Rhabdomyolysis and myoglobinuric renal failure in trauma and surgical patients: a review

February 6th, Kahramanmaraş earthquakes and the disaster management algorithm of adult emergency medicine in Turkey: An experience review

This compilation covers emergency medical management lessons from the February 6th Kahramanmaraş earthquakes. The objective is to review relevant literature on emergency services patient management, focusing on Koenig's 1996 Simple Triage and Rapid Treatment (START) and Secondary Assessment of Victim Endpoint (SAVE) frameworks. Establishing a comprehensive seismic and mass casualty incident (MCI) protocol chain is the goal. The prehospital phase of seismic MCIs treats hypovolemia and gets patients to the nearest hospital. START-A plans to expedite emergency patient triage and pain management. The SAVE algorithm is crucial for the emergency patient secondary assessment. It advises using Glasgow Coma Scale, Mangled Extremity Severity Score, Burn Triage Score, and Safe Quake Score for admission, surgery, transfer, discharge, and outcomes. This compilation emphasizes the importance of using diagnostic tools like bedside blood gas analyzers and ultrasound devices during the assessment process, drawing from 6 February earthquake research. The findings create a solid framework for improving emergency medical response strategies, making them applicable in similar situations.

Demographic and Clinical Characteristics of Earthquake Victims Presented to the Emergency Department with and without Crush Injury upon the 2023 Kahramanmaraş (Turkey) Earthquake

INTRODUCTION

Earthquakes are sudden-onset natural disasters that are associated with substantial material damage, resulting in the collapse of built environment with a high rate of mortality, injury, and disability. Crush syndrome, which can be seen after devastating earthquakes, can lead to acute kidney injury (AKI) and patients may require amputation, fasciotomy, and dialysis. Supportive treatment has an important role in the prognosis of these patients.

STUDY OBJECTIVE

The aim of this study was to investigate the demographic and clinical characteristics of traumatic earthquake survivors admitted to the emergency department (ED) of a hospital, which was close to the earthquake zone but not affected by the earthquake, after the February 6, 2023 Kahramanmaraş (Turkey) earthquakes.

MATERIALS AND METHODS

This study was conducted by retrospectively analyzing the data of 1,110 traumatized earthquake survivors admitted to the ED of a tertiary care university hospital from February 6th through February 20th, 2023. Age; gender; time of presentation; presence of comorbid diseases; ED triage category; duration of stay under debris; presence of additional trauma; laboratory tests; presence of AKI; presence of crush injury and injury sites; supportive treatment (fluid replacement and intravenous [IV] sodium bicarbonate); need for amputation, dialysis, and fasciotomy; duration of hospitalization; and outcome of ED were evaluated.

RESULTS

Of the 1,110 traumatic victims in this study, 55.5% were female patients. The mean age of the patients was 45.94 (SD = 16.7) years; the youngest was 18 years old and the oldest was 95 years old. Crush injury was detected in 18.8% and AKI in 3.0% of the patients. Dialysis, amputation, and fasciotomy were required in 1.6%, 2.8%, and 1.4% of the patients, respectively. In total, 29.2% of patients were hospitalized, including 2.9% admitted to the intensive care unit (ICU) and 26.3% to the relevant ward. In total, 0.3% of the patients included in the study died at ED.

CONCLUSION

Post-earthquake patients may present with crush injury, AKI may develop, and fasciotomy, amputation, and dialysis may be needed, so hospitals and EDs should be prepared for natural disasters such as earthquakes.

A Comparative Analysis of Fasciotomy Results in Children and Adults Affected by Crush-Induced Acute Kidney Injury following the Kahramanmaraş Earthquakes

Background and Objectives: The current study aims to determine the impact of fasciotomy on mortality and morbidity in children and adults with crush-related AKI following the 2023 Kahramanmaraş earthquakes. Materials and Methods: The study included individuals who had suffered crush injuries after the 2023 Kahramanmaraş earthquakes and were identified as having an acute kidney injury (AKI). Patients with an AKI were divided into two groups based on age: those under 18 years and those over 18 years. A comparative analysis was conducted between the mortality and morbidity rates of patients who underwent fasciotomy and those who did not. Disseminated intravascular coagulopathy (DIC), sepsis, and adult respiratory distress syndrome (ARDS) have all been identified as contributors to morbidity. Results: The study was conducted with a total of 40 patients (21 males and 19 females) aged between 4 and 83 years. A total of 21 patients underwent fasciotomy, and the patients underwent varying numbers of fasciotomy, ranging from 0 to 11. The mortality rate was 12.5%, corresponding to five adult patients. No instances of mortality were reported in the paediatric cohort. The application of fasciotomy in instances of crush-induced AKI did not result in elevated levels of mortality in either the paediatric or adult demographic. Within the adult population, a substantial difference in the duration of dialysis was observed between individuals who underwent fasciotomy and those who did not. A statistically significant increase in the number of fasciotomy incisions was observed in patients diagnosed with sepsis compared with those without sepsis. The study found a significant positive correlation between the number of fasciotomy incisions and dialysis days. Conclusions: Neither adult nor paediatric patients with crush-induced AKI showed an increased risk of death after fasciotomy. The number of fasciotomy incisions significantly correlated with the development of sepsis. Despite experiencing delays in hospital admission for paediatric patients, the incidence of both crush syndrome and mortality rates among children remained relatively low.

Delayed step-by-step decompression with DSF alleviates skeletal muscle crush injury by inhibiting NLRP3/CASP-1/GSDMD pathway

Crush injury (CI) is a common disease in earthquake and traffic accidents. It refers to long-term compression that induces ischemia and hypoxia injury of skeletal muscle rich parts, leading to rupture of muscle cells and release of contents into the blood circulation. Crush syndrome (CS) is the systemic manifestation of severe, traumatic muscle injury. CI rescue faces a dilemma. Ischemic reperfusion due to decompression is a double-edged sword for the injured. Death often occurs when the injured are glad to be rescued. Programmed cell death (PCD) predominates in muscle CI or ischemia-reperfusion injury. However, the function and mechanism of pyroptosis and apoptosis in the pathogenesis of skeletal muscle injury in CI remain elusive. Here, we identified that pyroptosis and apoptosis occur independently of each other and are regulated differently in the injured mice's skeletal muscle of CI. While in vitro model, we found that glucose-deprived ischemic myoblast cells could occur pyroptosis. However, the cell damage degree was reduced if the oxygen was further deprived. Then, we confirmed that delayed step-by-step decompression of CI mice could significantly reduce skeletal muscle injury by substantially inhibiting NLRP3/Casp-1/GSDMD pyroptosis pathway but not altering the Casp-3/PARP apoptosis pathway. Moreover, pyroptotic inhibitor DSF therapy alone, or the combination of delayed step-by-step decompression and pyroptotic inhibitor therapy, significantly alleviated muscle injury of CI mice. The new physical stress relief and drug intervention method proposed in this study put forward new ideas and directions for rescuing patients with CI, even CS-associated acute kidney injury (CS-AKI).

Crush injury and syndrome: A review for emergency clinicians

INTRODUCTION

Primary disasters may result in mass casualty events with serious injuries, including crush injury and crush syndrome.

OBJECTIVE

This narrative review provides a focused overview of crush injury and crush syndrome for emergency clinicians.

DISCUSSION

Millions of people worldwide annually face natural or human-made disasters, which may lead to mass casualty events and severe medical issues including crush injury and syndrome. Crush injury is due to direct physical trauma and compression of the human body, most commonly involving the lower extremities. It may result in asphyxia, severe orthopedic injury, compartment syndrome, hypotension, and organ injury (including acute kidney injury). Crush syndrome is the systemic manifestation of severe, traumatic muscle injury. Emergency clinicians are at the forefront of the evaluation and treatment of these patients. Care at the incident scene is essential and focuses on treating life-threatening injuries, extrication, triage, fluid resuscitation, and transport. Care at the healthcare facility includes initial stabilization and trauma evaluation as well as treatment of any complication (e.g., compartment syndrome, hyperkalemia, rhabdomyolysis, acute kidney injury).

CONCLUSIONS

Crush injury and crush syndrome are common in natural and human-made disasters. Emergency clinicians must understand the pathophysiology, evaluation, and management of these conditions to optimize patient care.

Prevalence of Rhabdomyolysis Following Bariatric Surgery and its Associated Risk Factors: a Meta-Analysis

PURPOSE

This study aimed to evaluate the prevalence of rhabdomyolysis (RML) following bariatric surgery and potential associated factors.

MATERIALS AND METHODS

We systematically searched PubMed, Embase, and CENTRAL for relevant trials from database inception through August 2022. Articles were eligible for inclusion if they reported the prevalence of RML after bariatric surgery and provided at least one of the following outcome indicators: preoperative mean BMI/mean operative time for the included population.

RESULTS

Sixteen studies with a total of 1540 patients were analyzed. The mean preoperative age distribution of the included patients was centered between 32.9 and 47.0 years, and the mean preoperative BMI ranged from 42.3 to 60.0 kg/m². The operative time varied between 126.7 and 403.3 min. The overall pooled crude prevalence of post-bariatric surgery RML was 19.4%. Subgroup analyses showed the pooled prevalence of RML was 8.1% for operative duration > 120 and ≤ 180 min, 32.8% for > 180 and ≤ 240 min, and 47.4% for > 240 min. Meta-regression revealed that operation time was an independent risk factor for developing RML. Besides, BMI > 50 kg/m² and open Roux-en-Y gastric bypass (RYGB) indicated a higher risk of RML.

CONCLUSION

Post-bariatric surgery RML prevalence occurred more frequently with the extension of the operation time. For bariatric subjects with surgery time > 180 min, open RYGB, or BMI > 50 kg/m², CKP could be routinely measured early to verify the presence of RML and to actively prevent its fatal complications.

Trauma-related electrolyte disturbances: From resuscitation to rhabdomyolysis

Traumatic injury results in drastic changes to a patient's normal physiology. The hormonal stress response, as well as some treatment strategies, lead to significant disruptions in electrolyte homeostasis that are important for clinicians to understand. In addition, advances in fluid resuscitation and modern transfusion practices have led to their own unique set of consequences, which we are just beginning to appreciate. Special attention is placed on rhabdomyolysis, as this distinct entity represents an extreme example of injury induced electrolyte derangements. This review describes the physiologic response to trauma and highlights some of the important electrolyte abnormalities that can be encountered while caring for the injured patient.

Upper limb replantation: Surgical strategy and the prophylaxis of acute renal failure due to ischemia reperfusion injury – A report of two cases

Introduction. The arm replantation is an extremely rare and challenging procedure. The recognized risk is myoglobinuria and, consenquently, ischemia reperfusion-induced renal failure. Case report. We presented two patients aged 24 and 46 years who were admitted after traumatic arm amputation. Ischemia time was six and two hours, respectively. Postoperative intensive care treatment with assisted ventilation, sedation, and obtaining sufficient urine output prevented myoglobin-induced renal injury. In the case where ischemia time was shorter, there was only one delayed reconstruction of skin defects after fasciotomy, but in the case where ischemia lasted longer, the patient had two secondary look procedures with acceptable definitive results. Conclusion. Arm replantation is a safe procedure even in cases with longer ischemia time. Postoperative control of urine output, correction of acidosis, and preventing myoglobin-induced tubular injury are crucial for stable postoperative recovery and.

Clinical implications of serum myoglobin in trauma patients: A retrospective study from a level 1 trauma center

Background:

We aimed to study the clinical implication of high serum myoglobin levels in trauma patients.

Methods:

A retrospective analysis was conducted on data from trauma patients who were admitted to a level 1 trauma center between January 2012 and December 2015. A receiver operating characteristic (ROC) curve analysis was performed for the optimum myoglobin cutoff plotted against hospital length of stay of >1 week. Patients were divided into two groups (Group 1; low vs. Group 2; high myoglobin), and a comparative analysis was performed.

Results:

There were 898 patients who met the inclusion criteria with a mean age of 35.9 ± 14.6 years. Based on ROC, the myoglobin optimum cutoff was 1000 ng/ml (64% of patients were in Group 1 and 36% in Group 2). The mean myoglobin level was 328 ng/ml in patients with the Injury Severity Score (ISS) <15 versus 1202 ng/ml in patients with ISS ≥15 (P < 0.001). Patients in Group 2 had higher ISS (22.2 ± 10 vs. 18.8 ± 10), more musculoskeletal injuries (18.3% vs. 4.2%), more blood transfusion (74% vs. 39%), intubation (57% vs. 46.5%), and sepsis (12% vs. 7.3%). The length of hospital stays was significantly higher in Group 2, but mortality was comparable. High myoglobin levels had a crude odd ratio 2.41; 95% confidence interval (1.470–3.184) for a longer hospital stay with a positive predictive value of 89% and a specificity of 77%.

Conclusions:

One-third of the admitted trauma patients have elevated serum myoglobin level, which is associated with the prolonged hospital stay. The discriminatory power of myoglobin value of 1000 in trauma is fair, and further prospective assessments are needed.

Myoglobin Mediates Autophagy of NRK-52E in Rat Renal Tubular Epithelial Cells Via the Pink1/Parkin Signaling Pathway

Background

The aim of this study was to investigate whether myoglobin mediates the autophagy of NRK-52E via the Pink1/Parkin signaling pathway.

Material/Methods

Differentially-expressed genes were selected by PCR chip analysis of the autophagy signaling pathway. RT-PCR and Western blot analyses were used to detect the expressions of Pink1/Parkin and autophagy-related proteins in myoglobin-treated NRK-52E. LC3 double-labeled lentivirus was used to infect NRK-52E for observing autophagy. The role of myoglobin mediates autophagy was evaluated through Pink1-siRNA inhibition of the Pink1/Parkin signaling pathway.

Results

Myoglobin acted on NRK-52E, caused differential expressions of Pink1, Parkin, and Beclin 1, increased apoptosis, and decreased cell viability. myoglobin increased the levels of Pink1, Beclin 1 and ATG5, decreased the levels of P62 and Parkin. The level of LC3II/LC3I showed significant elevation in NRK-52E cells at after incubated with 100 μmol/L myoglobin. Inhibiting Pink1/Parkin signaling pathway through Pink1-siRNA could alleviate myoglobin induced apoptosis, decrease the levels of Pink, Beclin1, ATG5, LC3II/LC3I, and elevate the levels of Parkin and P62. Moreover, the autophagy spots were reduced after silencing Pink1 in myoglobin-treated NRK-52E.

Conclusions

Myoglobin mediates the autophagy of NRK-52E in rat renal tubular epithelial cells via the Pink1/Parkin signaling pathway.

A "crush" course on rhabdomyolysis: risk stratification and clinical management update for the perioperative clinician

Rhabdomyolysis, the release of myoglobin and other cellular breakdown products from necrotic muscle tissue, is seen in patients with crush injuries, drug overdose, malignant hyperthermia, muscular dystrophy, and with increasing frequency in obese patients undergoing routine procedures. For the perioperative clinician, managing the resultant shock, hyperkalemia, acidosis, and myoglobinuric acute kidney injury can present a significant challenge. Prompt recognition, hydration, and correction of metabolic disturbances may reduce or eliminate the need for long-term renal replacement therapy. This article reviews the pathophysiology and discusses key issues in the perioperative diagnosis, risk stratification, and management of rhabdomyolysis.

Rhabdomyolysis associated acute renal failure - Report of two fatal cases and a brief review of literature

BACKGROUND

Rhabdomyolysis is a potentially fatal condition which occurs due to skeletal muscle injury and classically presents with myalgia and red-brown coloured urine. Presence of excess myoglobin in the glomerular filtrate forms myoglobin casts which causes severe obstruction and necrosis of the tubules leading to acute renal failure.

METHODS

We report two fatal cases of rhabdomyolysis associated acute renal failure. The first victim died in police custody and the second victim died due to severe physical exertion.

RESULTS

In both the cases, creatine kinase levels were elevated and myoglobin was detected in urine in the second case. Myoglobin immunohistochemistry detected the presence of myoglobin cast in the glomerular tubules of kidney in both the cases.

CONCLUSIONS

Myoglobin immunohistochemistry of renal tissues, serum creatine kinase, urine myoglobin analysis and muscle histopathology are the laboratory tests that should be considered at autopsy where rhabdomyolysis is suspected.

Non-traumatic and non-drug-induced rhabdomyolysis

Rhabdomyolysis (RM), a fortunately rare disease of the striated muscle cells, is a complication of non-traumatic (congenital (glycogen storage disease, discrete mitochondrial myopathies and various muscular dystrophies) or acquired (alcoholic myopathy, systemic diseases, arterial occlusion, viral illness or bacterial sepsis)) and traumatic conditions. Additionally, RM can occur in some individuals under specific circumstances such as toxic substance use and illicit drug abuse. Lipid-lowering drugs in particular are capable of causing RM. This comprehensive review will focus on non-traumatic and non-drug-induced RM. Moreover, the pathology of RM, its clinical manifestation and biochemical effects, and finally its management will be discussed.

Anisodamine Ameliorates Hyperkalemia during Crush Syndrome through Estradiol-Induced Enhancement of Insulin Sensitivity

Hyperkalemia is a major cause of on-site death in crush syndrome (CS), which is more severe and common in male victims. Anisodamine is a belladonna alkaloid and widely used in China for treatment of shock through activation of α7 nicotinic acetylcholine receptor (α7nAChR). The present work was designed to study the protective effect of anisodamine in CS and the possible role of estradiol involved. Male and ovariectomized female CS mice exhibited lower serum estradiol and insulin sensitivity, and higher potassium compared to the relative female controls at 6 h after decompression. There was no gender difference in on-site mortality in CS mice within 24 h after decompression. Serum estradiol increased with similar values in CS mice of both gender compared to that in normal mice. Anisodamine decreased serum potassium and increased serum estradiol and insulin sensitivity in CS mice, and methyllycaconitine, selective antagonist of α7nAChR, counteracted such effects of anisodamine. Treatment with anisodamine or estradiol increased serum estradiol and insulin sensitivity, decreased serum potassium and on-site mortality, and eliminated the difference in these parameters between CS mice received ovariectomy or its sham operation. Anisodamine could also increase blood pressure in CS rats within 3.5 h after decompression, which could also be attenuated by methyllycaconitine, without influences on heart rate. These results suggest that activation of α7nAChR with anisodamine could decrease serum potassium and on-site mortality in CS through estradiol-induced enhancement of insulin sensitivity.

Combined Therapy with Extracorporeal Shock Wave and Adipose-Derived Mesenchymal Stem Cells Remarkably Improved Acute Ischemia-Reperfusion Injury of Quadriceps Muscle

Extracorporeal shock wave (ECSW) and adipose-derived mesenchymal stem cells (ADMSCs) have been recognized to have capacities of anti-inflammation and angiogenesis. We tested the hypothesis that ECSW and ADMSC therapy could attenuate ischemia-reperfusion- (IR-) induced thigh injury (femoral artery tightened for 6 h then the tightness was relieved) in rats. Adult male SD rats (n = 30) were divided into group 1 (sham-control), group 2 (IR), group 3 (IR + ECSW/120 impulses at 0.12 mJ/mm² given at 3 h/24 h/72 h after IR), group 4 (allogenic ADMSC/1.2 × 10⁶ cell intramuscular and 1.2 × 10⁶ cell intravenous injections 3 h after IR procedure), and group 5 (ECSW + ADMSC). At day 7 after the IR procedure, the left quadriceps muscle was harvested for studies. At 18 h after the IR procedure, serum myoglobin/creatine phosphokinase (CPK) levels were highest in group 2, lowest in group 1, and with intermediate values significantly progressively reduced in groups 3 to 5 (all p < 0.0001). By day 5 after IR, the mechanical paw-withdrawal threshold displayed an opposite pattern of CPK (all p < 0.0001). The protein expressions of inflammatory, oxidative-stress, apoptotic, fibrotic, DNA-damaged, and mitochondrial-damaged biomarkers and cellular expressions of inflammatory and DNA-damaged biomarkers exhibited an identical pattern of CPK among the five groups (all p < 0.0001). The microscopic findings of endothelial-cell biomarkers and number of arterioles expressed an opposite pattern of CPK, and the angiogenesis marker was significantly progressively increased from groups 1 to 5, whereas the histopathology showed that muscle-damaged/fibrosis/collagen-deposition areas exhibited an identical pattern of CPK among the five groups (all p < 0.0001). In conclusion, ECSW-ADMSC therapy is superior to either one applied individually for protecting against IR-induced thigh injury.

Rhabdomyolysis After Prolonged Surgery: Report of 2 Cases and Review of Literature

Rhabdomyolysis is a condition in which damaged muscle tissue breaks down and intracellular contents, including myoglobin, are released into the circulation. This produces a nonspecific clinical syndrome including electrolyte disturbances, hypovolemia, metabolic acidosis, coagulopathies, and risk of acute kidney injury. Rhabdomyolysis has been reported as a complication of prolonged surgical procedures but has rarely been reported in the oral and maxillofacial surgery literature. Early diagnosis and treatment of rhabdomyolysis are important to avoid long-term complications such as renal failure. We present 2 cases of postoperative rhabdomyolysis after prolonged maxillofacial surgical procedures in which the patients were managed without long-term sequelae. The pathophysiology, risk factors, diagnosis, and treatment of postoperative rhabdomyolysis are discussed, with a brief review of the literature.

Fluids for Prevention and Management of Acute Kidney Injury

Fluids are the only known method of attenuating renal injury. Furthermore, whether for hydration, resuscitation or renal replacement therapy, fluid prescriptions must be tailored to the fluid and electrolyte, cardiovascular status and residual renal function of the patient. Different fluids have significantly different effects both on volume expansion as well as on the electrolyte and acid-base balance; while controversial, different fluids may even influence renal function differently. This systematic review focuses on fluids for prevention and management of acute kidney injury. We have reviewed the available evidence and have made recommendations for clinical practice and future studies.

Rectus Abdominis Rhabdomyolysis: Report of 2 Cases

Exercise-induced rhabdomyolysis is an unusual clinical entity for physicians and one that is frequently misdiagnosed. With the ever-increasing use of sonography by radiologists, sonographers, and sports physicians in the diagnosis of acute muscle injury, recognition of the typical sonographic appearance of rhabdomyolysis is paramount. Current literature using high-resolution ultrasound equipment is limited, with much of the literature offering dated or incongruent descriptions. We describe the sonographic findings of hyperechoic muscle and a hypoechoic halo of edema in 2 proven cases of rectus abdominis rhabdomyolysis after exercise.

Rare case of severe serotonin syndrome leading to bilateral compartment syndrome

The term 'serotonin syndrome' describes a constellation of symptoms caused by serotonergic overstimulation. Its characteristic clinical presentation consists of encephalopathy, neuromuscular signs and autonomic hyperactivity. After removal of the offending agent, the clinical course is usually self-limited but can occasionally lead to severe symptoms. We report the case of a 68-year-old woman who presented emergently with encephalopathy. Home medications included paroxetine and dextroamphetamine/amphetamine. Physical examination revealed tachycardia, tachypnoea, diaphoresis, rigidity, hyperreflexia and clonus. Given the fast onset of symptoms, a diagnosis of serotonin syndrome was made. Laboratory studies showed acute-on-chronic kidney injury and elevated creatine kinase. The patient's mental status quickly returned to baseline with supportive care. Her rhabdomyolysis, however, persisted and led to acute compartment syndrome in her lower extremities. After bilateral leg fasciotomies and treatment of a severe wound infection with intravenous antibiotics, the patient has now recovered with complete resolution of her symptoms.

Early Therapeutic Intervention for Crush Syndrome: Characterization of Intramuscular Administration of Dexamethasone by Pharmacokinetic and Biochemical Parameters in Rats

Crush syndrome (CS) is the systemic manifestation of muscle cell damage resulting from pressure and crushing. It is associated with a high mortality rate, even when patients are treated with conventional therapy. We demonstrated the utility of intramuscular administration of dexamethasone (DEX) in disaster medical care by using a model of CS to characterize the pharmacokinetics and biochemical parameters. We compared intravenous (IV) and intramuscular (IM) injection. The IM sites were the right anterior limb (AL), bilateral hind limbs (bHL), and unilateral hind limb (uHL). DEX (5.0 mg/kg) was administered in sham-operated (sham, S-IV, S-AL, S-bHL, S-uHL groups) and CS rats (control, C-IV, C-AL, C-bHL, C-uHL groups). The survival rate in the IM groups was lower than that in the C-IV group. Survival was highest in the C-AL group, followed by the C-uHL and C-bHL groups. The blood DEX concentration of the C-AL group was similar to that in the C-IV group. The C-bHL and C-uHL groups had decreased blood DEX concentrations. Moreover, inhibition of inflammation was related to these changes. Administration of DEX to non-injured muscle, as well as IV administration, increased the survival rate by modulating shock and inflammatory mediators, consequently suppressing myeloperoxidase activity and subsequent systemic inflammation, resulting in a complete recovery of rats from lethal CS. These results demonstrate that injection DEX into the non-injured muscle is a potentially effective early therapeutic intervention for CS that could easily be used in transport to the hospital.

Biochemical and Ultrastructural Lung Damage Induced by Rhabdomyolysis in the Rat

Rhabdomyolysis-induced oxidative stress is associated with morphological and functional damage to the kidney and other organs, but applications of this model in the lung are still lacking. The aim of the present study was to determine the relationship between oxidative stress and the morphological changes occurring in the lungs of rats subjected to rhabdomyolysis. Rhabdomyolysis was induced by intramuscular glycerol injection (50% v/v, 10 ml/kg), and the control group was injected with saline vehicle. Arterial blood samples were drawn at 0, 2, 4, and 6 hrs for measurement of arterial gases, creatine kinase activity, and plasma free F2-isoprostane levels. Six hours later, the lungs were removed to determine the wet-to-dry weight ratio, reduced glutathione (GSH) and GSH disulfide (GSSG) levels, and activity of antioxidant enzymes (cataiase [CAT], superoxide dismutase [SOD], and GSH peroxidase [GSH-Px]). Protein carbonylation and lipid peroxidation were assessed in the lungs by measurement of carbonyl and malondialdehyde (MDA) production, respectively. Bronchoalveolar lavage, cell counts, and lung ultrastructural studies were also performed. Six hours after glycerol injection, arterial PO2 and PCO2 were 23% and 38% lower, respectively, and plasma free F2-isoprostane levels were 72% higher, compared with control values. In lungs, protein carbonyl and MDA production were 58% and 12% higher, respectively; the GSH:GSSG ratio and GSH-Px activity were 43% and 60% lower, respectively; and activities of CAT and SOD showed no significant differences compared with controls. Rhabdomyolysis-induced ultrastructural impairment of the lung showed Type II cell damage, extracytoplasmic lamellar bodies and lack of tubular myelin reorganization, endothelial cellular edema, and no disruption of the alveolar-capillary barrier. These results provide evidence that rhabdomyolysis could induce tissue injury associated with increased oxidative stress, suggesting the contribution of oxidative stress to the pathogenic mechanism of acute lung injury.

Exercise-induced rhabdomyolysis mechanisms and prevention: A literature review

Exercise-induced rhabdomyolysis (exRML), a pathophysiological condition of skeletal muscle cell damage that may cause acute renal failure and in some cases death. Increased Ca²⁺ level in cells along with functional degradation of cell signaling system and cell matrix have been suggested as the major pathological mechanisms associated with exRML. The onset of exRML may be exhibited in athletes as well as in general population. Previous studies have reported that possible causes of exRML were associated with excessive eccentric contractions in high temperature, abnormal electrolytes balance, and nutritional deficiencies possible genetic defects. However, the underlying mechanisms of exRML have not been clearly established among health professionals or sports medicine personnel. Therefore, we reviewed the possible mechanisms and correlated prevention of exRML, while providing useful and practical information for the athlete and general exercising population.

Do Creatine Kinase (CK) Levels Influence the Diagnosis or Outcome in Patients with Compartment Syndrome?

We report a retrospective study in patients with compartment syndrome with the aim to analyse: 1) whether the level of rise in CK levels is a useful marker to the presence of compartment syndrome and; 2) whether an early fasciotomy assists in lowering of the elevated CK levels. The results of our study suggest that although raised CK levels are not diagnostic, they are a useful adjunct in making a diagnosis, and hence CK estimation should be done in all patients with suspected compartment syndrome. Moreover, an early fasciotomy (<12 hours) has a statistically significant influence in lowering elevated CK levels, confirming the view that the earlier the decompression, the lesser the muscle damage.

Bicarbonate and mannitol treatment for traumatic rhabdomyolysis revisited

BACKGROUND

A rhabdomyolysis protocol (RP) with mannitol and bicarbonate to prevent acute renal dysfunction (ARD, creatinine >2.0 mg/dL) remains controversial.

METHODS

Patients with creatine kinase (CK) greater than 2,000 U/L over a 10-year period were identified. Shock, Injury Severity Score, massive transfusion, intravenous contrast exposure, and RP use were evaluated. RP was initiated for a CK greater than 10,000 U/L (first half of the study) or greater than 20,000 U/L (second half). Multivariable analyses were used to identify predictors of ARD and the independent effect of the RP.

RESULTS

Seventy-seven patients were identified, 24 (31%) developed ARD, and 4 (5%) required hemodialysis. After controlling for other risk factors, peak CK greater than 10,000 U/L (odds ratio 8.6, P = .016) and failure to implement RP (odds ratio 5.7, P = .030) were independent predictors of ARD. Among patients with CK greater than 10,000, ARD developed in 26% of patients with the RP versus 70% without it (P = .008).

CONCLUSION

Reduced ARD was noted with RP. A prospective controlled study is still warranted.

Postoperative elevation in creatine kinase and its impact on renal function in patients undergoing complex partial nephrectomy

OBJECTIVE

To identify the risk factors associated with development of postoperative elevation of creatine kinase (CK) and study its effect on renal function in patients who underwent complex multifocal partial nephrectomy (PN).

METHODS

Patients who underwent PN at National Cancer Institute between January 2007 and December 2012 were included in the study. Elevated serum CK was defined as >2000 U/L. Kidney function was assessed using serum creatinine and estimated glomerular filtration rate (eGFR). Changes were reported as percent change from preoperative values and compared using the Wilcoxon test. Regression analysis was performed to identify the predictors of elevation in CK and decline in eGFR.

RESULTS

From 407 total cases, 207 had adequate CK data for analysis. Median number of tumors removed was 3 (1-70). Median peak CK was 1458 (82-36,788). Forty-two percent developed CK elevation >2000 U/L. Factors associated with postoperative elevation of CK > 2000 were young age (p = 0.009), high BMI (p = 0.003) and operating room time (p < 0.001). Although CK > 2000 was associated with significantly greater decline in eGFR (37.4 vs. 20.3 %, p < 0.001) in immediate postoperative period, this change largely resolved to a much less clinically relevant (9.2 vs 3.3 %, p = 0.040) change after 3 months. On multivariate analysis, postoperative elevation in CK was not found to be an independent factor determining renal function at 3 months.

CONCLUSION

In our cohort, a significant proportion of patients developed CK elevations >2000 U/L. While patients with elevated CK had more decline in eGFR in immediate postoperative period, postoperative elevations of CK did not appear to impact overall long-term renal function in patients undergoing PN.

Activation of α7 Nicotinic Acetylcholine Receptor Decreases On-site Mortality in Crush Syndrome through Insulin Signaling-Na/K-ATPase Pathway

On-site mortality in crush syndrome remains high due to lack of effective drugs based on definite diagnosis. Anisodamine (Ani) is widely used in China for treatment of shock, and activation of α7 nicotinic acetylcholine receptor (α7nAChR) mediates such antishock effect. The present work was designed to test whether activation of α7nAChR with Ani decreased mortality in crush syndrome shortly after decompression. Sprague-Dawley rats and C57BL/6 mice with crush syndrome were injected with Ani (20 mg/kg and 28 mg/kg respectively, i.p.) 30 min before decompression. Survival time, serum potassium, insulin, and glucose levels were observed shortly after decompression. Involvement of α7nAChR was verified with methyllycaconitine (selective α7nAChR antagonist) and PNU282987 (selective α7nAChR agonist), or in α7nAChR knockout mice. Effect of Ani was also appraised in C2C12 myotubes. Ani reduced mortality and serum potassium and enhanced insulin sensitivity shortly after decompression in animals with crush syndrome, and PNU282987 exerted similar effects. Such effects were counteracted by methyllycaconitine or in α7nAChR knockout mice. Mortality and serum potassium in rats with hyperkalemia were also reduced by Ani. Phosphorylation of Na/K-ATPase was enhanced by Ani in C2C12 myotubes. Inhibition of tyrosine kinase on insulin receptor, phosphoinositide 3-kinase, mammalian target of rapamycin, signal transducer and activator of transcription 3, and Na/K-ATPase counteracted the effect of Ani on extracellular potassium. These findings demonstrated that activation of α7nAChR could decrease on-site mortality in crush syndrome, at least in part based on the decline of serum potassium through insulin signaling-Na/K-ATPase pathway.

Prevention of Crush Syndrome through Aggressive Early Resuscitation: Clinical Case in a Buried Worker

Introduction Crush syndrome, of which little is known, occurs as a result of compression injury to the muscles. This syndrome is characterized by systemic manifestations such as acute kidney injury (AKI), hypovolemic shock, and hydroelectrolytic variations. This pathology presents high morbidity and mortality if not managed aggressively by prehospital care. Clinical Case A 40-year-old worker was rescued after being buried underground in a ditch for 19 hours. The patient was administered early resuscitation with isotonic solutions and monitored during the entire rescue operation. Despite having increased plasma levels of total creatine kinase (CK), the patient did not develop AKI or hydroelectrolytic variations.

CONCLUSION

Aggressive early management with isotonic solutions before hospital arrival is an effective option for nephron-protection and prevention of crush syndrome. Mardones A , Arellano P , Rojas C , Gutierrez R , Oliver N , Borgna V . Prevention of crush syndrome through aggressive early resuscitation: clinical case in a buried worker. Prehosp Disaster Med. 2016;31(3):340-342.

Recurrent Muscle Weakness with Rhabdomyolysis, Metabolic Crises, and Cardiac Arrhythmia Due to Bi-allelic TANGO2 Mutations

The underlying genetic etiology of rhabdomyolysis remains elusive in a significant fraction of individuals presenting with recurrent metabolic crises and muscle weakness. Using exome sequencing, we identified bi-allelic mutations in TANGO2 encoding transport and Golgi organization 2 homolog (Drosophila) in 12 subjects with episodic rhabdomyolysis, hypoglycemia, hyperammonemia, and susceptibility to life-threatening cardiac tachyarrhythmias. A recurrent homozygous c.460G>A (p.Gly154Arg) mutation was found in four unrelated individuals of Hispanic/Latino origin, and a homozygous ∼34 kb deletion affecting exons 3-9 was observed in two families of European ancestry. One individual of mixed Hispanic/European descent was found to be compound heterozygous for c.460G>A (p.Gly154Arg) and the deletion of exons 3-9. Additionally, a homozygous exons 4-6 deletion was identified in a consanguineous Middle Eastern Arab family. No homozygotes have been reported for these changes in control databases. Fibroblasts derived from a subject with the recurrent c.460G>A (p.Gly154Arg) mutation showed evidence of increased endoplasmic reticulum stress and a reduction in Golgi volume density in comparison to control. Our results show that the c.460G>A (p.Gly154Arg) mutation and the exons 3-9 heterozygous deletion in TANGO2 are recurrent pathogenic alleles present in the Latino/Hispanic and European populations, respectively, causing considerable morbidity in the homozygotes in these populations.

Rhabdomyolysis and acute kidney injury in the injured war fighter

BACKGROUND

Rhabdomyolysis is a recognized complication of traumatic injury. The correlation of an elevated creatine kinase (CK) level and the development of acute kidney injury (AKI) has been studied in the civilian population. We sought to review the prevalence of rhabdomyolysis in injured war fighters and determine if peak CK levels correlate with AKI.

METHODS

This is a retrospective cohort study of patients admitted at a US military treatment facility from January to November 2010. Inclusion criteria were active duty patients transported after explosive, penetrating, or blunt injury. Patients with burns or non-trauma-related admissions were excluded. Rhabdomyolysis was defined as a CK level greater than 5,000 U/L. AKI was defined using the Kidney Disease: Improving Global Outcomes classification. Mann-Whitney U-tests were used to determine the significance for continuous data. Correlations were determined using Spearman's ρ. Significance was set at p < 0.05.

RESULTS

Of the 318 patients included in our analysis, 310 (98%) were male, and the median age was 24 years (21-28 years). Blast was the predominant mechanism of injury (71%), with a median Injury Severity Score (ISS) of 22 (16-29). Rhabdomyolysis developed in 79 patients (24.8%). The median peak CK for all patients was 4,178 U/L and ranged from 208 U/L to 120,000 U/L. Stage 1, 2, and 3 AKI developed in 56 (17.6%), 3 (0.9%), and 7 (2.2%) patients, respectively. There was a weak but statistically significant correlation between peak CK and AKI (r = 0.26, p < 0.05).

CONCLUSION

Elevated peak CK levels in the injured war fighter are weakly associated with the development of AKI but are not predictive. The development of clinical practice guidelines would help standardize treatment for rhabdomyolysis in combat casualties and would allow for standardized comparisons in future work.

LEVEL OF EVIDENCE

Epidemiologic/prognostic study, level III.

White collar rhabdomyolysis with acute kidney injury

Rhabdomyolysis is a clinical syndrome resulting from the disintegration of muscle cell and spillage of toxic intracellular contents into circulation. Strenuous, unaccustomed exercise leads to exertional rhabdomyolysis and cause AKI. We report a 26-year-old female who developed white collar rhabdomyolysis with AKI after performing sit-ups (Super Yoga Brain) for 108 times in temple. She was managed with hemodialysis and supporting therapy. She made a full recovery after 4 weeks. Awareness of this condition and early diagnosis is highlighted.

The Contemporary Incidence and Sequelae of Rhabdomyolysis Following Extirpative Renal Surgery: A Population Based Analysis

PURPOSE

We evaluate the contemporary incidence and consequences of postoperative rhabdomyolysis after extirpative renal surgery.

MATERIALS AND METHODS

We conducted a population based, retrospective cohort study of patients who underwent extirpative renal surgery with a diagnosis of a renal mass or renal cell carcinoma in the United States between 2004 and 2013. Regression analysis was performed to evaluate 90-day mortality (Clavien grade V), nonfatal major complications (Clavien grade III-IV), hospital readmission rates, direct costs and length of stay.

RESULTS

The final weighted cohort included 310,880 open, 174,283 laparoscopic and 69,880 robotic extirpative renal surgery cases during the 10-year study period, with 745 (0.001%) experiencing postoperative rhabdomyolysis. The presence of postoperative rhabdomyolysis led to a significantly higher incidence of 90-day nonfatal major complications (34.7% vs 7.3%, p <0.05) and higher 90-day mortality (4.4% vs 1.02%, p <0.05). Length of stay was twice as long for patients with postoperative rhabdomyolysis (incidence risk ratio 1.83, 95% CI 1.56-2.15, p <0.001). The robotic approach was associated with a higher likelihood of postoperative rhabdomyolysis (vs laparoscopic approach, OR 2.43, p <0.05). Adjusted 90-day median direct hospital costs were USD 7,515 higher for patients with postoperative rhabdomyolysis (p <0.001). Our model revealed that the combination of obesity and prolonged surgery (more than 5 hours) was associated with a higher likelihood of postoperative rhabdomyolysis developing.

CONCLUSIONS

Our study confirms that postoperative rhabdomyolysis is an uncommon complication among patients undergoing extirpative renal surgery, but has a potentially detrimental impact on surgical morbidity, mortality and costs. Male gender, comorbidities, obesity, prolonged surgery (more than 5 hours) and a robotic approach appear to place patients at higher risk for postoperative rhabdomyolysis.

Disaster nephrology: a new concept for an old problem

Natural and man-made mass disasters directly or indirectly affect huge populations, who need basic infrastructural help and support to survive. However, despite the potentially negative impact on survival chances, these health care issues are often neglected by the authorities.

Treatment of both acute and chronic kidney diseases (CKDs) is especially problematic after disasters, because they almost always require complex technology and equipment, whereas specific drugs may be difficult to acquire for the treatment of the chronic kidney patients. Since many crush victims in spite of being rescued alive from under the rubble die afterward due to lack of dialysis possibilities, the terminology of ‘renal disaster’ was introduced after the Armenian earthquake. It should be remembered that apart from crush syndrome, multiple aetiologies of acute kidney injury (AKI) may be at play in disaster circumstances.

The term ‘seismonephrology’ (or earthquake nephrology) was introduced to describe the need to treat not only a large number of AKI cases, but the management of patients with CKD not yet on renal replacement, as well as of patients on haemodialysis or peritoneal dialysis and transplanted patients. This wording was later replaced by ‘disaster nephrology’, because besides earthquakes, many other disasters such as hurricanes, tsunamis or wars may have a negative impact on the ultimate outcome of kidney patients.

Disaster nephrology describes the handling of the many medical and logistic problems in treating kidney patients in difficult circumstances and also to avoid post-disaster chaos, which can be made possible by preparing medical and logistic scenarios. Learning and applying the basic principles of disaster nephrology is vital to minimize the risk of death both in AKI and CKD patients.

[Rhabdomyolysis after radical nephrectomy in the lateral decubitus position: report of 2 cases]

Rhabdomyolysis is a rare perioperative complication, however, potentially lead to fatal outcome. We experienced 2 cases of rhabdomyolysis after radical nephrectomy and nephroureterectomy in the lateral decubitus position. (Case 1) A 40-years old man was seen in our hospital because of asymptomatic grosshematuria. Computed tomography revealed right renal pelvic cancer, cT3N0M0. Right radical nephroureterectomy, lymph node dissection, partial cystectomy was underwent, and the operation was finished without any trouble. At the post-operative day 1, serum creatinine level was elevated to the point of 4.2 mg/dl, and serum creatine kinase was 1,945 IU/l. Continuous hemodiafiltration (CHDF) was done at intensive-care unit (ICU), and serum creatinine and creatine kinase level were decreased. At the post-operative day 1, urine myoglobin level was prominently elevated (2,943.7 ng/ml), so we diagnosed acute renal failure due to rhabdomyolysis. (Case 2) A 40-years old man was incidentally pointed out of right renal tumor that was seen as renal cell carcinoma, cT1aN0M0. Open partial nephrectomy was underwent, and there was no trouble during the operation. After recovering from anesthesia, the patient felt left thigh pain strongly. Serum creatine kinase was 888 IU/L after the operation. At the postoperative day 1, serum creatine kinase level was markedly increased (31,138 IU/L). Serum creatinine level was 1.34 mg/dl. Urine and serum myoglobin level was prominently elevated (89,000 ng/ml and 8,634 ng/ml, respectively). We diagnosed it rhabdomyolysis, and he received large amount of fluid intravenously at intensive-care unit. Serum creatine kinase was peak out at the post-operative day 3 (20,709 IU/L), and hemodialysis was not performed.

Elevated serum creatine phosphokinase is associated with mortality and inotropic requirement in critically injured adults

BACKGROUND

Hemeproteins such as free myoglobin can undergo autoxidation and catalyse lipid peroxidation, increasing oxidative stress. Creatine phosphokinase (CPK) elevation is a marker for free myoglobin after myocyte damage. Since oxidative injury is a key mechanism of injury-related organ dysfunction, we hypothesised that serum CPK levels correlate with mortality and need for inotropic medication and duration of inotropic support, i.e. shock, among critically injured patients.

METHODS

We conducted a retrospective review of 17,847 patients admitted to a single Trauma Intensive Care Unit over 9 years. 2583 patients with serum CPK levels were included in the analysis. Patient data were collected continuously into an electronic ICU repository. Univariate analysis was accomplished using Spearman correlation and the Mann–Whitney U test. Propensity score adjustment models accounting for potential confounders were used to assess the independent effect of CPK level on mortality, need for inotropic support, and duration of inotropic support.

RESULTS

Median CPK was significantly higher in patients who died (916 [IQR 332, 2472] vs. 711 [253, 1971], p = 0.004) and in those who required inotropic medications (950 [353, 2525] vs. 469 [188, 1220], p < 0.001). After adjusting for propensity score and potential confounders the odds of mortality increased by 1.10 (95% CI 1.02–1.19, p = 0.020) and the odds of inotropic medication use increased by 1.30 (95% CI 1.22–1.38, p < 0.001) per natural log unit increase in CPK. There was a significant association between CPK level and duration of inotropic support (Spearman's rho .237, p < 0.001) that remained significant in a propensity score-adjusted model.

CONCLUSION

In critically injured patients, elevated serum CPK level is independently associated with mortality, need for inotropic medication, and duration of inotropic support. This study is the first to evaluate the relationship of CPK level and mortality in addition to surrogate measures of shock in a population of critically injured patients. If these associations are verified prospectively, there may be a role for treatment with hemeprotein reductants, such as paracetamol, to mitigate the effects of shock and end-organ dysfunction.

Associated factors for non-ischemic serum myoglobin release after cardiac surgical procedures

BACKGROUND

Myoglobin has become established as a serum marker of myocardial injury. However, myoglobin levels can increase exponentially without any correlation to postoperative clinical ischemia symptoms. In this retrospective study, we analyzed the associated factors for a non-ischemic myoglobin release.

METHODS

We performed a data analysis from 532 consecutive cardiac surgery patients (2010 to 2011, 73% males; age 65 ± 11 years). Non-ischemic myoglobin elevation was defined as CK-MB <50 U/l and/or the absence of any ischemic clinical events (eg, myocardial infarction, mesenteric vascular occlusion).

RESULTS

Using a multifactorial model, predictive elements and associated factors for non-ischemic myoglobin increase were male sex, ejection fraction < 30%, BMI > 30 and transfusions. Serum myoglobin was not significantly different in patients with high muscle mass.

CONCLUSIONS

A non-ischemic serum myoglobin release is rare, but could be associated in subgroups of patients. Further investigations should focus on clinical targets, for example, concomitant medications for which our study was not powered.

Rhabdomyolysis: review of the literature

Rhabdomyolysis is a serious and potentially life threatening condition. Although consensus criteria for rhabdomyolysis is lacking, a reasonable definition is elevation of serum creatine kinase activity of at least 10 times the upper limit of normal followed by a rapid decrease of the sCK level to (near) normal values. The clinical presentation can vary widely, classical features are myalgia, weakness and pigmenturia. However, this classic triad is seen in less than 10% of patients. Acute renal failure due to acute tubular necrosis as a result of mechanical obstruction by myoglobin is the most common complication, in particular if sCK is >16.000 IU/l, which may be as high as 100,000 IU/l. Mortality rate is approximately 10% and significantly higher in patients with acute renal failure. Timely recognition of rhabdomyolysis is key for treatment. In the acute phase, treatment should be aimed at preserving renal function, resolving compartment syndrome, restoring metabolic derangements, and volume replacement. Most patients experience only one episode of rhabdomyolysis, mostly by substance abuse, medication, trauma or epileptic seizures. In case of recurrent rhabdomyolysis, a history of exercise intolerance or a positive family history for neuromuscular disorders, further investigations are needed to identify the underlying, often genetic, disorder. We propose a diagnostic algorithm for use in clinical practice.

Rhabdomyolysis in bariatric surgery: a systematic review

BACKGROUND

Rhabdomyolysis (RML) is a rare complication of bariatric surgery. A systematic review was performed to identify risk factors and patient outcomes in morbidly obese patients undergoing bariatric surgery who develop RML.

METHODS

A comprehensive search was performed between January 1990 and March 2012 using relevant MeSH terms. Studies were chosen based on predefined inclusion criteria. RML was defined as a creatine kinase of more than 1,000 IU/L. The parameters assessed included patient characteristics of the RML population, type of bariatric surgery performed, operating time, complications, presentation and diagnosis of RML.

RESULTS

Twenty-two studies were analysed which included 11 case reports, two case series, six prospective and three retrospective comparative studies. Overall 145 patients with RML were reported following bariatric surgery. Acute renal failure was found in 20 patients (14 %) and was significantly more likely to occur in patients with postoperative muscle pain (p < 0.05). The mortality rate after renal failure was 25 % (n = 5). In the comparative studies, 87 RML patients were compared with 325 non-RML patients. The RML patients were more likely to be male, had a greater mean body mass index (BMI) (52 vs 48 kg/m(2), p < 0.01) and underwent a longer operation (255 vs 207 min, p < 0.01) compared to non-RML patients.

CONCLUSIONS

Risk factors of developing RML following bariatric surgery include male gender, elevated BMI and prolonged operating time. Patients with a biochemical diagnosis of RML and postoperative myalgia after bariatric surgery are at increased risk of developing acute renal failure and mortality. These patients must be identified and treated promptly.

Crush syndrome: a case report and review of the literature

BACKGROUND

Crush trauma to the extremities, even if not involving vital organs, can be life threatening. Crush syndrome, the systemic manifestation of the breakdown of muscle cells with release of contents into the circulation, leads to metabolic derangement and acute kidney injury. Although common in disaster scenarios, emergency physicians also see the syndrome in patients after motor-vehicle collisions and patients "found down" due to intoxication.

OBJECTIVE

The objectives of this review are to discuss the pathophysiology of crush syndrome, report on prehospital and emergency department treatment, and discuss the relationship between crush syndrome and compartment syndrome.

DISCUSSION

We present the case of a young man found down after an episode of intoxication, with compartment syndrome of his lower extremity and crush syndrome. Although he eventually required an amputation, aggressive fluid resuscitation prevented further kidney injury and metabolic derangement.

CONCLUSIONS

Early, aggressive resuscitation in the prehospital setting, before extrication if possible, is recommended to reduce the complications of crush syndrome. Providers must be aware of the risk of hyperkalemia shortly after extrication. Ongoing resuscitation with i.v. fluids is the mainstay of treatment. Compartment syndrome is a common complication, and prompt fasciotomies should be performed when compartment syndrome is present.

Disaster nephrology: crush injury and beyond

Disasters result in a substantial number of renal challenges, either by the creation of crush injury in victims trapped in collapsed buildings or by the destruction of existing dialysis facilities, leaving chronic dialysis patients without access to their dialysis units, medications, or medical care. Over the past two decades, lessons have been learned from the response to a number of major natural disasters that have impacted significantly on crush-related acute kidney injury and chronic dialysis patients. In this paper we review the pathophysiology and treatment of the crush syndrome, as summarized in recent clinical recommendations for the management of crush syndrome. The importance of early fluid resuscitation in preventing acute kidney injury is stressed, logistic difficulties in disaster conditions are described, and the need for an implementation of a renal disaster relief preparedness program is underlined. The role of the Renal Disaster Relief Task Force in providing emergency disaster relief and the logistical support required is outlined. In addition, the importance of detailed education of chronic dialysis patients and renal unit staff in the advance planning for such disasters and the impact of displacement by disasters of chronic dialysis patients are discussed.

Hyponatraemia induced hyperCKaemia

A 32-year-old woman presented to Kasturba Hospital, Manipal with the features of gastroenteritis and one episode of generalised tonic clonic seizure with loss of consciousness for 5 min. No abnormalities were found during neurological examination. Her baseline investigations showed low sodium, low serum osmolality, normal renal and liver function tests, urine myoglobin and antinuclear antibodies profile were negative. Incidentally her creatine kinase (CK) levels were found to be very high. She was treated with intravenous fluids and high salt diet for hyponatraemia. With correction of hyponatraemia, CK levels also improved, suggesting the probable diagnosis of hyponatraemia induced myopathy leading to hyperCKaemia. The importance of early recognition of this potentially-dangerous and rare condition is emphasised.

Skeletal muscle evaluation by MRI in a rabbit model of acute ischaemia

OBJECTIVE

To assess rhabdomyolysis-associated skeletal muscle changes induced by complete ischaemia in rabbits using MRI.

METHODS

Acute ischaemia was induced in the right hind limb of 34 New Zealand white rabbits by arterial ligation. MRI of vastus lateralis was carried out pre-operatively and every hour post-operatively up to 7 h. T1 weighted images, T2 weighted images with fat suppression, T2 maps and diffusion tensor scans were obtained. The correlation of MRI findings with histopathological changes in biopsies of vastus lateralis was examined.

RESULTS

Histopathology demonstrated early cellular oedema 1 h post ischaemia and irreversible injuries by 7 h, including loss of striation and broken muscle fibres. T2 weighted images with fat suppression showed inhomogeneous high signal intensity of vastus lateralis, which progressively increased from 2 h following ischaemia. The T2 relaxation rate of ischaemic vastus lateralis was significantly greater than normal muscle (p<0.001) and demonstrated a linear increase with time following ischaemia. A similar linear increase was also found in the ischaemic vastus lateralis apparent diffusion coefficient (ADC) 1-5 h post ischaemia (p=0.006). Both the T2 ADC and fractional anisotropy (FA) were significantly higher on the ischaemic side 7 h post ischaemia (for T2, p=0.02; for ADC, p=0.004).

CONCLUSION

Muscle oedema is detectable on MR images and is reflected well by T2, ADC and FA values. MRI may have value in clinical evaluation of rhabdomyolysis.

ADVANCES IN KNOWLEDGE

Ischaemic changes detected by MRI may have value in the diagnosis of rhabdomyolysis.

Leukocyte infiltration in lung, muscle, and liver after limb compression in rats

Muscle crush injury is associated with systemic manifestations known as crush syndrome. A systemic inflammatory response syndrome may be triggered by isolated crush injury. Using myeloperoxidase (MPO) activity and plasma fatty acid composition, we investigated the inflammatory response in distant organs after isolated limb compression in rats. Male Wistar rats were submitted to 1h of hind limb compression by a latex ribbon. Myeloperoxidase activity was measured in muscle, liver, and lung at progressive times (1, 2 or 4h) after bandage release. Plasma fatty acid composition was evaluated as an indirect measure of oxidative stress. The liver and hind limb muscles showed a transient increase in MPO activity. Pulmonary MPO activity, otherwise, increased progressively throughout the study and reached statistically significant values at 4h when compared to all other groups (p<0.05). Plasma levels of unsaturated fatty acids decreased gradually after decompression (p<0.05 compared to controls after 4h). Blunt traumatic muscle compression was associated with rapid and transient muscle and liver inflammatory cell infiltration but otherwise, polymorphonuclear cells showed progressive aggregation in lungs. The plasmatic unsaturated index decreased throughout the 4h after muscle release. We demonstrated that limb compression was associated with oxidative stress and distant inflammatory responses. Progressive inflammatory cell infiltration in lungs could be related with the delayed systemic adverse responses found after crush injury.

Rhabdomyolysis: risk factors and incidence in polytrauma patients in the absence of major disasters

PURPOSE

Rhabdomyolysis is a syndrome caused by musculoskeletal tissue damage that leads to the release of large amounts of intracellular elements, which particularly affect renal function. The most common causes are severe trauma, ischemia, surgical procedures, and drug abuse. We aimed to determine the incidence of rhabdomyolysis by measuring muscle injury markers (CK, myoglobin), to identify pre/post-admission as well as iatrogenic risk factors for rhabdomyolysis in severe polytrauma, to clarify the relevance of orthopedic injuries and surgical treatment in the onset/worsening of rhabdomyolysis, and to correlate risk factors with its main complication-acute renal failure (ARF).

METHODS

Prospective study of severe polytrauma patients (Injury Severity Score (ISS) >15), with CK and myoglobin values measured at admission and after 24, 48, and 72 h. Peak values, variations between admission and peak, and variations between admission and day 3 were all determined. The correlations of those values with the onset of ARF and other negative outcomes were assessed.

RESULTS

A total of 57 consecutive patients with a median ISS of 29 were included. ARF was present in 20 patients (38 %). CK-0 level was correlated with male gender (p < 0.027) and ISS (0.014); Mb-0 level was correlated with hypovolemic shock (0.003) and skeletal fracture (p < 0.043). CK-max was correlated with surgery (p < 0.038) and surgery duration (p < 0.014); Mb-max was correlated with surgery (p < 0.002) and anesthesia duration (p < 0.005). Δ-CK was correlated with surgery (p < 0.01) and surgery duration (p < 0.017), and Δ0-3-CK was correlated with surgery (p < 0.042). Logistic regression analysis found relationships between Δ0-3-CK and both ICU admission (p < 0.003) and MODS (p < 0.012), and between Mb-max and ARF (p < 0.034).

CONCLUSION

We found that a large number of factors are implicated in CK and Mb variations. Rhabdomyolysis is a very frequent complication, but increase in CK marker alone does not seem to be correlated with the incidence of ARF. Therefore, Mb level should be considered in this group of patients.

Management of crush victims in mass disasters: highlights from recently published recommendations

Crush syndrome is the second most common cause of death after earthquakes (the first most common is direct trauma). Many logistic problems with the treatment of patients with crush syndrome are due to chaotic disaster circumstances; consequently, medical and logistic recommendations on the treatment of crush victims are needed. In a joint initiative of the Renal Disaster Relief Task Force of the International Society of Nephrology and European Renal Best Practice, a work group of nephrologists, intensivists, surgeons, and logisticians with disaster experience or experts in guideline preparation collaborated to provide comprehensive information and recommendations on the management of crush casualties considering their occurrence with "epidemic" dimensions after mass disasters. The result is the monograph "Recommendations for the Management of Crush Victims in Mass Disasters", which may help provide effective health care to disaster victims with renal problems. This article discusses medical and logistic principles of the treatment of crush victims, both at the disaster field and on admission to hospitals, and guidance is described. The importance of early fluid administration even before extrication of the victims and avoidance of potassium-containing solutions during the treatment of crush victims is underlined. Also, the logistic problems in treating crush casualties are emphasized. The most important aspects of the recently published recommendations are highlighted.