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As such, there is a case report describing rhabdomyolysis-induced compartment syndrome three days after a vigorous workout in a year old man taking atorvastatin [26], and another describing rhabdomyolysis in marathon runner taking statins [28]. Exertional heat illness EHI represents a spectrum of disease caused by intense physical stress or exercise in the heat [29].
Both syndromes can present with an array of symptoms such as energy depletion, nausea, vomiting, dizziness, headache, muscle aches and tachycardia. However, the major distinguishing factor between the two is the degree of physiologic compensation. With heat exhaustion, body temperature may be normal or slightly elevated but physiologic thermoregulatory mechanisms remain intact, so profuse sweating may be present. By contrast, patients with EHS are in a state of physiologic decompensation.
This includes neurologic findings such as central nervous system dysfunction encephalopathy presenting as altered mental status, agitation, ataxia and even seizures or coma [1, 29]. EHS can rapidly progress to florid thermoregulatory failure [29].
Athletes are at an elevated risk of EHS. In the United States, high school football players have the highest risk, estimated at 4. Most EHI cases were associated with football and most commonly occurred during the month of August. While exertion or exercise is a major precipitating factor for EHI, there are several confounders which should raise suspicion for more severe EHI, or the possibility of imminent EHS.
Electrical Injuries in the Emergency Department: Chronic Obstructive Pulmonary Disea After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia's Northern Territory, Perth and Melbourne. While the data on mortality varies with cause of rhabdomyolysis and AKI, studies have shown that in all causes, AKI increases the likelihood of mortality. He is physically active with occasional running and biking, but does not typically strength train. Skin and Soft Tissue Infe
Not surprisingly, a review temperature and participant data from multiple United States marathons found that hotter race days correlated with drop-out rate, hyponatremia incidence and heat stroke [32]. Most patients with EHI present with collapse during exertion often followed by a period of altered mental status. The differential diagnosis should generally include potential causes of exercise-associated collapse such as:. When initially assessing patients presenting with likely EHI, consider two major guiding principles [36, 37]:.
The first principle dictates that suspicion for severity be maintained in any patient who presents with any symptoms along the EHI spectrum described above, as EHS may develop despite no obvious initial signs of thermoregulatory decompensation at presentation. The second principle emphasized the importance of initiating immediate rapid cooling.
There are several external and internal cooling methods which can be employed in the setting of suspected EHS. External cooling measures include water cold or ice water immersion , ice packs to areas adjacent to large blood vessels axilla and groin and evaporative air cooling fanning, air conditioners [1] [38]. If all potential cooling techniques are immediately available, ice water immersion has been shown to be the most effective [38]. In fact, the National Athletic Trainers Association Position Statement recommends ice bags and a tub or kiddy pool be available either in the locker room or on the field during intense athletic training periods, such as preseason training [29].
Overall, the most valuable rapid cooling technique is whatever is most rapidly accessible to the patient and first responders at the time to prevent delay in cooling therapy. Internal cooling methods involve gastric, bladder and rectal cooling with cooled IV fluids [39].
EB Medicine publishes Emergency Medicine Practice, EM Practice Guidelines Update, Rhabdomyolysis is a potentially life-threatening condition caused by a . Rhabdomyolysis: advances in diagnosis and treatment. It is vital that emergency clinicians consider the diagnosis when patients present with circumstances.
The use of IV cooling is a theoretical option which may be most useful in the setting of transport when a cooling tub is not available. However, this method has not been thoroughly studied in clinical trials and no specific recommendations or guidelines are available. It is recommended that all patients with EHS be monitored for 24 at least hours, mindful of early identification of potential end-organ damage and complications [29]. A list of potential complications and their potential underlying etiologies, which may be either directly caused by hyperthermia or secondary to associated physiologic characteristics.
Note that depending on clinical picture, further workup regarding each of the following potential complications may be warranted. For example, neuroimaging is not generally performed in the setting of EHS. However, if AMS is prolonged and not improving despite response to rapid cooling and hydration, neuroimaging may be warranted.
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We are actively recruiting both new topics and authors. This project is rolling and you can submit an idea or write-up at any time! Contact us at editors emdocs. Algorithm for the Management of Atrial Fibrillation. Exercise-Induced Emergencies in the Heat: This morning, his urine was dark red-brown. Yesterday, he completed a lifting workout which included bench pressing and pushups. He initially thought his soreness was a normal consequence of his workout, but became concerned when he noticed the dark urine.
He is physically active with occasional running and biking, but does not typically strength train.
Initial vital signs are HR 80 and a elevated temperature at Active range-of-motion in the upper extremities is full, but painful. Diagnostic testing should be performed in patients who present with: The combination of muscle soreness and pigmenturia specifically, dark brown or red urine Either muscle soreness OR pigmenturia who have a recent history positive for any of the potential causes for rhabdomyolysis listed above; categories defined as: Traumatic trauma, crush injury Exertional strenuous exercise, hyperthermia Metabolic infections, drug and other toxins A patient who has undergone prolonged immobilization, presents with absence of muscle soreness or pigmenturia OR is unable to describe symptoms and history, but has at least one of the following signs or symptoms which may be indicative of muscle breakdown: Muscle tenderness on exam Pressure-associated skin breakdown Signs of trauma or crush injury Serum chemistry suggestive of cell breakdown hyperkalemia, hyperphosphatemia, hypocalcemia AKI The two most important diagnostic laboratory tests when rhabdomyolysis is suspected are 1 serum CK and 2 urinalysis.
Serum CK is the most sensitive marker of muscle damage [1]. Urinalysis, both dipstick and microscopic analysis should be performed. In addition to these two first laboratory tests, there are other additional tests which are recommended and can further evaluate for complications: Several classification systems have been developed to characterize the numerous causes of rhabdomyolysis. None of these systems is universally recognized, and each has its limitations. Table lists commonly recognized causes. In general, the most common causes of rhabdomyolysis in adults appear to be alcohol and drugs of abuse, followed by medications, muscle diseases, trauma, neuroleptic malignant syndrome, seizures, immobility, infection, strenuous physical activity, and heat-related illness.
Patients in coma are at risk for development of rhabdomyolysis due to immobility from unrelieved pressure on gravity-dependent body parts. In one study, the positions most commonly leading to rhabdomyolysis were the lateral decubitus, lithotomy, sitting, knee-to-chest, and prone positions.
Nutritional compromise, hypokalemia, hypomagnesemia, and hypophosphatemia, all common in alcoholics, increase the risk of rhabdomyolysis. Commonly prescribed medications associated with the development of rhabdomyolysis include antipsychotics, lipid-lowering agents i. Statin-related rhabdomyolysis is rare, varies with the particular statin 0. Please enter User Name Password Error: Please enter Password Forgot Username? Sign in via Shibboleth. Clinical Sports Medicine Collection. Search Advanced search allows to you precisely focus your query. Search within a content type, and even narrow to one or more resources.
You can also find results for a single author or contributor. A Comprehensive Study Guide, 8e. Accessed December 18, View Table Favorite Table Download. Please enter User Name. View All Subscription Options. Pop-up div Successfully Displayed This div only appears when the trigger link is hovered over.