Rhabdomyolysis and crush syndromes

Background

Severe rhadomyolysis secondary to crush syndromes was classically described following trapping in collapsed buildings, but in local settings may also follow physical trauma by assailants. The condition is associated with major morbidity, usually related to the severity of the illness, the presence of associated co-morbidity, and the speed and extent of intervention. A study from Turkey¹ looking at outcomes and complications in patients injured in an earthquake found an overall mortality rate of 15%, with 75% of patients needing dialysis. The biggest single causes of mortality were sepsis (30%), but DIC (8%) and ARDS (12%) were other important factors, both increasing the unadjusted odds of death by about 5 times.

Recognition

Consider the condition in any patient subjected to major trauma or other conditions likely to lead to muscle necrosis (cytotoxic snake bites, compartment syndromes, malignant neurolept syndrome, severe alcohol toxicity, status epilepticus or even just prolonged immobilisation – hypothermia and stroke patients. More recently, an association with Covid-19 infection has been described, and there is a background of associations with other severe viral infections causing muscle injury.)² Oliguria is a late sign, but complaints of dark or concentrated urine, and the finding of tender muscles should alert one to the condition.

Diagnosis

The key features are myoglobinuria in the presence of evidence of muscle damage; the tests of value are a serum creatinine kinase, where levels of 20 000 IU/L or more are not unusual (and a finding of > 5 times ULN is highly suggestive), and a positive urine dipstix for blood, without finding red cells on urine microscopy. Useful investigations include monitoring pH, creatinine and potassium, but also serum phosphate (rises) and calcium (falls).

Management

Fluids

Fluid resuscitation to maintain urine output is traditionally seen as a useful starting point, despite little high quality evidence of efficacy. A 2019 review found three observational studies only, two of which found benefit from liberal fluids and one of which found harm…³ Commonly proposed infusion rates of 1 to 3 ml/kg/hour ( 100 to 200 ml per hour) must be linked to proportionate urine output – simply pouring fluid into an oliguric patient is not sensible as it often leads to rapid onset pulmonary oedema and a need for emergency dialysis.⁴ Which fluid to use is also not clear – normal saline makes sense from the perspective of worsening hyperkalaemia but may worsen acidosis, Ringer’s lactate contains potassium but may be less likely to cause acidosis; in practice careful monitoring of acidosis and pH is probably more important than the starting fluid.

Renal replacement therapy (dialysis)

Dialysis indications are the usual traditional ones (fluid overload, uncorrectable hyperkalaemia, severe or worsening acidosis or severe uraemic symptoms. Dialysis probably has no effect on the natural history of the renal injury and recovery, and thus has no role as ‘primary prevention’.

Diuretics and bicarbonate

There is no convincing evidence that either of these have any useful effect on outcome – best avoided.

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1. Ekrem Erek, Mehmet Sükrü Sever, Kamil Serdengecti, Raymond Vanholder, Emel Akoğlu, Mahmut Yavuz, Hülya Ergin, Mustafa Tekce, Neval Duman, Norbert Lameire, An overview of morbidity and mortality in patients with acute renal failure due to crush syndrome: the Marmara earthquake experience, Nephrology Dialysis Transplantation, Volume 17, Issue 1, January 2002, Pages 33–40, https://doi.org/10.1093/ndt/17.1.33 ↩

2. Taxbro K, Kahlow H, Wulcan H, et al Rhabdomyolysis and acute kidney injury in severe COVID-19 infection. BMJ Case Reports CP 2020;13:e237616 ↩

3. Michelsen J, Cordtz J, Liboriussen L, Behzadi MT, Ibsen M, Damholt MB, Møller MH, Wiis J. Prevention of rhabdomyolysis-induced acute kidney injury – A DASAIM/DSIT clinical practice guideline. Acta Anaesthesiol Scand. 2019 May;63(5):576-586. doi: 10.1111/aas.13308. Epub 2019 Jan 15. PMID: 30644084. ↩

4. Kodadek L, Carmichael Ii SP, Seshadri A, Pathak A, Hoth J, Appelbaum R, Michetti CP, Gonzalez RP. Rhabdomyolysis: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open. 2022 Jan 27;7(1):e000836. doi: 10.1136/tsaco-2021-000836. PMID: 35136842; PMCID: PMC8804685. ↩

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