, an
immediate threat to life in the hours immediately after injury
and occurs in
10-40% of cases. Liberated potassium can cause life-threatening
dysrhythmias
and death.
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.
Vigorous
hydration with isotonic crystalloid is the cornerstone of
therapy for
rhabdomyolysis. Administer isotonic crystalloid 500 mL/h and
then titrate to
maintain a urine output of 200-300 mL/h.
Because injured myocytes can sequester large volumes of
extracellular
fluid, crystalloid requirements may be surprisingly large.
Case created by Julie
Darling, 2011.