Rhabdomyolysis is more prevalent than what many have been taught in the EMS classroom. A typical EMS course teaches the condition in a limited situation that’s associated with crush injury or compartment syndrome. Traditional textbooks contain some degree of content. As a result, the condition gets very little attention.
Although rhabdomyolysis occurs when skeletal muscle is entrapped for long periods, it also occurs with many other conditions, including routine lifestyle activities. Watch the local news each football season and you’ll see reports of the poorly informed coach who physically pushed his players too hard. The result was dozens of players who were hospitalized. Further, it’s likely that you, a friend or a family member experienced the condition while attempting to get physically fit: If a high-intensity exercise routine was initiated and it was overly rigorous, alarming pain and hospitalization with aggressive fluid therapy might have ensued.
What is rhabdomyolysis?
Rhabdomyolysis (rhabdo, rodlike (muscle fibers); myo, muscle; and lysis, breakdown) is a degenerative process that involves the destruction of skeletal muscle. The process occurs because of necrosis and cellular changes with the release of metabolic byproducts and toxins. Of key interest is the release of myoglobin, phosphate, potassium and lactic acid. When high levels of myoglobin are released, it can accumulate in the renal tubules and lead to renal failure. Increased potassium (hyperkalemia) can reduce cardiac muscle responses to electrical stimuli, which can lead to cardiac dysrhythmia and sudden cardiac arrest.
What are causes of rhabdomyolysis and how do we enhance street-level recognition? Mnemonics are useful tools that often are applied in EMS to remember fragments of cognitive information. Much like the patient history prompts, such as OPQRST and SAMPLE, the more common causes of rhabdomyolysis can be remembered with the mnemonic of DOT: drugs (NSAIDs, statins, antipsychotics, cocaine, amphetamines, ecstasy, alcohol and others); overexertion (high-intensity exercise, seizure and heat emergencies); and trauma (compartment syndrome, crush injury, burns, electrocution, fall victims—particularly the elderly—who are found days later and severe soft tissue trauma
Signs & symptoms
Common signs and symptoms can involve many body systems. These are observed in conjunction with the DOT history. Often, the patient will describe dark urine that’s the color of tea or cola. It’s common to find muscle pain (myalgia), muscle swelling, bruising, flank pain, malaise and weakness. Because of the possibility of hyperkalemia, dysrhythmias can be discovered.
Typical treatment
Finding a specific clinical practice guideline is sporadic at best. Treating your patient in accordance with the patient findings is essential. Often, generic universal patient care guidelines should be followed.
The traditional treatment for rhabdomyolysis is rehydration and renal flushing via aggressive fluid therapy. An intentional assessment for hyperkalemia (often confirmed with blood work in the hospital), ECG monitoring and pain management are required. Of course, this is for the patient who’s stable.
Traditional advanced cardiovascular life support (ACLS) therapies should be used for dysrhythmias that are associated with hyperkalemia. These may include intravenous calcium (calcium gluconate or chloride). If the renal failure is severe enough, hospital treatments may include temporary hemodialysis.
Importance
If the paramedic believes that rhabdomyolysis only occurs in a crush injury or with compartment syndrome, a lot of rhabdomyolysis conditions will be missed in the field. Patient care might be suboptimal.
When the patient presents with a medical history and physical assessment findings that are consistent with the condition, the paramedic should consider fluid therapy, ECG monitoring, pain management and compassionate care. If a particular clinical practice guideline exists, this should be followed. If not, online medical direction should be sought.
