What is the diagnosis and management for an older adult patient with a history of diabetes, hypertension, and chronic medication use, presenting with cardiac arrest, cataract formation, delayed labial artery bleeding, and rhabdomyolysis?

Diagnosis: Statin-Induced Rhabdomyolysis with Multi-Organ Complications

This clinical presentation is most consistent with statin-induced rhabdomyolysis complicated by acute kidney injury, hyperkalemia-induced cardiac arrest, and delayed bleeding from antiplatelet therapy, occurring in a high-risk older adult with diabetes and hypertension. 1, 2

Immediate Life-Threatening Management

Cardiac Arrest Protocol

• Initiate advanced cardiac life support (ACLS) immediately with focus on identifying and treating reversible causes, particularly hyperkalemia from rhabdomyolysis-induced acute kidney injury. 3, 4
• Hyperkalemia is a critical precipitant of cardiac arrest in patients with rhabdomyolysis and acute kidney injury, especially in diabetic patients on angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. 5
• Post-cardiac arrest syndrome management requires aggressive hemodynamic stabilization, temperature control, and early neurological prognostication. 3

Rhabdomyolysis Recognition and Treatment

• Discontinue all statins immediately if rhabdomyolysis is suspected, as the FDA mandates stopping atorvastatin when markedly elevated creatine kinase (CK) levels occur or myopathy is diagnosed. 1
• Risk factors present in this patient include age ≥65 years, diabetes mellitus, hypothyroidism (if present), renal impairment, and polypharmacy—all significantly increase rhabdomyolysis risk. 1, 2
• Initiate aggressive intravenous fluid resuscitation (target urine output 200-300 mL/hour) and urine alkalinization with sodium bicarbonate to prevent myoglobin-induced tubular damage. 6

Acute Kidney Injury and Electrolyte Management

• Emergent hemodialysis is indicated for refractory hyperkalemia, metabolic acidosis, or fluid overload—all life-threatening complications of myoglobinuric acute renal failure. 2, 6, 4
• Monitor for compartment syndrome by assessing intra-compartmental pressures; perform fasciotomy if pressures are critically elevated. 6
• Treat early hypocalcemia cautiously (calcium administration may worsen tissue calcification), but monitor for late hypercalcemia during recovery phase. 6

Delayed Labial Artery Bleeding Management

Antiplatelet/Anticoagulant Assessment

• Immediately assess the patient's antiplatelet (aspirin, clopidogrel) and anticoagulant (warfarin, direct oral anticoagulants) medication profile, as elderly patients with diabetes and hypertension commonly take these medications for cardiovascular disease prevention. 7
• Elderly trauma patients on anticoagulants have high risk for significant bleeding even after minor trauma. 7
• Apply direct pressure to the labial artery bleeding site; consider topical hemostatic agents or surgical ligation if bleeding persists despite conservative measures.

Reversal Considerations

• If on warfarin: administer vitamin K and prothrombin complex concentrate for life-threatening bleeding.
• If on direct oral anticoagulants: consider specific reversal agents (idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors) if available and bleeding is severe.
• Balance bleeding risk against thrombotic risk from cardiac arrest and potential acute coronary syndrome, as this patient has multiple cardiovascular risk factors. 7

Cataract Management in This Context

Timing of Intervention

• Defer elective cataract surgery until the patient has fully recovered from cardiac arrest, rhabdomyolysis, and acute kidney injury, as the American Academy of Ophthalmology recommends surgery only when the patient desires improved vision and can tolerate the procedure. 8
• Cataract surgery timing should be based on mutual agreement between patient and surgeon, not arbitrary visual acuity thresholds. 8

Preoperative Optimization When Stable

• Mandatory diabetic retinopathy screening with dilated comprehensive eye examination by an ophthalmologist experienced in diabetic retinopathy before proceeding with cataract surgery. 8
• Optimize glycemic control before surgery, as diabetes increases risk of postoperative complications including diabetic macular edema, progression of diabetic retinopathy, and endophthalmitis. 8
• Surgery may be needed to improve visualization and management of coexisting diabetic retinopathy. 8

Risk Factor Modification After Stabilization

Cardiovascular Risk Management

• Once stable, optimize medical therapy with beta-blockers and ACE inhibitors or ARBs for hypertension and cardiovascular protection, as these medications reduce mortality in patients with heart failure and ventricular arrhythmias. 7
• Achieve blood pressure control with target systolic <130 mmHg using thiazide diuretics as first-line, adding beta-blockers, ACE inhibitors, or ARBs as needed. 7
• Restart statin therapy at the lowest effective dose (atorvastatin 10 mg) only after complete resolution of rhabdomyolysis and normalization of CK levels, with careful patient education about reporting muscle symptoms immediately. 1, 2

Fall Prevention

• Screen for orthostatic hypotension (≥20 mmHg systolic or ≥10 mmHg diastolic drop) before restarting or adjusting antihypertensive medications, as elderly hypertensive patients have 6-30% prevalence of orthostatic hypotension. 7, 9
• Discontinue or dose-reduce fall-risk medications including benzodiazepines, alpha-blockers, antipsychotics, or tricyclic antidepressants. 9
• Implement balance training and lower extremity strengthening, as stroke survivors (if applicable) have fall rates up to 50%. 9

Critical Monitoring Parameters

Laboratory Surveillance

• Monitor CK levels daily until declining and <5 times upper limit of normal; peak CK may reach >6000 U/L in severe rhabdomyolysis. 4
• Monitor myoglobin levels (normal 9-83 ng/mL); levels >20,000 ng/mL indicate severe myoglobinuria requiring aggressive treatment. 4
• Serial cardiac troponin measurements at presentation and 3-6 hours to rule out Type 1 or Type 2 myocardial infarction as precipitant of cardiac arrest. 7
• Daily electrolytes focusing on potassium, phosphate, and calcium; renal function (creatinine, blood urea nitrogen); and acid-base status. 6

Cardiac Monitoring

• Continuous telemetry monitoring for recurrent arrhythmias, as ventricular arrhythmias may recur with persistent electrolyte abnormalities or underlying structural heart disease. 7
• Obtain 12-lead ECG to assess for ischemic changes, QT prolongation, or hyperkalemic changes (peaked T waves, widened QRS). 7
• Consider echocardiography to assess for structural heart disease, left ventricular hypertrophy, or regional wall motion abnormalities suggesting myocardial infarction. 7

Common Pitfalls to Avoid

• Do not restart statins prematurely; rhabdomyolysis may occur with delayed presentation even after drug discontinuation, as demonstrated in cases occurring 1 month after stopping gemfibrozil. 2
• Do not assume normal or mildly elevated potassium excludes severe hyperkalemia risk in diabetic ketoacidosis or acute kidney injury; severe hyperkalemia can develop rapidly and cause cardiac arrest. 5
• Do not overlook the need for hemodialysis in rhabdomyolysis; waiting for spontaneous recovery when refractory hyperkalemia, acidosis, or fluid overload exists increases mortality. 2, 6
• Do not combine statins with fibrates in elderly patients with diabetes and renal impairment, as this dramatically increases rhabdomyolysis risk through pharmacodynamic interactions. 2
• Do not ignore muscle symptoms in patients on statins; even mild symptoms warrant immediate CK measurement and consideration of drug discontinuation. 1, 2