Nephrology Question 39 Instructor

Unfortunately a 37 year old male construction worker suffered severe musculoskeletal injuries after a crane had fallen on him.

Outline the principals of management to lower his risk of rhabdomyolysis.

Rhabdomyolysis is the breakdown of myocytes with leakage of potentially toxic cellular contents into the systemic circulation.

The clinical sequelae of rhabdomyolysis include the following:

  • Acute renal failure (nephrotoxic effect of myoglobin)
  • Hypovolemia (third-spacing into injured myocytes)
  • Hyperkalemia (due to myocyte degeneration)
  • Metabolic acidosis (release of cellular phosphate and sulfate)
  • Disseminated intravascular coagulation (DIC)

The general recommendations for the treatment of rhabdomyolysis includes fluid resuscitation and prevention of end-organ complications:

Administer isotonic crystalloid 500 mL/h and titrate to maintain a urine output of 200-300 mL/h. Consider invasive monitoring to assess volume status, if indicated.

Acute renal failure develops in 30-40% of patients with rhabdomyolysis. To prevent renal failure, many authorities advocate urine alkalinization (titrated to urine pH higher than 7), mannitol, and loop diuretics.

After establishing an adequate intravascular volume, mannitol may be administered to enhance renal perfusion.

Loop diuretics may be used to enhance urinary output in oliguric patients, despite adequate intravascular volume.

Monitor for the development of compartment syndrome, which would necessitate a consultation for fasciotomy.

Patients with rhabdomyolysis should be supported with renal replacement therapy as indicated.

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