116. Rhabdo

Question 1

What is rhabdo?

Answer 1

Process where striated m breaks down releasing CK, k, phosphate and ca and uric acid

Question 2

What is the classic clinical triad of rhabdo

Answer 2

Myalgias
Weakness
Dark colored urine

Question 3

Rhabdo basic management

Answer 3

Treat underlying cause
IVF to u/o 2-3cc/kg per hour and euvolemia

Question 4

Diagnosis of rhabdo lab value

Answer 4

> 5x ULN CK

Question 5

What are the 4 pathophysiologic processes involved in rhabdo

Answer 5

1. Impaired production of ATP at the muscle (due to failure of regular ca - higher in cytoplasm)
2. Disruption of o2 and nutrients of the muscle at a cellular level
3. Increased demand over supply
4. Direct myocyte damage

Question 6

Why is high calcium in to cytoplasm bad in rhabdo?

Answer 6

Activates proteases and phsophoslipases further depleting atp and destruction of skeletal muscle
Toxic waste from this breakdown results in edema and area disruption to vasculature (oschemia) + ROS

Question 7

What is the most common symptom for rhabdo?

Answer 7

Localized m ache

Question 8

Why do people not always have dark urine in rhabdo?

Answer 8

Muscle mass dep, severity of illness, renal function

Question 9

When ATP is depleted how does this effect the na ca exchanger?

Answer 9

Reversal, rising IC calcium

Question 10

Which membrane protein exchangers/channels are affected in rhabdo? Name 2

Answer 10

Na k atpase
Na ca channel

Question 11

Name 5 early complications of Rhabdo

Answer 11

1. Compartment Syndrome
2. Hyperkalemia
3. Hypovolemia
4. AST (level of rise consistent with severity rhabdo)
   5, metabolic acidosis
5. Significant phosphate which can cause hypocalcemia and fatal dysrhythmia * whereas late can get hypercalcemia

Question 12

Which membrane protein exchangers/channels are affected in rhabdo? Name 2

Answer 12

Na k atpase
Na ca channel

Question 13

Name a late complication of rhabdo and how this occurs

Answer 13

Myoglobin induced AKI (from distal tubule, ATN) and also from direct toxicity at proximal tubule due to acidosis causing oxidation of ROS as iron dissociates from heme

Question 14

When does myoglobin vs CK peak in blood?

Answer 14

Myo 12h and gone by 24h Vs CK peak 24, lasts 3d

Question 15

Why do we measure CK for rhabdo diagnosis?

Answer 15

CK acts as a reservoir for atp

Question 16

Why do we measure CK for rhabdo diagnosis?

Answer 16

CK acts as a reservoir for atp

Question 16

What is myoglobin made up of ?

Answer 16

Globin and heme

Question 17

Name 6 different classifications/broad categories for rf for rhabdo

Answer 17

Drugs
Exertion
Trauma or compression
Extreme body temp changes
Electrolyte alteration
Muscle ischemia/hypoxia
Infection
Endocrine
Autoimmune
Food borne
Genetic

Question 18

Name 5 RF for rhabdo - exertional

Answer 18

Intense exercise
Seizure
Sickle cell crisis
Status asthmatics
Etoh withdrawal

Question 19

Name 6 different classifications/broad categories for rf for rhabdo

Answer 19

Drugs
Exertion
Trauma or compression
Extreme body temp changes
Electrolyte alteration
Muscle ischemia/hypoxia
Infection
Endocrine
Autoimmune
Food borne
Genetic

Question 20

Name 5 RF for rhabdo -trauma compression

Answer 20

MVC
Prolonged lie
Crush
Burns
Electrical injury

Question 21

Name 5 RF for rhabdo -excess increase body temp

Answer 21

Heat stroke
Hyperthermia
Hypothermia
Serotonin syndrome
NMS
Malignant hyperthermia

Question 22

Name 5 RF for rhabdo -electrolyte disturbances

Answer 22

Hypokalemia, phosphate, ca or na
Also high na or BG

Question 23

Name 3 RF for rhabdo - muscle ischemia/hypoxia

Answer 23

Arterial occlusion due to Thrombus
Embolism or during vascular surgery

Question 24

Name 5 RF for rhabdo - infections

Answer 24

Ebv Sepsis Salmonella GAS Staph aureus Clostridium species Legionella Coxsackie Hsv HIV

Question 25

Name 5 RF for rhabdo - infections

Answer 25

Ebv Sepsis Salmonella GAS Staph aureus Clostridium species Legionella Coxsackie Hsv HIV

Question 26

Name 8 RF for rhabdo - drugs

Answer 26

Statins Other antilipid agents like ezetimibe PPI Snri Ssri TCA Li Barb Etoh Cocaine Opioids LSD Bath salts Antihistamines Propofol Arsenic Co Quinidine Salicylates Succ Vasopressin Terbutalline Theophylline

Question 27

Name 2 RF for rhabdo -endocrine

Answer 27

Thyroid abnormalities Hyperaldosteronism

Question 28

Name 2 RF for rhabdo - autoimmune

Answer 28

Dermatomyositis Polymyositis

Question 29

Name 5 RF for rhabdo -genetic

Answer 29

Krebs cycle deficiency G6PD deficiency Lipid abnormalities Mitochondrial chain disorders Muscular dystrophy

Question 30

What is a very concerning late complication of rhabdo

Answer 30

DIC

Question 31

Name 5 RF for rhabdo - foodborne

Answer 31

Eel Crayfish Pike Burbot Buffalo fish Other crustaceans

Question 32

How to differentiate myoglobinuria vs hemoglovinuria

Answer 32

Urine microscopy shows RBC on hemoglobinuria, no myoglobin despite qualitatively red urine

Question 33

Name 4 conditions that may have red urine

Answer 33

Hemlglobonuris Myoglobinuria Porphyria Foods Bile pigment Drugs - defuroxamine, chloroquine, ibuprofen

Question 34

Characteristic bun:cr ratio in rhabdo

Answer 34

<10:1

Question 35

Name 2 late complications of rhabdo

Answer 35

DIC myoglobinuria induced aki

Question 35

How common is RRT in patients with AKI from rhabdo?

Answer 35

20%