Exertional Rhabdomyolysis. Christopher A. Gee, MD, MPH, FACEP Department of Orthopaedics University of Utah

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1 Exertional Rhabdomyolysis Christopher A. Gee, MD, MPH, FACEP Department of Orthopaedics University of Utah

2 Objectives Define history and current topics of condition Review pathophysiology Present cases and risk factors for condition Outline prevention, education and treatment options

3 Rhabdo-What is it? Condition of muscle breakdown from over exertion, trauma, electrocution, medications Intracellular components (myoglobin, CK, LDH, etc) released in the blood stream Normal carrying capacity of plasma proteins overwhelmed Components spilled into urine, collect in tubules leading to renal dysfunction and failure

4 History Observed in ancient times- Consumption of quail by Israelites who later died (Book of Numbers 11:31-35). Resulted in myolysis after eating. Due to intoxication by hemlock herbs, which are consumed by quails during their spring migration Modern reports 1908 Messina Earthquake-crush victims developed ARF WW1 German soldiers buried in trenches 1940 Battle of Britain- 4 bombing victims, linked ARF to rhabdo Vanholder R, Sever MS, Erek E, Lameire N. Rhabdomyolysis. Jour Amer Soc Neph. 2000;11(8):

5 Why Sports Medicine?

6 Uncle Rhabdo Uncle Rhabdo introduced by Dr Will Wright 2011 Article meant to warn cross fit athletes of dangers of rhabdo Overtime, became the center of large debate within cross fit community

7 Uncle Rhabdo Some began to advise that a visit to Uncle Rhabdo was the only way to make significant strength gains CrossFit, at its core, is about the hard truths of life. Good things take effort. Results don t come easy. Sometimes, to get to a really good place, you have to go through a really bad time. Heavy things are hard to pick up. Strength takes guts. And, if you re a cheater, you re an a*****. These are essential truths

8 Pukie Opponents have pointed out the real dangers of rhabdo Coaches and trainers are the ambassadors of our clients health and well-being. Given this unique position, there are predisposing conditions that trainers should be aware of; they include the types of exercises being performed, environmental conditions, and most importantly, the capabilities of the client and his or her known medical conditions need to be considered. Dr Wright

9 Rhabdo Ultimately rhabdomyolysis can occur in any athlete of any age or sport who pushes muscles to the extreme Factors: Type of exercise (ie, downhill walking vs uphill, spin, crossfit) Hydration status Ambient temperature Medical conditions or medicines used by the athlete Conditioning status of athlete (46 cases spinning rhabdo, 42 first timers)

10 Rhabdo Cases Am J Med Apr;130(4): doi: /j.amjmed Epub 2016 Nov 29. Freebie Rhabdomyolysis: A Public Health Concern. Spin Class-Induced Rhabdomyolysis. Brogan M1, Ledesma R2, Coffino A2, Chander P2. Case 1: 33-year-old woman presented with bilateral thigh pain and weakness 4 days after 15 minutes of spinning. This was her first spin class. She dismounted the bike for symptoms of lightheadedness and vomiting. On presentation, she had thigh weakness, tenderness, and swelling. Labs showed Cr 0.5 mg/dl, AST 1092 U/L, and ALT 282 U/L. Urinalysis showed 1+proteinuria, 3+ blood, and 0-3 red cells/hpf. She was aggressively hydrated. Her peak CPK was 60,000 U/L

11 Case 2 A 20-year-old man with a history of Gilbert syndrome presented with bilateral thigh pain 3 days after spinning. He exercised regularly but it was his first spin class. He was unable to lift his lower extremities against gravity. There was thigh tenderness and swelling. Initial blood work showed creatinine 0.8 mg/dl, AST 1140 U/L, ALT 270 U/ L, and CPK 14,493 U/L. Urinalysis showed 2+ proteinuria, 3+ blood, and 3-5 red cells/hpf. His peak CPK was 132,832 U/L.

12 Case 3 A 33-year-old woman p/w thigh pain, decreased urine output, n/v x 2 days after first spin class. She had thigh tenderness and swelling. Serum Cr peaked at 6.8 mg/dl, ALT 2583 U/L, AST 742 U/L, LDH 10,167 U/L, and CPK peaked at >80,000 U/L. Despite aggressive hydration with NS, required hemodialysis for oliguria. Due to the severity of her renal failure and history of NSAID use, a kidney biopsy was performed, which confirmed rhabdomyolysis. Her Cr improved to 0.7 mg/dl 5 1/2 weeks later, with normalization of her CPK.

13 Cases Highlight issues Be aware of medical conditions and medicines used (nsaids, statins, myopathy, renal disease) Intensity of exercise performed-need to listen to body Often present few days later with n/v, pain, weakness, dark urine Initially, Cr and renal function preserved but can quickly deteriorate Tx is to aggressively hydrate and flush out the muscle products to limit damage

14 Treatment Prevention! Early detection: Not all muscle soreness is normal Aggressive Hydration!

15 Treatment Prevention! Educate athletes about the risk of exertion rhabdo and the need to ensure hydration, avoid routine nsaid use and gradually work into exercise routines Early Detection Not all muscle soreness is normal. Swelling, significant pain, weakness, dark urine, decreased urine output Check UA, CPK (5x Nml), LDH, AST, ALT, electrolytes (K) Aggressive Hydration Often times can require 1-2 L/hr to ensure adequate UOP ( ml/ hr)

16 Treatment Urine Alkalization Some reports show a potential benefit from alkalinizing urine. (decreases formation of hemeprotein complexes that block tubules) Only used if severe cases with rising CPK despite adequate tx Patient must have adequate urine output and must be in a setting where bicarb, ph and other parameters can be closely monitored

17 References Vanholder R, Sever MS, Erek E, Lameire N. Rhabdomyolysis. Jour Amer Soc Neph. 2000;11(8): Wright W. Rhabdomyolysis Revisited. The Crossfit Journal. June 2011:1-4.

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