Clinical presentation

The clinician may be confronted with clinical evidence or suspicion of acute traumatic rhabdomyolysis in different clinical settings. The crush syndrome occurs when people are trapped in vehicles or under rubble after catastrophes such as explosions or earthquakes. These patients often have flaccid paralysis and sensory loss that are unrelated to the distribution of nerves in the affected limbs. Victims immobilized under fallen masonry appear to be initially relatively protected from the systemic consequences of the muscle injury. Decompression of the limbs during extrication releases muscle cell components into the circulation, which in turn accelerates the development of shock, hemoconcentration, hyperkalemia, and acute renal failure. These potentially lethal consequences must be prevented.

Muscle destruction may or may not be obvious in patients subjected to constant direct electrical shock. Extensive burns, particularly if circular, can cause a tourniquet-like compression which leads to muscle cell lysis. In both these situations rhabdomyolysis may be severe and fatal.

The possibility of acute traumatic rhabdomyolysis must be raised under several circumstances in which muscle damage may not be clinically apparent. Muscle compression secondary to coma, post-trauma or postseizure, or postural syndrome is sufficient to generate acute rhabdomyolysis. Electrocution or thundershock may also cause muscle necrosis. Postexertional rhabdomyolysis may occur after strenuous physical exercise, particularly in unprepared military recruits or occasional sportsmen. Other etiological and contributing factors include hypothermia, heat stroke, metabolic derangements, drug or cocaine abuse, acute or chronic alcoholism, and hereditary or acquired myopathies (T§.ble,.!).

Table 1 Etiological and contributive factors to rhabdomyolysis

Myalgias are the most common symptom. Muscle stiffness, edema visible with compression, paresthesias, and skin lesions are infrequent findings. Dark brown urine may be the only visible sign; an orthotoluidine reactive-paper test may be falsely positive for blood and protein.

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