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Maternal Serum Triple Analyte Screening in Pregnancy. Renal damage results from the mechanical obstruction of tubules by myoglobin precipitation, the direct toxic effect of free chelatable iron on tubules, and hypovolemia. When muscles are damaged, CK levels increase; Repeated tests are needed to determine if CK levels are rising or falling; Urine dipstick tests to check for myoglobin, a muscle cell component Rhabdomyolysis. Kaehny WD, Kohl L, Insert the dipstick into the urine sample, ensuring all reagent squares are fully immersed. The American Journal of Emergency Medicine, https://doi.org/10.1016/j.ajem.2008.06.020. Line RL, He completed a residency at Frimley Park Hospital, Surrey, U.K., and a family practice residency at Niagara Falls Memorial Medical Center. However, urine screening for rhabdomyolysis may be performed by dipstick if the urine sediment is also examined. Biswas S, Mannitol therapy revisited (1940–1997). Graves EJ, 1996;22:995–6. This is because, the dipstick test is unable to distinguish between myoglobin and haemoglobin. There may be tea-colored urine or an irregular heartbeat. Massry SG. Serum creatine kinase (CK) can be used as an initial screening investigation as it is always significantly elevated in rhabdomyolysis. Intensive Care Med. When a genetic disorder is suspected, forearm ischemic testing can be used to help differentiate among possible inherited causes (Table 6).19 A muscle biopsy with histochemical analysis is necessary to determine the specific cause of a genetic myopathy. 9. Renal failure and heatstroke. Severe rhabdomyolysis with renal failure after intranasal cocaine use. Rhabdomyolysis is a condition in which damaged skeletal muscle breaks down rapidly. Poka A, Because it takes several days to obtain results, neither test should be relied on in making therapeutic decisions. Abassi ZA, Conn Med. Rhabdomyolysis and myohemoglobin-uric acute renal failure [Editorial]. If given enough time, many patients partially or completely recover renal function. Urine dipstick tests are not a good way to diagnose rhabdo: These tests check for myoglobin (a muscle cell component) indirectly. 7. Rhabdomyolysis and myoglobinuric renal failure. When the dipstick and a requested urinalysis do not correspond, myoglobinuria and rhabdomyolysis are likely to be present. Knochel JP. Sinert R, Deighan CJ, Urine dipstick is positive for red blood cells. Patel AN. Nobile-Buetti L, End result of any disease process that causes muscle cell (myocyte) lysis. Under physiologic circumstances, the plasma concentration of myoglobin is very low (0 to 0.003 mg per dL). Rhabdomyolysis can be traumatic or non-traumatic (Table 1). Note that the differential diagnosis of blood positive urine dipstick excludes: porphyria, bile pigments, and food/drug causes. Moghtader J, Viruses: influenza virus B, parainfluenza virus, adenovirus, coxsackievirus, echovirus, herpes simplex virus, cytomegalovirus, Epstein-Barr virus, human immunodeficiency virus, Bacteria: Streptococcus, Salmonella, Legionella, Staphyloccus and Listeria species, Snake bites (mostly in South America, Asia and Africa), Electrolyte imbalances: hyponatremia, hypernatremia, hypokalemia, hypophosphatemia, hypocalcemia. Homsi E, Urine dipsticks are a rapid and relatively sensitive (>80%) method for detecting haematuria in a freshly voided sample of urine. Dark, tea-colored urine that is dipstick positive for blood despite the absence of red blood cells on microscopy is suggestive of myoglobinuria and rhabdomyolysis. This work has not been published elsewhere. 6. Rhabdomyolysis is the breakdown of skeletal muscle fibers with leakage of potentially toxic intracellular contents into the systemic circulation, characterised by elevated plasma creatine kinase, myoglobinuria and risk of renal impairment. Harden P. 1995;15:329–34. Horowitz BZ, Am Surg. The initial clue to the presence of rhabdomyolysis may be a dipstick positive for blood but with no red cells present in the urine. Maxine A. Papadakis, et al. There should be The most common causes are crush injury, overexertion, alcohol abuse and certain medicines and toxic substances. In addition, it is impor-tant to measure serum potassium Hojs-Fabjan T. 22. HMG-CoA reductase inhibitors, especially in combination with fibrate-derived lipid-lowering agents such as niacin (nicotinic acid; Nicolar) Cyclosporine (Sandimmune) Itraconazole (Sporanox) Erythromycin Colchicine Zidovudine (Retrovir) Corticosteroids, Alcohol Central nervous system depressants Cocaine Amphetamine Ecstasy (MDMA) LSD Neuromuscular blocking agents. Ren Fail. Rainone T, Myoglobin is a protein found inside myocytes. Draw a blood sample from the antecubital vein for use in obtaining baseline ammonia and lactic acid levels. Myoglobin in the renal glomerular filtrate can precipitate and cause renal tubular obstruction, leading to renal damage. Orlando JM, Wevers RA, 1997;63:361–4. 1989;71:392–400. A spectrum of injury. Harper J. Rhabdomyolysis and myohemoglobin-uric acute renal failure [Editorial]. However, these measures should not be employed if oliguria is established despite initial generous hydration with normal saline. Dr. Sauret is board certified in family medicine.... GEORGE MARINIDES, M.D., is clinical assistant professor in the Department of Medicine at SUNY-Buffalo School of Medicine and Biomedical Sciences. However, due to rapid excretion of myoglobin, rhabdomyolysis cannot be excluded in the absence of myoglobinuria or urine discoloration. A delay of more than six hours in diagnosing this complication can lead to irreversible muscle damage or death. Rhabdomyolysis can be defined as a clinical syndrome associated with the breakdown of skeletal muscle fibres and myocyte cell membranes, leading to release of muscle contents into the circulation, resulting in multiple complications, including hyperkalaemia. Akmal M, Symptoms may include muscle pains, weakness, vomiting, and confusion. 10. The cause of rhabdomyolysis can be obscure. 6. To see the full article, log in or purchase access. The spectrum of rhabdomyolysis. Acute renal failure complicating muscle crush injury. Brady WJ, Alejandro DS, 1996;15:254–7. Heat dissipation impairment18  from wearing heavy sports equipment or exercising in humid, warm weather increases the risk of rhabdomyolysis. Despite treatment, patients with rhabdomyolysis often develop oliguric acute tubular necrosis. Mechanistic and therapeutic implications. Myoglobinuria may be sporadic or resolve early in the course of rhabdomyolysis. Rust GS. Urine dipsticks are a rapid and relatively sensitive (>80%) method for detecting haematuria in a freshly voided sample of urine. Bessa O. We use cookies to help provide and enhance our service and tailor content and ads. 2 However, as well as intact red blood cells (RBC), urine dipstick may also detect haemoglobin from lysed RBC caused by haemolytic conditions, or myoglobin from crush injuries, rhabdomyolysis or myositis. Hemodialysis may be a therapeutic modality. A metabolic acidosis with a high anion gap is commonly reported in rhabdomyolysis with associated AKI. After the cuff is inflated, have the patient perform repeated hand-grip exercises to fatigue the fore-arm. The presence of blood on a qualitative urine dipstick test while red blood cells (RBCs) are absent on microscopy is suggestive of myoglobinuria and thus rhabdomyolysis . Prompt recognition and vigorous treatment of the underlying cause is necessary. Heat injury is a common, potentially life-threatening medical condition. However, other studies found a lack of adequate sensitivity [19]. Better OS, Winaver JM, Scalea T. Eur J Emerg Med. Using 1000U/L, urine dipstick testing had a sensitivity of 14% and a specificity of 85%. A dipstick positive for blood in the absence of hematuria on urine microscopy examination is suggestive of rhabdomyolysis. Li PK, [5] List 4 treatments of Rhabdomyolysis Management of rhabdomyolysis focuses on treatment of the cause, prevention of renal failure, and management of life- … Rhabdomyolysis and myoglobinemia in neonates. 2009 Sep. 27(7):875-7. Schwartz JT, Inflate the sphygmomanometer cuff to above 200 mm Hg. Lai KN. Urine microscopy reveals an absence of red blood cells. Sinkeler SP, Hojs-Fabjan T. Urine dipstick testing for blood is not a useful screening test for rhabdomyolysis in patients suspected to have significant heat injury. Wang AY, (Because this pressure is greater than the systolic pressure, ischemia is created.). 1990;10:49–52. 5. Numerous infectious and inflammatory processes can lead to rhabdomyolysis. Ward MM. Combined mannitol and deferoxamine therapy for myohemoglobinuric renal injury and oxidant tubular stress. JOHN M. SAURET, M.D. Reversible hepatic dysfunction associated with rhabdomyolysis. Take a sample of your blood to measure levels of creatnine kinase, a protein that muscles release when they disintegrate. Address correspondence to John M. Sauret, M.D., Department of Family Medicine, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Office of Research and Development, 462 Grider St., Buffalo, NY 14215 (e-mail: The authors thank Eileen De Biasio for assistance in the preparation of the manuscript, The authors indicate that they do not have any conflicts of interest. Muscle Nerve. Bessa O. Rhabdomyolysis. Brown urine: can be caused by the presence of bile pigments (e.g. [5] List 4 treatments of Rhabdomyolysis Management of rhabdomyolysis focuses on treatment of the cause, prevention of renal failure, and management of life- … Dar KJ, Renal failure and heatstroke. The objective of the study was to determine if a simple urine dipstick test for blood is sensitive for detection of rhabdomyolysis in the suspected heat injury patient. Ivatury RR, Contact Full metabolic and endocrine panels should be included as part of the investigative work-up for rhabdomyolysis. Next: Maternal Serum Triple Analyte Screening in Pregnancy, Home Has this patient a signi® cant degree of rhabdomyolysis? Myoglobin gives a positive reaction with conventional urine dipstick testing for haem containing components. J Bone Joint Surg [Am]. Rhabdomyolysis and acute renal failure in intensive care unit. Performance of urinalysis for diagnosis of rhabdomyolysis: The sensitivity of a heme-positive urine is good (>90%) ( 22082877 , 24332910 ) . Clinical features are often nonspecific, and tea-colored urine is usually the first clue to the presence of rhabdomyolysis. GORDON K. WANG, M.D., is a family physician at Burnt Store Family Health Center, Punta Gorda, Fla. Dr. Wang received his medical degree from the Federal University of London–St. 1991;324:1417–22. 3. Gabow et al, in a study of 87 cases (CK >500 IU/L), found that 26% of patients tested negative with the urine orthotolidine-toluidine dipstick test for myoglobin. However, other studies found a lack of adequate sensitivity [19]. Sinkeler SP, In ambiguous cases, clinical suspicion of rhabdomyolysis is confirmed by a positive urine or serum test for myoglobin. Intravenous (IV) hydration must be initiated as early as possible. Crit Care Nurse. Curr Opin Rheumatol. Muscle Nerve 1986;9:731–7. Immediate, unlimited access to all AFP content. It is a medical emergency and can lead to cardiac arrest if not promptly treated. Panacek EA, Am J Emerg Med . 1988;148:1553–7. Joosten EM, Screening may be performed with a urine dipstick in combination with urine microscopy. Van't Hof MA, Zager RA. Combined mannitol and deferoxamine therapy for myohemoglobinuric renal injury and oxidant tubular stress. The value of urine dipstick testing for myoglobinuria screening was also evaluated. Brumback RJ, Ivatury RR, Burgess AR. Because it contains a heme component, both myoglobin and hemoglobin appear as +blood on urine dipstick. Urine output should be maintained at 300 mL per hour until myoglobinuria has ceased. Detailed diagnoses and procedures, National Hospital Discharge Survey, 1995. Sinert R, afpserv@aafp.org for copyright questions and/or permission requests. A urine dipstick test for blood that has positive findings in the absence of red blood cells (RBCS) suggests myoglobinuria. As we wanted to assess the efficacy of dipstick urine test at the site of the In this situation, hemodialysis should be started and carried on aggressively, frequently on a daily basis. Lay the dipstick flat on a paper towel. Lui SF, Joosten EM, Oei LT, 1990;10(3):32–6. Binkhorst RA, Kidney Int. Accuracy of urine dipstick in the detection of patients at risk for crush-induced rhabdomyolysis and acute kidney injury. Note that the differential diagnosis of blood positive urine dipstick excludes: porphyria, bile pigments, and food/drug causes. Prophylaxis of acute renal failure in patients with rhabdomyolysis. Sinkovic A, 1995;59:519–21. Some of the muscle breakdown products, such as the protein myoglobin, are harmful to the kidneys and may lead to kidney failure.. Multiple complications can occur and are classified as early or late. Lakatos R, tions of rhabdomyolysis, the clinical laboratory may be asked to make various measurements, including serum creatine kinase (CK), serum myoglobin and urine myoglobin, to answer three related questions: 1. 3. QJM. Leech RW. Copyright © 2002 by the American Academy of Family Physicians. Semin Nephrol. Patients with a urine dipstick positive for blood, but no red blood cells on urine microscopy, should have their CK measured. Kasik JW, Leuschen MP, Bolam DL, Nelson RM. After receiving his medical degree from the Aristotle University of Thessaloniki, Greece, he completed an internal medicine residency at Mercy Hospital, Buffalo, and a fellowship in nephrology at SUNY-Buffalo. Initially, normal saline should be given at a rate of 1.5 L per hour. Get Permissions, Access the latest issue of American Family Physician. In the patient with a crush injury, IV fluids should be started even before the trapped limb is freed and decompressed, and certainly no later than six hours after decompression. Sinkovic A, Potassium. Schwartz JT, Symptoms  The characteristic triad of complaints in rhabdomyolysis is The diagnosis of rhabdomyolysis in this case was first indicated by the urinalysis, which showed positive dipstick for blood and negative microscopy for RBCs, confirmed by the elevation of total serum CK with normal CKMB isoform and troponin I. Ramelli GP, Clinical features of rhabdomyolysis are listed in Table 5. Scalea T. In addition, the release of vasoactive kinins from muscle may interfere with renal hemodynamics. Myoglobinuria is typically diagnosed by the presence of a very positive urine dipstick test for blood, with disproportionately few red blood cells in urine. Other significant causes of rhabdomyolysis include electrical shock injury16 and crush injury. Brumback RA, When initially evaluating a patient with dark-colored urine, a positive urine dipstick test for blood without evidence of RBCs on microscopy is a clue to the presence of rhabdomyolysis, because myoglobin will also react with the orthotolidine test reagent. 1 Several reviews suggest that urine myoglobin is unstable with subpar performance in rhabdomyolysis 1 , often defined as creatine kinase (CK) elevation 5 times the upper limit of normal in the proper context (eg, crush injury, … A diagnosis of vaccine-related rhabdomyolysis on a background of … / Vol. Hypocalcemia and hypercalcemia in patients with rhabdomyolysis with and without acute renal failure. Simon R, Acute renal failure, the more serious complication, develops in up to 15 percent of patients21 and is associated with high morbidity and mortality. Choose a single article, issue, or full-access subscription. Norman AW, 1999;21:675–84. Deighan CJ, Sources of funding: none reported. The urine dipstick is used to assess for a wide variety of renal, urinary tract and systemic pathologies. 1986;9:731–7. Urinalysis, both dipstick and microscopic analysis should be performed. 26. Although CK peak is a late severity marker of rhabdomyolysis, CK level of 5000 U/L or greater, which is likely related to AKI caused by rhabdomyolysis [ 11 ], is one of the indices to start preventive dialysis treatment. By continuing you agree to the use of cookies. A normal rise in ammonia and lactic acid levels indicates the presence of a disorder of lipid metabolism. Objectives: To evaluate the utility of urine dipstick test (UDT) for detecting rhabdomyolysis and acute kidney injury (AKI) due to crush injury. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. In one review of 26 intensive care patients, the cause was ischaemic by vascular obstruction (50%), crush injury by trauma (23%), sepsis (11.5%), heat stroke/hyperthermia (11.5%), and hyponatraemia in a single patient.2 Alcohol is commonly associated with rhabdomyolysis. Pediatr Neurol. The most common causes are crush injury, overexertion, alcohol abuse and certain medicines and toxic substances. An EKG is obtained and seen in Figure A. Urine toxicology is performed and returns positive for amphetamines and cocaine. Higa EM. Better OS. 2002 Mar 1;65(5):907-913. There are many causes of rhabdomyolysis including physical damage, infective, inflammatory, toxic, and metabolic problems. Exertional rhabdomyolysis in an adolescent athlete. This complication occurs primarily in muscles whose expansion is limited by tight fascia, such as the anterior tibial muscles. Tea-coloured urine is noted in only 3.6% of patients and muscle swelling is noted in only 5% of patients. Wang AY, Young SE, Miller MA, Docherty M. Urine dipstick testing to rule out rhabdomyolysis in patients with suspected heat injury. Zager RA. J Clin Endocrinol Metab. Ramelli GP, Odeh M. Leech RW. 5(March 1, 2002) Akmal M, Myoglobinuria can be inferred if a urinary dipstick is positive for blood when there are no red cells in the urine sediment. 1 Several reviews suggest that urine myoglobin is unstable with subpar performance in rhabdomyolysis1, often defined as creatine kinase (CK) elevation 5 times the upper limit of normal in the proper context (eg, crush injury,… Dar KJ, Several investigators7,8 have attempted to categorize the many diverse causes and risk factors for rhabdomyolysis. Clinical features are often nonspecific, and tea-colored urine is usually the first clue to the presence of rhabdomyolysis. This study is the opinion of the authors and does not necessarily represent the opinions of the US Army or the Department of Defense. The role of reperfusion-induced injury in the pathogenesis of the crush syndrome. MDMA induced hyperthermia: a report of a fatality and review of current therapy. 1997;19:283–8. Patel AN. 2012;19(5):329-332. / 29th ed. Reprints are not available from the authors. Rainone T, Alcohol can also damage the sarcolemma directly and can cause … There may be tea-colored urine or an irregular heartbeat. jaundice) or myoglobin (e.g. Improvement of screening in exertional myalgia with a standardized ischemic forearm test. Acute exertional rhabdomyolysis. Address correspondence to John M. Sauret, M.D., Department of Family Medicine, State University of New York at Buffalo School of Medicine and Biomedical Sciences, Office of Research and Development, 462 Grider St., Buffalo, NY 14215 (e-mail:sauret@acsu.buffalo.edu). 1993;5:725–31. Take a sample of your blood to measure levels of creatnine kinase, a protein that muscles release when they disintegrate. High rates of IV fluid administration should be used at least until the CK level decreases to or below 1,000 units per L. If these measures successfully thwart the development of oliguria, the patient can be switched to 0.45 percent saline with the addition of one or two ampules of sodium bicarbonate (40 mEq) and 10 g per L of mannitol. In crush injury, rhabdomyolysis occurs because of the release of necrotic muscle material into the circulation after compression is relieved in, for example, persons trapped in crashed cars or collapsed buildings. Rhabdomyolysis. Oei LT, Hojs R, When the dipstick and a requested urinalysis do not correspond, myoglobinuria and rhabdomyolysis are likely to be present. Hoffman A, Rhabdomyolysis and acute renal failure in intensive care unit. [Medline] . Coma, whether from alcohol or other causes, can lead to prolonged muscle compression and ischaemia. Rubinstein I, Sources of funding: none reported. Critically ill patients with acute renal failure are also likely to develop multiorgan failure syndrome, with a resultant increase in mortality.5. Fiber necrosis in rhabdomyolysis (hematoxylin and eosin). The diagnosis is effectively confirmed by a urine dipstick and urine microscopy. McBrien ME. Order a urine test to check the levels of myoglobin in your urine. 23. In austere or mass-casualty conditions an easy to use, sensitive screening test could be a valuable tool to care providers and evacuation planners. Traumatic, heat-related, ischemic and exertional causes of rhabdomyolysis are listed in Table 2. The complications of rhabdomyolysis can be classified as early or late (Table 7). Telfer N, At a high concentration, myoglobin excreted into the urine changes its color to red or brown and can be assessed with a dipstick analysis. Pedrozzi NE, Other markers of rhabdomyolysis include elevated lactate dehydrogenase and serum transaminase levels and the presence of myoglobinuria. In this setting, a serum sample with normal color indicates myoglobinuria, whereas a pigmented brown or red serum sample indicates hemoglobinuria. 1998;18:558–65. Zager RA. Gillum BS. Am Fam Physician. 18. Knochel JP. Hyperkalaemia can be life threatening in rhabdomyolysis. Factors predictive of acute renal failure in rhabdomyolysis. Brumback RJ, Several inherited genetic disorders, such as McArdle's disease and Duchenne's muscular dystrophy, are predisposing factors for the syndrome. Simon R, Exaggerated lithotomy position-related rhabdomyolysis. 29th ed. A spectrum of injury. 2. However, urine dipstick tests are positive in only half of patients with rhabdomyolysis and a nega-tive result does not rule out the diagnosis. Elderly patients should be treated in an intensive care unit so that vital signs, intake and hourly output can be closely monitored and fluid overload can be quickly detected. Some antimalarial medication, such as chloroquine, also cause brown discolouration of the urine. Rhabdomyolysis and acute renal failure resulting from alcohol and drug abuse. Bishop JE, Philadelphia: Saunders, 2000.... 2. Brumback RA, Gabow PA, Remove the dipstick immediately and tap off any residual urine using the edge of the container, making sure to hold the dipstick horizontally to avoid cross-contamination of the reagent squares. Knochel JP. Lakatos R, A urine dipstick test that is pos-itive for blood in the absence of red blood cells on microscopy strongly suggests myoglobinuria. When initially evaluating a patient with dark-colored urine, a positive urine dipstick test for blood without evidence of RBCs on microscopy is a clue to the presence of rhabdomyolysis, because myoglobin will also react with the orthotolidine test reagent. Decompressive fasciotomy should be considered if the compartment pressure is greater than 30 mm Hg.22, The treatment of rhabdomyolysis is primarily directed at preserving renal function. Muscle Nerve 1986;9:731–7. RHABDOMYOLYSIS: PREVENTION AND TREATMENT SUMMARY With an increasing knowledge and understanding of the disease, rhabdomyolysis (RM) ... Myoglobinuria is the presence of MG in the urine. Semin Neurol. Norman AW, Rhabdomyolysis and acute renal failure resulting from alcohol and drug abuse. Biswas S, Exaggerated lithotomy position-related rhabdomyolysis. rhabdomyolysis) in the urine. Systemic features may include tea-colored urine, which is usually the first sign, along with fever and malaise. Rhabdomyolysis is a condition characterized by muscle cell death and the release of muscle cell constituents into the circulation. 12. 16. JOHN M. SAURET, M.D., is clinical assistant professor in the Department of Family Medicine at the State University of New York (SUNY) at Buffalo School of Medicine and Biomedical Sciences. There is a loose predictive correlation between CK levels and the development of acute renal failure, with levels higher than 16,000 units per L more likely to be associated with renal failure.21 The rate at which serum creatinine levels increase is typically faster in patients with myoglobinuric renal failure (up to 2.5 mg per dL per day [220 μmol per L]) than in those with other causes of acute renal failure. CK, myoglobin, and urine dipstick are among the most studied predictive factors for AKI following rhabdomyolysis. Hypocalcemia and hypercalcemia in patients with rhabdomyolysis with and without acute renal failure. Myoglobinuria can be inferred if a urinary dipstick is positive for blood when there are no red cells in the urine sediment.

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