Exertional rhabdomyolysis

Knapik JJ, O’Connor FG. Exertional Rhabdomyolysis: Epidemiology, Diagnosis, Treatment, and Prevention. J Spec Oper Med. 2016 Fall; 16(3):65-71.

Exertional rhabdomyolysis (ER) is a medical condition whereby damage to skeletal muscle is induced by excessive physical activity in otherwise healthy individuals. The individual performs so much activity that he/ she presumably depletes local muscle energy stores and muscle cells are unable to maintain cellular integrity, resulting in cell damage and the release of cellular contents, with resultant secondary complications. In the military services, the incidence of ER appeared to increase in the period 2004 to 2015. Risk factors for ER include male sex, younger age, a prior heat injury, lower educational level, lower chronic physical activity, and activity in the warmer months of the year. Acute kidney injury is the most serious potential complication of ER and is thought to be due to a disproportionate amount of free myoglobin that causes renal vasoconstriction, nephrotoxic effects, and renal tubular obstructions. Patients typically present with a history of heavy and unaccustomed exercise with muscle pain, swelling, weakness, and decreased range of motion, largely localized to the muscle groups that were involved in the activity. Diagnostic criteria include the requisite clinical presentation with a serum creatine kinase level at least level 5 times higher than the upper limit of normal and/ or a urine dipstick positive for blood (due to the presence of myoglobin) but lacking red blood cells under microscopic urinalysis. Core treatment is largely supportive with aggressive fluid hydration. Although the great majority of individuals return to activity without consequence, patients should initially be stratified into high and low risk for recurrence, and those at high risk provided additional evaluation. Risk of ER in normal healthy individuals can be reduced by emphasizing graded, individual preconditioning before beginning a more strenuous exercise regimen after recommended work/rest and hydration schedules in hot weather, and discussing supplements and medications with knowledgeable medical personnel.

Children’s and Emory users, contact Emily Lawson for this article. 


Armed Forces Health Surveillance Bureau. Update: Exertional rhabdomyolysis, active component, U.S. Armed Forces, 2012-2016. MSMR. 2017 Mar;24(3):14-18.

Among active component service members in 2016, there were 525 incident diagnoses of rhabdomyolysis likely due to physical exertion and/or heat stress (“exertional rhabdomyolysis”). The crude incidence rate in 2016 was 40.7 cases per 100,000 person-years. Annual rates of incident diagnoses of exertional rhabdomyolysis increased 46.2% between 2013 and 2016, with the greatest percentage change occurring between 2014 and 2015. In 2016, relative to their respective counterparts, the highest incidence rates of exertional rhabdomyolysis affected service members who were male; younger than 20 years of age; and black, non-Hispanic. During the surveillance period, annual incidence rates were highest among service members of the Marine Corps, intermediate among those in the Army, and lowest among those in the Air Force and Navy. Most cases of exertional rhabdomyolysis were diagnosed at installations that support basic combat/recruit training or major ground combat units of the Army or the Marine Corps. Medical care providers should consider exertional rhabdomyolysis in the differential diagnosis when service members (particularly recruits) present with muscular pain or swelling, limited range of motion, or the excretion of dark urine (possibly due to myoglobinuria) after strenuous physical activity, particularly in hot, humid weather.

Free full-text (click View the MSMR Archive and go to vol. 24, issue 3 to download article.)

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Practice Based Learning: Management of acute pancreatitis

Lyndsi Paumen MD

 

 

 

 

Presented by Lyndsi Paumen MD (PGY1)

Traditional management of mild acute pancreatitis:

  • NPO (with IVFs, Jejunal feeds, or TPN) – “Rest the Pancreas”
    • Rationale: food in duodenum → cholecystokinin release → pancreatic enzyme secretion
    • Activation of proteolytic enzymes → autodigestion/tissue injury

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EBM Review: The Pediatric Intravenous Maintenance Solution study (PIMS): a randomised controlled double-blind trial.

McNab S, Duke T, South M, et al. 140 mmol/L of sodium versus 77 mmol/L of sodium in maintenance intravenous fluid therapy for children in hospital (PIMS): a randomised controlled double-blind trial. Lancet. 2014 Nov 28.

BACKGROUND: Use of hypotonic intravenous fluid to maintain hydration in children in hospital has been associated with hyponatraemia, leading to neurological morbidity and mortality. We aimed to assess whether use of fluid solutions with a higher sodium concentration reduced the risk of hyponatraemia compared with use of hypotonic solutions.

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Practice Based Learning: Is oral rehydration therapy an effective alternative to IV rehydration therapy in children?

Lajja Desai MD

Presented by Lajja Desai, MD

Key points:

PBL chart

Bottom Line:

1.    Oral rehydration therapy should be the first course of treatment for mild and moderate dehydration in children with AGE.
2.    Oral rehydration therapy can be initiated quicker than IV therapy in the ED setting. Can lead to shorter hospital stays and lower admission rates.
3.    Oral rehydration therapy can be utilized in “high risk groups”: moderate dehydration, children < 3 years of age.

References:

Arcara K and Tschudy M. The Harriet Lane Handbook, 19e. 2001.

Bellemare S, et al. Oral rehydration versus intravenous therapy for treating dehydration due to gastroenteritis in children: a meta-analysis of randomized controlled trials. BMC Medicine 2004, 2:11.

Harding L, et al. Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children (Review). Cochrane Database of Systematic Reviews 2006, Issue 3. Art No: CD0004390.

Huang, LH, et al. Dehydration treatment and management. Medscape. March 12, 2012.

Spandorfer PR, et al. Oral versus intravenous rehydration of moderately dehydrated child: a randomized, controlled trial. Pediatrics 2005; 115;295.