|Three Cases (and Three Causes) of Rhabdomyolysis|
|By Jeffrey E. Keller MD|
Rhabdomyolysis is one of those diseases, like acute alcohol withdrawal, that I have seen much more commonly in my jails than I ever did when I worked in the emergency department.
Rhabdomyolysis occurs when skeletal muscle cells die and rupture, releasing the protein myoglobin into the blood stream. The kidneys attempt to clear the myoglobin, however, if the concentration of myoglobin is too high, it will literally solidify inside the renal tubules, causing kidney failure. This is considered bad!
There are two main symptoms of rhabdomyolysis. The first is dark “Coca-cola” urine caused by myoglobin in the urine. The second major symptom is pain in the affected muscles caused by the inflammatory chemicals. The affected muscles will tighten up, commonly causing a unique stork-like walk in which the patient can’t bend his knees or hips well. After you have seen a few of these patients, you can pick them out by their gait alone!
There are two main blood tests that can confirm the diagnosis and help you determine how serious this particular case is. The first is creatinine phosphokinase (CPK), which is an enzyme found inside muscle cells. Like myoglobin, CPK is released into the blood when muscle cells rupture. You can to some extent gauge the amount of muscle damage by how high the CPK climbs. Rhabdomyolysis can be diagnosed by a CPK 5 times greater than normal but may exceed 100,000 in severe cases. BUN and creatinine, the kidney function tests, are also critical to obtain to determine if the rhabdomyolysis is severe enough to cause renal impairment. There are several other tests that may help in particular cases, such as urine myoglobin, electrolytes and CO2 (for acidosis).
Treatment for rhabdomyolysis is to clear the myogobin. In most cases, this can be done by aggressively hydrating the patient, either orally or with IV fluids, which gives the kidneys the water they need to flush the myoglobin without its solidifying in the renal tubules. In bad cases with very high CPK levels and kidney failure, hemodialysis may be needed.
Several things can cause rhabdomyolysis, but these are the Big Three: Overexertion, crush trauma, and drugs. I have seen all three in my jails.
Three Cases of Rhabdomyolysis
Corrections.com author, Jeffrey E. Keller is a Board Certified Emergency Physician with 25 years of practice experience before moving full time into the practice of Correctional Medicine. He is the Chief Medical Officer of Centurion. He is also the author of the "Jail Medicine" blog
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