Crush Injuries and Rhabdomyolysis

Tracy So Trauma/ICU conference

Rhabdomyolysis
Release of intracellular components from injured myocytes into the circulation
Old Testament Book of Numbers 11 (31-35): Israelites suffered a mass plague during their exodus following ingestion of quail. In the Mediterranean, quails eat hemlock during spring migration, and rhabdo from eating the birds is a recognized phenomenon. Hemlock (Conium maculatum )

Poison hemlock was used to execute Socrates.

Causes of Rhabdomyolysis
In US: alcohol abuse and subsequent immobility and coma, direct myotoxic effects of alcohol
Crush injuries, long surgeries in lithotomy or lateral decub, surgery on morbidly obese patients (gluteal), contact sports, burns, lifting heavy weights Vascular compromise compartment syndrome, embolus and subsequent reperfusion
DTs, NMS, hyperthermia, long-term vecuronium Electrolyte disturbances Drugs (HMGCoA red. inh., psychedelic) Infections-Legionella, strep, influenza, HIV

Myocyte Injury
Tolerable-no permanent histological changes
Muscle necrosis 2 Irreversible anatomic and functional changes 4 6

Hours of 0 ischemia

Cell Ion Physiology

intracellular extracellular

Pathogenesis of Myocyte Injury

Ca++
compression
Protease activation ischemia Influx of Ca++, Na+ and fluids Attraction of PMNs Membrane degradation Nuclease activation Lipid peroxidation

Decreased ATP production

cell lysis

More Ca++ influx

When to Suspect Rhabdo

Occurs in up to 85% of patients with traumatic injuries.
Those with severe injury who develop rhabdomyolysis-induced renal failure have a 20% mortality rate

Multiple orthopedic injuries Crush injury to any part of the body (eg: hand)
Laying on limb for long period of time patient found down Long surgery Brown urine

What to Watch for if you suspect Rhabdo: Clinical: Mm pain, weakness, dark urine
Hypovolemia, shock Electrolyte abnormalities : K+, Ca++ (sequestered in injured tissues), acidemia upon reperfusion

Pathophysiology of ARF
Crush syndrome first recorded in bombing of London during WWII: 5 people who were crushed presented in shock with swollen extremities, dark urine. Later died from renal failure.

5-35% of patients with rhabdomyolysis develop ARF mortality is 3-50%

Pathophysiology of ARF
CONTRIBUTORS:
Not reabsorbed

Binds TammHorsfell proteins

Dehydration (hypovolemia) Aciduria Renal vasoconstriction Cast formation Heme-induced toxicity to tubule cells

Myoglobin 1-3% of wet mm weight

Diagnosis
Serum CKMM
Correlates w/severity of rhabdo Normally 145-260 U/L Levels peak w/in 24h >5000 high correlation with renal failure #s in 100,000s not uncommon high t(1/2): 1.5 days
sample UA

Serum myoglobin
t(1/2) 2-3 h Excreted in bile
uric acid crystals

Ca++ UA-myoglobinuria
dipstick will be (+) for hemoglobin, RBCs and myoglobin Microscopy: no RBCs, brown casts, uric acid crystals

(+) for blood

Other measures: carbonic anhydrase III, aldolase

Treatment Algorithm for preventing renal failure

Malinoski, et al. (2004)

Early Treatment
FLUIDS
Begin early, even on the field
Damaged muscles attract a lot of fluid
Up to 10L/day

Ideally NS with 100mmol/L bicarb

prevents tubular precipitation reduces risk of hyperkalemia from damaged mm corrects acidemia not proven beneficial however not deleterious

10ml/h 15% mannitol

renal vasodilator free radical scavenger

Forced diuresis w/in 6 hrs of admission

Late Treatment
Dialysis
intermitted preferred to continuous
Reduce use of anticoagulants in trauma patients

Studies
Many done after earthquakes, mass beatings, other natural disasters
Spitak earthquake of 1988 in Armenia 600 required dialysis Marmara earthquake Turkey 1999 n=462 on dialysis, 19% mortality which was much better than before 1995 International Society of Nephrology created Disaster Relief Task Force to prev/treat crush injury-induced ARF

The causes of death in 50 patients with the crush syndrome following the HanshinAwaji Earthquake. Deaths from hypovolemia and hyperkalemia were the most common in the early period, while sepsis leading to multiple organ failure was responsible for most of the late deaths