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Christine Binter RN BSN
Alverno College
Spring 2010
Rhabdomyolysis:An Elderly Trauma Patient Case Study
Objectives
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Click on underlined words to learn more about them.
Quiz 1Quiz 2Quiz 3Quiz 4
Rhabdomyolysis Home Page
Laboratory Findings
Case Study
• Falls Prevention
• Virus• Drugs• Genetics
• Statins
• Stress Response
• Definition• Inflammati
on• Aging
Patho-physiology
Signs and Symptoms
Treatment
History and Diagnosis
Navigation
Navigation
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you to return back to the question.
Objectives
Definition of Rhabdomyolysis
Rhabdomyolysis is the rapid breakdown of skeletal muscle due to injury to muscle tissue.
Damaged skeletal muscles release products such as myoglobin into the blood stream leading to acute kidney failure.
Criddle, L. 2003With permission
skeletalmuscle.jpg
Patient Case Study
84 year old Mrs. F Fell from toilet Found by
daughter 12 hours later.
Brought to hospital via 911 call to Paramedics.
With permission nursinglife.net
Case Study
The paramedics found Mrs. E. responsive still breathing and a cervical collar and long board were applied.
A large amount of swelling is at the back of her head.
Her right leg is shortened and internally rotated.
An IV is started. The National Institute of Clinical Excellence Guidelines 2007 advises adults who have sustained a head injury and present with risk factors for spinal cord injury should have cervical spine immobilization.
With permission paramedicine.com
Pathophysiology
Intracellular and extracellular balance is maintained by the
Criddle, L. 2003
Cell membraneCell membrane
Pathophysiology
The sodium pump preserves essential intracellular and extracellular distribution of electrolytes.
This pump is energy dependent, fueled by adenosine triphosphate (ATP).
A steady supply of oxygen is needed to produce ATP.
In falls tissue compression and vascular occlusion occur causing hypoxia to muscle cells.
Without oxygen delivery and ATP production , pump dysfunction occurs.
Muscal, E. 2009
Cell membrane
Na+
pump
O2
Pathophysiology
Potassium (K+), Magnesium, and Phosphate (Ph) are intracellular
Sodium (Na+), Calcium(Ca+), Chloride(Chl), Bicarbonate (B)
are chiefly extracellular.
Muscal, E. 2009
Cell membrane
Magnesium
K+
Ph
Na+Ca+
Chl
B
Pathophysiology
When a fall, crush injury or obstruction by confinement in a fixed position occur,
the cell membrane breaks
Massive influx of sodium occurs
Followed by water
Causing increased swelling of muscle cells
Criddle, L. 2003
intracellular
extracellular NA
H2O
Na+
Na+
Na+H2O
H2O
Contribution of Inflammation
In addition, neutrophils enter the damaged muscle, producing an inflammatory reaction.
The swollen and inflamed muscle compresses structures in the fascia causing compartment syndrome.
The swelling compromises blood supply to the area.
Hydroxyl free radicals are produced causing nephrotoxicity by vasoconstriction through interaction with nitric oxide and endothelin receptors.
Muscal, E. 2009
Porth, C. and Matfin, G. 2009
With permission from [email protected]
With permission from OrthoWorld.com
Pathophysiology
Large amounts of intravascular fluid leave circulation and are trapped in damaged muscle tissues.
This fluid shift produces intravascular hypovolemia.
The dramatic decrease in intravascular fluid volume leads to vasoconstriction and renal failure.
Russell, T. 2000
With permission from kidneydisease-symptoms.com
Pathophysiology
Intracellular
extracellular
Potassium leaks into the extracellular space causing cardiac toxic effects and dysrhythmias.
Criddle, L. 2003K+
K+
K+
Pathophysiology
Myoglobin, the dark red protein that gives muscle cells their red-brown color, leaks out of the muscle cells and flows into the urine causing a noticeable reddish-brown urine.
Craig, S. 2009
With permission from answers.com
Pathophysiology
Uric acid precipitates in the tubules causing obstruction.
Myoglobin accumulates in the kidney tubules, forming reactive oxygen species inflammation that obstruct the normal flow of fluid in the nephron.
Criddle, L. 2003
With permission from kidney-disease-symptoms.comWith permission from kidney-disease-symptoms.com
Pathophysiogy
Thromboplastin and tissue plasminogen are released from injured muscle cells making patients susceptible to disseminated intravascular coagulation (DIC)
Vanholder, R. 2000With permission from mdconsult.com
Pathophysiology Quiz
What maintains intracellular and extracellular
balance?Tissue compression
Neutrophils
Cell Membrane
Pathophysiology Quiz Answer
Exactly Right!
Pathophysiology Answer
Try Again
Pathophysiology Quiz
When the cell membrane breaks, massive influx occurs of:
Myoglobin
Potassium
Sodium and Water
Pathophysiology Quiz Answer
You are right!
Pathophysiology Answer
Try again
Case Study
A CT scan is positive for subdural hematoma. X-Ray is positive for right femoral neck
fracture. With aging there is a reduction in muscle
size and strength related to loss of muscle fibers and reduction in size of existing fibers.
With aging there is a loss of bone mass and weakened bone structure.
Porth, C. and Matfin, G. 2009
Contribution of Aging
Frailty in the elderly is caused by inflammation due to decreased action of anabolic hormones causing loss of muscle strength and frequent falls.
Inflammaging is a low grade inflammatory process in elderly caused by a constant low-grade activation of cytokine. Chronic inflammation is due to infiltration of macrophages, lymphocytes and fibroblasts leading to persistent swelling and weakened cell wall membranes.
Inflammaging , frailty and weakend, small muscle fibers make Mrs. F a high risk for rhabdomyolysis.
Licastro, F. et al., 2005
Signs and Symptoms
Only 50% of adult patients present with triad
In most patients the signs and symptoms are subtle, its history indicates the cause.
Muscal, E. 2009
Use history to find rhabdomyolysis Crush Injury or fall is
compression of the body or extremities that causes muscle swelling
Typically affected are legs(74%), arms (10%), trunk (9%)
Muscal, E. 2009
With permission from 911research.com
With permission from thewe.cc
Use history to find rhabdomyolysis
Viruses directly attack muscle cell membrane.
The most common are Influenza A and B, Salmonella, herpes.
Legionella directly invades and degenerates muscle fibers.
Any microbe that causes sepsis may cause muscle damage and necrosis
Muscal, E. 2009
Influenza B. Permission from wikimedia.org
Use history to find rhabdomyolysis
Drugs Alcohol abuse causes
metabolic abnormality and immobilization leading to muscle compression and muscle ischemia
Narcotic overdose causes altered sensorium and immobilization for long periods. Pressure necrosis develops
Cocaine damages muscle tissue by vasoconstriction.
Antipsychotics may cause neuroleptic malignant syndrome and muscle rigidity leading to rhabdomyolysis
Richards, J. 2009Permission from floridacrimminalattorneysblog.com
Use history to find rhabdomyolysis Genetics
Genetic muscle defects cause rhabdomyolysis by inability to use ATP. Because of inadequate ATP, the mismatch of energy supply results in break down of cell membrane in exercise.
An impairment of energy delivery is found in McArdle’s disease, and phophoglycerated kinase deficiency (PGK)
Muscal, E. 2009
McArdle’s Disease.With permission from Musclular Dystrophy Foundation
Quiz Choose True or False
Genetic muscle defects cause rhabdomyolysis by an inability to use ATP?
True False
Answer
You are right!
Answer
Consider with inadequate ATP the mismatch of energy supply results in break down of cell membrane in exercise. Try Again.
Signs and Symptoms by taking history
Statins cause muscle cells to break down
Statin medications impair the production of proteins involved in muscle metabolism
The higher the dose of statins the higher the risk of rhabdomyolysis
Muscal, E. 2009Permission from videowasi.com
Contribution of Stress Response
A stress response is seen in both Mrs. F’s nervous and endocrine system.
CNS stress response is increased heart and respiratory rate, hands and feet are moist, pupils are dilated.
Endocrine stress response is causing vasconstriction of blood vessels and increased water absorption in the kidney.
Porth, C. and Matfin, G. 2009
Laboratory Findings
The actual diagnosis of rhabdomyolysis is confirmed by lab tests.
Total Creatine Kinase (CK) is the most reliable test for rhabdomyolysis.
Normal CK levels are 45-260 U/L.
With rhabdomyolysis CK levels are massively elevated 10,000 to 200,000 U/L.
Craig, S. 2009
With permission from ehow.com
CKMB is isolated for heart muscleCKMM is isolated for skeletal muscle50% of patients with rhabdomyolysis have elevated cardiac troponin 1 level. Of these 58% were true myocardial infarction.Craig, S. 2009
Laboratory Findings
Urine dipsticks are a quick way to screen for myoglobinuria
Urine dipsticks are positive in <50% of patients with rhabdomyolysis
If dipstick is positive for blood and UA microscopy is negative for RBCs, myoglobin is present.
Confirm with elevation of Total CK and normal CKMB and normal troponin.
Craig, S. 2009 With permission from healthforworld..
Laboratory Findings
Acute Renal Failure Develops in 40% of patients.
Measure BUN and creatinine levels
Normal BUN is 10-20mg/dL Normal Creatinine is 0.5-
1.1mg/dL In one study based on 97
adults with rhabdomyolysis, no patient with initial creatinine <1.7 developed acute renal failure.
Vanholder, R. et al., 2000 With permission from kidney-disease-symptoms.com
Laboratory Findings
Clotting studies are useful to detect disseminated intravascular coagulation (DIC)
Obtain prothrombin time (pt), partial prothrombin time (ptt), and platelet count
Russell, T. 2000 With permission from crossfit.com
Laboratory Findings
Metabolic Acidosis is due to increases in lactic acid, uric acid, sufate, and potassium in circulation.
Criddle, L. 2003
Metabolic Acidosis
Increased lactic acid
Increased uric acid
Quiz
What are three complications from rhabdomyolysis?
Respiratory Acidosis, Urinary tract infection, Bowel Obstruction
Metabolic Acidosis, Acute Renal Failure, Disseminated Intravascular Coagulation
Metabolic Alkalosis, Chronic Renal Failure,DiverticulitisQuiz Answers
Quiz Answers
Alright!
Quiz Answers
Plenty of cover to try again
Case Study
Mrs. F’s initial labs show: Potassium (K) 6.4 mEQ/L Blood Urea Nitrogen (BUN) = 36 mg/l Creatinine (CR) =6.5 mg/l Creatine Kinase= 90,000 units
Mrs. F’s high BUN and Creatinine indicate Kidney Failure
Mrs. F’s high Creatine Kinase indicate large amount of skeletal muscle breakdown.
Mrs. F. needs treatment for rhabdomyolysis.
Treatment
Rapid fluid infusion will restore intravascular volume and flush kidneys.
IV Normal Saline rate of 500-1000ml/hr to maintain hourly urine output of 150-300ml/hr.
Criddle, L. 2003
With permission from stockphotopro.com
Treatment
Alkalize the urine to a pH of 6.5-7.0 to prevent increased nephrotoxic effects by adding sodium bicarb to IV NS.
Place foley catheter to monitor fluid output.
Criddle, L. 2003 With permission from impactlab.com
Treatment
When kidneys do not respond, emergency hemodialysis is necessary to manage oliguria, metabolic acidosis and fluid overload.
Russel, T. 2000
With permission from commons.wikimedia.org
With permission tmsplc.win
Case Study
Mrs F’ has 5-10 cc of dark brown urine over the first two hours in ED. Her IV fluids consisted of 1 L of NS with 50mEq of Sodium Bicarb at 250cc/hr. Low dose Dopamine was started in her central line to improve her renal status.
In spite of treatment, Mrs. F. had 50 cc urine output at hour 4 and dialysis was started upon admission to NICU.
By the tenth day Mrs. F begins making urine. Plans are made for surgery to repair her fx hip.
Prevent Falls
Reducing the risk of harm from patient fall has been a JACHO National Patient Safety Goal since 2005.
WHO IS AT RISK to FALL? Consider the following criteria to asses risk:
Confusion or disorientation Impaired by sedation, alcohol or drugs Patient age >70 years Dizziness with standing Inability to walk unassisted; uses walker or
cane Fall within last 3 months.
Prevention
Appropriate Interventions include and are not limited to: Move patient to room within “eye view” Keep curtain open Assess frequently Remind patient not to get up without assistance Place call light within reach and demonstrate how to use it Assure family or caregiver remains with patient Place side rails up for safety
KNOW:Severe injuries have been associated with patients that climb over side rails
Call for low bed. Transfer patient to low bed when boarded in ED.
Summary
“Rhabdomyolysis is a clinical syndrome in which the contents of injured muscle cells leak into circulation. This leakage results in electrolyte abnormalities, acidosis, clotting disorders, hypovolemia, and acute renal failure. Traumatic and nontraumatic conditions lead to rhabdomyolysis. Intervention consists of early detection, volume replacement, and aggressive diuresis or hemodialysis…. Nurses are instrumental in both early detection and management of this life-threatening syndrome.”
Criddle, L. 2003
References Carriere, S. (1998). Found down: compartment syndrome, rhabdomyolysis, and renal failure.
Journal of Emergency Nursing. 24:214-217. Craig, S. (2009). Rhabdomyolysis: differential diagnosis & workup. eMedicine Emergency
Medicine. Retrieved March 27, 2010 from http://rhabdomyolysis e-medicine Criddle. L. (2003) . Pathophysiology, recognition, and management. Critical Care Nurse.
23(6),14-28. Frei, F. (1997). Reactive oxygen species and antioxidant vitamins. The Linus Pauling Institute.
Retrieved February 20, 2010 from http://courses.alverno.edu Licastro, F. et al., (2005). Innate immunity and inflammation in ageing: a key for understanding
age-related diseases. Retrieved February 20, 2010 from http://www.immunityageing.com
Muscal, E. (2009). Rhabdomyolysis. eMedicine. Retrieved March 27, 2010 from http:emedicine.medscape.com
Porth, C. and Matfin, G. (2009). Pathophysiology Concepts of Altered Health States. Philadelphia: Lippincott, Williams & Wilkins.
Richards, J. (2009). Rhabdomyolysis and drugs of abuse. Journal of Emergency Medicine. 19:51-56.
Russell, T. (2000). Acute renal failure related to rhabdomyolysis; pathophysiology, diagnosis, and collaborative management. Nephrology Nurse. 27:567-577.
Vanholder, R. et al. (2000). Rhabdomyolysis. Journal of American Sociology of Nephrology. 11:1553-1561.
