Rhabdomyolysis and crush syndrome

Last updated: June 30, 2022

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Rhabdomyolysis is the breakdown of skeletal muscle tissue that results in the release of intracellular contents, such as myoglobin, potassium, phosphate, creatine phosphokinase (CPK), and urate, into the blood and extracellular space. Rhabdomyolysis has many causes, including trauma and crush injuries, drugs, overexertion, temperature extremes, infections, and prolonged immobility. The classic presenting triad of myalgia, generalized weakness, and tea-colored urine is seen in a minority of patients. The diagnosis is confirmed in patients with an elevated serum CPK, typically > 5× the upper limit of normal. Serious complications include acute kidney injury from myoglobin-induced tubular damage, cardiac arrhythmias and arrest from electrolyte derangements, and compartment syndrome. Crush syndrome is the systemic manifestation of a crush injury. It typically manifests with signs of volume depletion (hypovolemia, shock) and compartment syndrome of the affected extremity, and it is often associated with acute kidney injury. Treatment of rhabdomyolysis includes aggressive fluid resuscitation and the correction of metabolic abnormalities. In cases of renal failure, renal replacement therapy may be indicated.

Recurrent episodes of rhabdomyolysis may indicate an underlying inherited metabolic myopathy. [2]

Rhabdomyolysis

Many patients are asymptomatic on presentation. The classic triad of myalgia, generalized weakness, and tea-colored urine is seen in a minority of patients. [9]

Crush syndrome

General principles [4]

Acute kidney injury is a complication that suggests a poor prognosis in patients with rhabdomyolysis. [8]

While there is no specific CPK threshold for the diagnosis of rhabdomyolysis, a concentration of CPK > 5× the ULN or > 1000 IU/L is commonly used. [9][11]

Diagnostic studies

Myoglobinuria causes a false-positive result for blood on urine dipstick. Suspect myoglobinuria if urine dipstick is positive for blood in the absence of red blood cells in urine sediment.

Elevated serum myoglobin or myoglobinuria are not required to establish a diagnosis but may be useful to confirm the presence of rhabdomyolysis if there is diagnostic uncertainty.

Approach [4][8][9][11][13]

Fluid resuscitation is indicated in all patients with CPK > 5× the ULN or > 1000 IU/L and should be continued until CPK levels decrease to below this level. [3]

Fluid management [4][8][9][11]

The longer it takes for IV fluids to be started, the more likely it is that acute renal failure will develop. [8]

Diuretics [4][11][12]

The following therapies are not routinely recommended but may be considered under specialist guidance. Their use remains controversial. [11]

  • Loop diuretics (e.g., furosemide): may be considered to force diuresis only after the patient's volume has been expanded.
  • Mannitol: may be considered under specialist guidance

Management of electrolyte derangements [4][6][12]

Disposition [2][3]

  • Admission
    • Typically required for IV fluid therapy, monitoring, and management of complications
    • Consider ICU admission for patients with: [4][8][10]
  • Discharge can be considered in otherwise healthy patients with all of the following:

Early complications [4][9]

Late complications [4][9]

Compartment syndrome can occur at any stage of rhabdomyolysis and is an orthopedic emergency. [4][12]

We list the most important complications. The selection is not exhaustive.

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  2. Torres PA, Helmstetter JA, Kaye AM, Kaye AD. Rhabdomyolysis: pathogenesis, diagnosis, and treatment. Ochsner J. 2015; 15 (1): p.58-69.
  3. Khan FY. Rhabdomyolysis: a review of the literature. Neth J Med. 2009; 67 (9): p.272-83.
  4. Chatzizisis YS, Misirli G, Hatzitolios AI, Giannoglou GD. The syndrome of rhabdomyolysis: Complications and treatment. Eur J Intern Med. 2008; 19 (8): p.568-574. doi: 10.1016/j.ejim.2007.06.037 . | Open in Read by QxMD
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  8. Vanholder R, Sever MS, Erek E, Lameire N. Rhabdomyolysis. J Am Soc Nephrol. 2000; 11 (8): p.1553-1561.
  9. Genthon A, Wilcox SR. Crush syndrome: a case report and review of the literature. J Emerg Med. 2014; 46 (2): p.313-319. doi: 10.1016/j.jemermed.2013.08.052 . | Open in Read by QxMD
  10. Crush Injury and Crush Syndrome. https://www.acep.org/imports/clinical-and-practice-management/resources/ems-and-disaster-preparedness/disaster-preparedness-grant-projects/cdc---blast-injury/cdc-blast-injury-fact-sheets/crush-injury-and-crush-syndrome/. Updated: June 1, 2009. Accessed: May 23, 2022.
  11. Bosch X, Poch E, Grau JM. Rhabdomyolysis and Acute Kidney Injury. N Engl J Med. 2009; 361 (1): p.62-72. doi: 10.1056/nejmra0801327 . | Open in Read by QxMD
  12. McMahon GM, Zeng X, Waikar SS. A Risk Prediction Score for Kidney Failure or Mortality in Rhabdomyolysis. JAMA Intern Med. 2013; 173 (19): p.1821. doi: 10.1001/jamainternmed.2013.9774 . | Open in Read by QxMD
  13. Kodadek L, Carmichael II SP, Seshadri A, et al. Rhabdomyolysis: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open. 2022; 7 (1): p.e000836. doi: 10.1136/tsaco-2021-000836 . | Open in Read by QxMD
  14. Chavez LO, Leon M, Einav S, Varon J. Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice. Crit Care. 2016; 20 (1). doi: 10.1186/s13054-016-1314-5 . | Open in Read by QxMD
  15. Oshima Y. Characteristics of Drug-Associated Rhabdomyolysis: Analysis of 8,610 Cases Reported to the U.S. Food and Drug Administration. Intern Med. 2011; 50 (8): p.845-853. doi: 10.2169/internalmedicine.50.4484 . | Open in Read by QxMD

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