Transcript Rhabdomyolysis : An Elderly Trauma Patient Case Study

Rhabdomyolysis:
An Elderly Trauma Patient
Case Study
Christine Binter RN BSN
Alverno College
Spring 2010
Rhabdomyolysis Home Page

• Stress
Response
• Definition
• Inflammation
Click Below for Instructions on
Navigation
• Aging
PathoObjectives
physiology
Case Study
History
and
Navigation
Signs and
Symptoms
Laboratory Findings
Treatment
Quiz 1
Quiz 2
Quiz 3
Quiz 4
Diagnosis
•
•
•
•
Virus
Drugs
Genetics
Statins
• Falls
Prevention
Click on underlined words to learn
more about them.
Navigation



Click on
to go to previous slide.
Click on
to home page.
An incorrect answer page will only allow you to
return back to the question.
Objectives
Understand
pathophysiology
Recognize signs and
symptoms
Describe laboratory
findings that lead to
diagnosis
Prevent falls
Discuss treatment plans
Definition of Rhabdomyolysis
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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. 2003
With permission skeletalmuscle.jpg
Patient Case Study
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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
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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.
With permission paramedicine.com
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.
Pathophysiology
intracellular
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Intracellular and
extracellular balance
is maintained by the
Cell membrane
extracellular
Criddle, L. 2003
Pathophysiology
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intracellular
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extracellular
O2
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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
Pathophysiology
K
+
Ph
intracellular
B
extracellular
Na+
Ca
+
Potassium (K+),
Magnesium, and
Phosphate (Ph) are
intracellular
 Sodium (Na+),
 Calcium(Ca+),
 Chloride(Chl),
 Bicarbonate (B) are
chiefly extracellular.
Muscal, E. 2009
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Magnesium
Chl
Pathophysiology
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intracellular
Na+
H2O
H2O
Na+
H2O
Na+
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
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extracellular
N
A
Contribution of Inflammation
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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 OrthoWorld.com
With permission from
[email protected]
Pathophysiology
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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
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Intracellular
Potassium leaks into
the extracellular space
causing cardiac toxic
effects and
dysrhythmias.
Criddle, L. 2003
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K+
K+
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extracellular
K+
Pathophysiology
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Myoglobin, the dark
red protein that gives
muscle cells their redbrown 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
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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.com
With permission from kidney-diseasesymptoms.com
Pathophysiogy
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Thromboplastin and
tissue plasminogen are
released from injured
muscle cells making
patients susceptible to
disseminated
intravascular
coagulation (DIC)
Vanholder, R. 2000
With permission from mdconsult.com
Pathophysiology Quiz
What maintains intracellular and extracellular
balance?
Tissue compression
Cell Membrane
Neutrophils
Pathophysiology Quiz Answer
Exactly Right!
Pathophysiology Answer
Try Again
Pathophysiology Quiz
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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
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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
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Signs and Symptoms
Muscle
weakness
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Myalgia
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Dark Urine
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
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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
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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
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Drugs
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Alcohol abuse causes metabolic
abnormality and immobilization
leading to muscle compression and
muscle ischemia
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Narcotic overdose causes altered
sensorium and immobilization for long
periods. Pressure necrosis develops
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Cocaine damages muscle tissue by
vasoconstriction.
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Antipsychotics may cause neuroleptic
malignant syndrome and muscle rigidity
leading to rhabdomyolysis
Richards, J. 2009
Permission from
floridacrimminalattorneysblog.com
Use history to find rhabdomyolysis
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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
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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. 2009
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Permission from videowasi.com
Contribution of Stress Response
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
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A stress response is
seen in both Mrs.
F’s nervous and
endocrine system.
Laboratory Findings
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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 muscle
CKMM is isolated for skeletal muscle
50% of patients with rhabdomyolysis have
elevated cardiac troponin 1 level. Of these
58% were true myocardial infarction.
Craig, S. 2009
Laboratory Findings
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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
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Acute Renal Failure Develops in
40% of patients.
Measure BUN and creatinine
levels
Normal BUN is 10-20mg/dL
Normal Creatinine is 0.51.1mg/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
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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
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Metabolic Acidosis is
due to increases in
lactic acid, uric acid,
sufate, and potassium
in circulation.
Metabolic Acidosis
Increased lactic acid
Increased uric acid
Criddle, L. 2003
Quiz
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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
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Mrs. F’s initial labs show:
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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 150300ml/hr.
Criddle, L. 2003
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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
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With permission from impactlab.com
Treatment
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When kidneys do not
respond, emergency
hemodialysis is
necessary to manage
oliguria, metabolic
acidosis and fluid
overload.
With permission from commons.wikimedia.org
Russel, T. 2000
With permission
tmsplc.win
Case Study
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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
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Reducing the risk of harm from patient fall has been a JACHO National
Patient Safety Goal since 2005.
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WHO IS AT RISK to FALL?
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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.
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Prevention
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Appropriate Interventions include and are not
limited to:
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Move patient to room within “eye view”
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Keep curtain open
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Assess frequently
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Remind patient not to get up without assistance
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Place call light within reach and demonstrate how to use it
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Assure family or caregiver remains with patient
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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
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“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 lifethreatening syndrome.”
Criddle, L. 2003
References
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Carriere, S. (1998). Found down: compartment syndrome, rhabdomyolysis, and renal failure.
of
Emergency Nursing. 24:214-217.
Journal
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
related diseases. Retrieved February 20, 2010 from http://www.immunityageing.com
age-
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.