First Things First (assess & treat for the following)

• Rhabdomyolysis is a constellation of pathophysiologic changes resulting from injury to skeletal muscle w/ the resultant release of intracellular contents (including myoglobin). Can result from both traumatic & atraumatic causes. Most common causes: alcohol, drug abuse, overexertion, seizure, compression or crush syndrome.
• Traumatic causes
  • Cold salt water near-drowning, crush syndrome, prolonged compression (eg, splints), ischemia, postexertional, seizures, heatstroke, malignant hyperthermia, electric shock/burns, prolonged CPR, decerebrate posturing
• Nontraumatic causes
  • Medical disorders: peripheral blood stem cell transplantation, status asthmaticus, addisonian crisis, Becker muscular dystrophy, Duchenne muscular dystrophy, pancreatitis
  • Metabolic disorders: myophosphorylase deficiency, phosphofructokinase deficiency, carnitine palmitoyltransferase deficiency, phosphoglycerate mutase deficiency, myoadenylate deaminase deficiency, DKA, nonketotic hyperosmolar coma, hyperthyroidism/hypothyroidism, sickle cell trait
  • Electrolyte deficiency: hypokalemia, hypophosphatemia, hypomagnesemia, severe hyponatremia
  • Inflammatory muscle disease: polymyositis, dermatomyositis, arteritis/vasculitis, idiopathic paroxysmal myoglobinuria
  • Infection: CMV, EBV, adenovirus, Streptococcus pneumoniae, bacteremia, hepatitis, influenza/coxsackie viruses, shigellosis, salmonellosis, gram-negative septic shock, Legionella, leptospirosis, Rocky Mountain spotted fever, trichinosis, tetanus, gangrene, HIV
• W/ history of trauma, maintain high index of suspicion if pt entrapped for prolonged length of time (>4 hrs).
• If the result of trauma, begin w/ ATLS algorithm (chapter 1.4). Will need large-bore IV access & Foley catheter.
• Begin NS (wide open) to avoid additional potassium & begin to replace third-spaced fluid. Administer 2 L for adults or 20 cc/kg for children as initial volume.
• Place on cardiac monitor. Cardiac arrest at scene may occur secondary to hyperkalemia.