Demographic and Clinical Characteristics of Rhabdomyolysis in Emergency Service: A Prospective Clinical Research

  

    
Additional Disease
    
N (%)
  
  

    
No additional disease
    
43 (66.2 %)
  
  

    
Diabetes mellitus + hypertension + congestive    heart disease
    
8(12.3%)
  
  

    
Hypertension
    
7 (10.8 %)
  
  

    
Diabetes mellitus
    
4 (6.2%)
  
  

    
Epilepsy
    
1 (1.5%)
  
  

    
Familial Mediterranean fever
    
1 (1.5%)
  
  

    
Chronic kidney disease
    
1 (1.5%)
  
  

    
Total
    
65
  

Table 3:  Distribution according to additional disease.

Forty-nine patients (75.38%) were discharged from the emergency service, and 16 patients (24.61%) were hospitalized for observation. One of the hospitalized patients was taken into intensive care unit due to diagnosis of Multiple Organ Failure (MOF). This patient died in intensive care unit because of severe acidosis. One patient was taken to hemodialysis. Other 14 patients were discharged after treatment.

Discussion

Rhabdomyolysis is a clinical and laboratory syndrome in which skeletal muscle cell injuries lead to inclusion of intracellular contents in the circulation. Although the classical clinical presentation of rhabdomyolysis generally include myalgia, fatigue, dark-colored urine associated with myoglobinuria, and increased serum levels of muscle enzymes such as Creatine Kinase (CK), the clinical features may vary from increased asymptomatic muscle enzyme to ARF and MOF [1,2,7].

The literature data on general rhabdomyolysis incidence (traumatic or non-traumatic) is few. In a retrospective study, the incidence of rhabdomyolysis was reported as 0.06% [5]. The observed incidence of 0.052% in our study is compatible with the previous data [5].

In a study carried out by Melli et al., of the 475 patients with rhabdomyolysis 151 were women and 475 were men and the mean age was 47 [8]. In accordance with literature our study 31% were women and 69% were men. Mean age was 46.22 ± 2.09 years [8]. According to our view, the underlying reason for the high rate of men with rhabdomyolysis compared to that of women is muscle overactivity.

Rhabdomyolysis can occur as a result of trauma, medicine and toxins, infection, electrolyte abnormalities, hypoxia, hyperthermia, alcohol, exercise and/or seizure [1-3,7,9]. In the literature data obtained from USA, the major causes of rhabdomyolysis in patients presenting to emergency services and being diagnosed with rhabdomyolysis were reported as cocaine, exercise and immobilization, and seizure [3]. In our study, the most common etiological factor was muscle over-activity, but no case related to substance-use was recorded.

The drug-related rhabdomyolysis frequency was found as 7.7% was recorded 11% in literature [8]. The rhabdomyolysis causing drugs were determined as antidepressants, statins, Oral Anti-Diabetics (OAD) and anti-hypertensive medicines in our study compatible with literature [2,3].

The classical presenting symptoms are reported as muscle pain, muscle weakness and dark-colored urine [1-3,7]. However, in over half of the patients, the presenting symptoms may not include weakness or muscle pain [2,3]. When we had looked into the presenting symptoms of patients in our study, we found that though the most common presenting symptoms were muscle pain and weakness (47.7%), only 4.6% of all patients suffered from urine color change. These data are similar to that of Chen et al. who reported urine color change as 5.6% [6].

The measurement of CK and measurement of serum myoglobin level may be useful for the diagnosis. The CK measurement is more sensitive for rhabdomyolysis diagnosis compared to the myoglobin measurement [2,7,9]. CK is a perfect marker for rhabdomyolysis, because it is an easily measurable content that can be measured in serum immediately after any muscle injury, and the half-life of 1.5 days also. is not cleared from serum as fast as myoglobin. In general, CK exhibits peak 24-36 hours after a muscle injury, and shows an approximately 39% decrease at last day compared to peak [2,7]. In an ongoing increased level of CK, an ongoing muscle injury or compartment syndrome should be taken into consideration. An increase of 5-folds or more in CK level compared to normal value is diagnostic for rhabdomyolysis [2,3,7]. In literature, the high levels of CK, especially levels over 16,000 U/L, were reported to be associated with ARF [2]. Brown et al. have stated that CK levels over 5000 U/L in trauma patients are indicative of increased risk for ARF [3]. In our study, serum or urine myoglobin levels could not be measured. In urine test, patients showing positive for hemoglobin and negative for erythrocyte were reevaluated with respect to myoglobinuria, and the diagnosis was made based on CK values. The highest CK value found in our study was 32,442 U/L. This patient had presented with symptoms of extreme weakness and decreased urinary volume, and declared a trauma history. The patient was diagnosed with ARF and rhabdomyolysis secondary to trauma, and taken to hemodialysis. The treatment was continued with hydration and bicarbonate. When a recovery in general health condition thereof was observed in terms of laboratory and clinical findings, the patient was discharged with an appointment of polyclinic check for 12 days later. CK value of 2 of 8 patients with a ARF diagnosis was over 5000 U/L (25%), and the etiology of one of these two patients was trauma. Hemodialysis was not needed except for one patient. ARF occurrence secondary to rhabdomyolysis was found as 12.3% in our study, while it had been reported with wide ranges such as 5-15% or 10-50% in previous studies [7,8,11]. Rhabdomyolysis and ARF occurrence were more common among men compared to women in our study. The most common etiological factor in patients with a rhabdomyolysis diagnosis was muscle over-activity, e.g. sports activity, carrying heavy loads etc.

A number of complications such as hypovolemia, compartment syndrome, and electrolyte abnormalities, ARF or MOF may be observed in patients with rhabdomyolysis. Therefore, the early diagnosis and treatment are crucial. The early treatment has been reported to be able to decrease the incidence of ARF [2,3,7,9]. The treatment of rhabdomyolysis includes initial stabilization, resuscitation and to prevent development of acute renal failure. At the beginning of treatment, a normal saline infusion of 1-1.5 L/hour is given so as to have an hourly urinary excretion of 200-300 ml. It is important to monitor vital findings, urinary output, electrolytes. If acute renal failure establishes, the patient requires hemodialysis [7].

In our study, hydration was administered to patients with a rhabdomyolysis diagnosis within the scope of treatment. Hemodialysis was required for only one case (1.53%). Forty-nine (75.38%) of all patients were discharged from the emergency service. The hospitalization was needed for 16 patients (24.61%) to be able to monitor them. One of these patients died due MOF, while other patients were discharged upon recovery as a result of medical treatment. The prognosis was good with early diagnosis and treatment.

Study Limitation

In this study, serum or urine myoglobin levels could not be measured; the diagnosis was made based on CK values. The sample size was limited.

Conclusion

The etiological factors of rhabdomyolysis vary, such as muscle over-activity, injection, infection, dehydration, trauma, medicine. The male gender and muscle over-activity are critical factors for rhabdomyolysis. Patients with rhabdomyolysis caused by dehydration also showed ARF.

References

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