Improving Outcomes, Improving Throughput

Summertime R & R (Rhabdo & Review)

With 90 degrees coming tomorrow, I thought a quick rhabdomyolysis pearl may prove useful. I had previously been told based on InterQual (what my previous care management team used for observation vs admission) was that a CK > 2000 met admission criteria. That seems a bit low, and frankly, an admission based on a CK level without overt symptoms that looks and feels well with normal GFR and creatinine seems like a disservice to the patient. There is not a whole lot of evidence to guide decisions for rhabdo, and the only thing I could really find (PMID: 21057287) actually seems like a logical screening tool: CK <15000, normal creatinine, absence of sickle cell trait (yes, trait), absence of infectious cause of rhabdo, absence of profound dehydration (the elderly found on the floor for who knows how long isn’t going home anyway), and without prolonged analgesic use (NSAIDs). Meeting the above criteria for exertional rhabdomyolysis one could likely be followed as an outpatient with very low risk of adverse outcome or long term sequelae. If you can not resist the urge to keep the patient in the hospital, or if they have poor outpatient follow up- then consider placing them in observation for an evening… And give them…


Lactated Ringers.


     A comparison study of LR vs NS for doxylamine-induced rhabdo (13 vs 15 patients, respectively) gave IV fluid at a rate of 400ml/hr. After 12 hours, the LR group had less bicarb administered, less diuretics administered, and less metabolic acidosis without a significant serum potassium change. Admittedly, this is a very small study, and a toxin-induced rather than exercise-induced rhabdomyolysis. However, the hyperchloremic acidosis you are inducing by providing NS, may be mistaken for a worsening rhabdo, and iatrogenically prolong the patients stay.

     This is yet another example of setting the right course in the ED. Lactated Ringers started in the ED will be less likely to cause an acidosis down the road, and the patient will be less likely to receive bicarb and forced diuresis, thereby safely discharging your patients sooner and safer from the hospital after receiving the best care possible by your ED.

Enjoy the Summer!

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PMID: 17384382
PMID: 21057287


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PMID: 17384382
PMID: 21057287

 

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