From the Guidelines
Traumatic rhabdomyolysis is a condition that occurs when muscle damage results from direct physical injury, whereas nontraumatic rhabdomyolysis develops without direct physical trauma and can be caused by various factors, including certain medications, illicit drugs, and metabolic disorders. The key difference between the two types of rhabdomyolysis lies in their etiology and presentation. Traumatic rhabdomyolysis typically occurs after a severe physical injury, such as a crush injury or severe burn, and is often localized to the injured area 1. Nontraumatic rhabdomyolysis, on the other hand, can be caused by a range of factors, including certain medications (e.g., statins, antipsychotics), illicit drugs (e.g., cocaine, heroin), alcohol abuse, extreme exercise, infections, metabolic disorders, or electrolyte abnormalities 1.
Some common causes of nontraumatic rhabdomyolysis include:
- Certain medications, such as statins and antipsychotics
- Illicit drugs, such as cocaine and heroin
- Alcohol abuse
- Extreme exercise
- Infections
- Metabolic disorders
- Electrolyte abnormalities
Both types of rhabdomyolysis can present with similar symptoms, including:
- Muscle pain
- Weakness
- Dark urine
- Electrolyte imbalances
- Compartment syndrome
- Acute kidney injury
The treatment for both traumatic and nontraumatic rhabdomyolysis includes aggressive intravenous fluid administration, electrolyte monitoring and correction, and addressing the underlying cause. Patients with either type of rhabdomyolysis should be monitored for creatine kinase levels, renal function, and electrolytes, particularly potassium, as hyperkalemia can lead to cardiac arrhythmias 1. In patients with severe limb trauma, the risk of developing compartment syndrome and rhabdomyolysis is high, and early detection and treatment are crucial to prevent long-term morbidity and mortality 1.
In terms of detection and prevention of acute kidney injury in patients with post-traumatic rhabdomyolysis, it is recommended to perform repeated bio-assessment combining plasma myoglobin, plasma creatine phosphokinase (CPK) and kalaemia measurements, as well as bladder catheterisation to monitor hourly urine output and urine pH 1. The management of kidney injury built up after rhabdomyolysis has no specificity, and experts refer to the French recommendations for acute kidney injury in the perioperative period and intensive care units 1.
Overall, the key to managing both traumatic and nontraumatic rhabdomyolysis is early detection and treatment, as well as addressing the underlying cause of the condition. By providing aggressive intravenous fluid administration, electrolyte monitoring and correction, and addressing the underlying cause, patients with rhabdomyolysis can be effectively managed and their risk of long-term morbidity and mortality reduced.
From the Research
Definition and Causes of Rhabdomyolysis
- Rhabdomyolysis is a condition characterized by the rapid breakdown of striated, or skeletal, muscle, resulting in the release of cell degradation products and intracellular elements within the bloodstream and extracellular space 2.
- The causes of rhabdomyolysis can be categorized into traumatic and non-traumatic, with direct muscle injury being the most common cause, and additional causes including hypoxic, physical, chemical, or biological factors 2, 3.
Traumatic vs Non-Traumatic Rhabdomyolysis
- Traumatic rhabdomyolysis is caused by direct muscle injury, such as crush syndrome, while non-traumatic rhabdomyolysis is caused by other factors, including hypoxic, physical, chemical, or biological factors 2, 4.
- Both traumatic and non-traumatic rhabdomyolysis can lead to acute kidney injury, with the percentage of patients developing acute kidney injury varying from 13% to over 50% depending on the cause and clinical setting 2.
Clinical Features and Diagnosis
- The conventional triad of symptoms for rhabdomyolysis includes muscle pain, weakness, and dark urine 2.
- The laboratory diagnosis of rhabdomyolysis is based on the measurement of biomarkers of muscle injury, with creatine kinase (CK) being the biochemical "gold standard" for diagnosis, and myoglobin being the "gold standard" for prognostication, especially in patients with non-traumatic rhabdomyolysis 2.
Management and Treatment
- The essential clinical management of rhabdomyolysis involves targeted intervention to manage the underlying cause, combined with infusion of fluids and eventually sodium bicarbonate 2.
- Aggressive intravenous fluid resuscitation (IVFR) has been shown to decrease the incidence of acute renal failure and need for dialysis in patients with rhabdomyolysis 5, 4.
- The use of bicarbonate and mannitol in the treatment of rhabdomyolysis is not recommended, as they have not been shown to improve outcomes 5.