\n\nHb 114\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 WCC 10.2 \u00a0 \u00a0\u00a0 Plt <\/span>234\u00a0<\/span><\/span><\/p>\nK 6.4\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0 \u00a0Na 136\u00a0 \u00a0 \u00a0 \u00a0 Urea 22.0<\/span><\/p>\nCreat\u00a0 320\u00a0 \u00a0 \u00a0 eGFR 21<\/span><\/p>\n<\/td>\n
\n[H+<\/sup>] = 50 nmol\/L\u00a0 pH = 7.3<\/span><\/p>\nPaCO2<\/sub> = 3.2 kPa<\/span><\/p>\n[HCO3<\/sub>] = 12 mmol\/L<\/span><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/figure>\n\n\n\nWhat does this ABG reveal about this patient’s blood picture?<\/span><\/strong><\/p>\n\n\n\n (choose one of these and then click to see if you are correct)<\/em><\/p>\n\n\n\nMetabolic acidosis<\/strong><\/button>\n
This is metabolic acidaemia with partial respiratory compensation. The metabolic acidaemia is due to renal failure.<\/p>\n<\/div><\/div>\n\n\n\n
Metabolic Alkalaemia<\/strong><\/button>\n
Typical metabolic alkalaemia presents with increased HC03 – followed by a small compensatory PC02 increase.<\/p>\n<\/div><\/div>\n\n\n\n
Respiratory Acidosis<\/strong><\/button>\n
Typical respiratory acidaemia presents with increased PaC02 and compensatory increased [HC03-].<\/p>\n<\/div><\/div>\n\n\n\n
Respiratory alkalaemia<\/strong><\/button>\n
The PaC02 is low, which occurs in respiratory acidaemia, but in this case the low PaC02 is due to compensatory response to metabolic acidaemia.<\/p>\n<\/div><\/div>\n\n\n\n
Mixture of Metabolic acidosis and Respiratory alkalosis<\/strong><\/button>\n
Consider the clinical circumstances. [HC03-] is lowered which indicates acidaemia but the drop in PaC02 is a compensatory effect due to hyperventilation.<\/p>\n<\/div><\/div>\n\n\n\n
\n\n\n\n
What is the cause of his acid base disturbance?<\/strong> <\/span><\/p>\n\n\n\n(choose one of these and then click to see if you are correct)<\/em><\/p>\n\n\n\nAcute Kidney Injury<\/strong><\/button>\n
Myoglobin is less soluble in more acidic conditions and precipitates in renal tubules leading to renal impairment and possible kidney failure.<\/p>\n<\/div><\/div>\n\n\n\n
Crush Injury – Rhabdomyolysis <\/strong><\/button>\n
In rhabdomyolysis muscle cells are damaged with the release of their content. Symptoms related to this may include muscle pain and reddish\/brown discolouration of urine.<\/p>\n<\/div><\/div>\n\n\n\n
Poor respiratory effort\/ Abnormal gas exchange<\/strong><\/button>\n
This would cause respiratory acidaemia.<\/p>\n<\/div><\/div>\n\n\n\n
Overhydration<\/strong><\/button>\n
This is unlikely and you would tend to see peripheral signs of overload (peripheral oedema etc) prior to this occurring.<\/p>\n<\/div><\/div>\n\n\n\n
<\/p>\n\n\n\n
You suspect the above diagnoses are related to his current condition and you move on to undertake some further investigations<\/p>\n\n\n\n
What tests might be helpful to confirm the diagnosis?<\/strong><\/span><\/p>\n\n\n\nElectrocardiogram<\/strong><\/button>\n
Whilst myoglobin is raised in rhabdomyolysis in someone like this gentleman, where the disease is already progressed, it is likely that this will no longer show in the urine due to blockage in the renal tubule.<\/p>\n<\/div><\/div>\n\n\n\n
<\/p>\n\n\n\n
Serum Bilirubin<\/strong><\/button>\n
This would be unusual to find in a patient with rhabdomyolysis. If there is significant haemolysis, this would lead to an increase in unconjugated bilirubin hover the most common liver enzyme derangement in rhabdomyolysis is ALT.<\/p>\n<\/div><\/div>\n\n\n\n
<\/p>\n\n\n\n
Serum Creatine Kinase<\/strong><\/button>\n
This tends to be markedly elevated and is the most specific test in rhabdomyolysis and we would expect this to be raised in this gentleman’s case.<\/p>\n<\/div><\/div>\n\n\n\n
<\/p>\n\n\n\n
Urinary Myoglobin<\/strong><\/button>\n
Whilst myoglobin is raised in rhabdomyolysis in someone like this gentleman, where the disease is already progressed, it is likely that this will no longer show in the urine due to blockage in the renal tubule.<\/p>\n<\/div><\/div>\n\n\n\n
<\/p>\n\n\n\n
Blood pressure<\/strong><\/button>\n
Blood pressure can be abnormal for a whole variety of reasons and as such is not a specific indicator of Rhabdomyolysis.<\/p>\n<\/div><\/div>\n\n\n\n
<\/p>\n\n\n\n
You carry out the investigations that we have agreed on above<\/p>\n\n\n\n
Results<\/strong><\/button>\n
\n
ECG – Tented T- waves and broad QRS complexes<\/p>\n\n\n\n
CK : 3689U\/L<\/p>\n\n\n\n
Urine myoglobin – positive<\/p>\n<\/div><\/div>\n<\/div><\/div>\n\n\n\n
<\/p>\n\n\n\n
Given the results that you have for your patient you decide to instigate treatment for this individual. <\/p>\n\n\n\n
What will be important in this gentleman’s management?<\/span><\/strong><\/p>\n\n\n\nSelect all options that apply<\/em><\/p>\n\n\n\nIntravenous fluids <\/strong><\/button>\n
In most cases of rhabdomyolysis IV fluids will form a part of the management of this condition. This needs to be used with caution in those individuals with significant renal impairment who are anuric or oligouric and thus there is a risk of fluid overload leading to peripheral or pulmonary oedema<\/p>\n<\/div><\/div>\n\n\n\n
Oral Bicarbonate<\/strong><\/button>\n
While IV bicarbonate has previously been used in the management of rhabdomyolysis (little evidence that this is of benefit) oral bicarbonate is certainly not involved in the management of rhabdomyolysis.<\/p>\n<\/div><\/div>\n\n\n\n
Dialysis<\/strong><\/button>\n
In some individuals, impairment to their kidneys will be so severe that dialysis will be required. Remember indications for emergency dialysis – hyperkalaemia which is not responsive to medical management, pulmonary oedema, progressive uraemic encephalopathy.<\/p>\n<\/div><\/div>\n\n\n\n
Calcium Gluconate<\/strong><\/button>\n
Whilst not a specific treatment for Rhabdomyolysis it is important to treat hyperkalaemia in this gentleman. As he has cardiac changes related to hyperkalaemia, calcium gluconate is important to stabilise the cardiac membrane and prevent progression to deadly arrhythmias.<\/p>\n<\/div><\/div>\n\n\n\n
Blood transfusion<\/strong><\/button>\n
This gentleman is mildly anaemic however not to an extent to where he would require blood products. A potential complication of rhabdomyolysis is DIC and should this become an issue then blood products may be required, however there is no indication that this would be part of the management at this time.<\/p>\n<\/div><\/div>\n\n\n\n
<\/p>\n\n\n\n
General feedback on these answers<\/strong><\/button>\n
You decide a management plan and discuss it with your senior who agrees.<\/p>\n\n\n\n
This gentleman is managed in a ICU setting and with the measures you have decided on he and his renal function gradually improves over the next 9 days.
Well done you have completed this case.<\/p>\n<\/div><\/div>\n","protected":false},"excerpt":{"rendered":"
A 28 year old gentleman was involved in road traffic accident. He had been trapped under a car for several hours prior to being extracted by the fire service. He sustained bilateral injuries to his legs with femoral and tibial and fibular fractures. Following his injuries he was catheterised and\u2026<\/p>\n
Continue reading<\/span><\/i><\/a> <\/p>\n","protected":false},"author":2,"featured_media":0,"parent":4912,"menu_order":73,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"class_list":["post-4530","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4530","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/comments?post=4530"}],"version-history":[{"count":36,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4530\/revisions"}],"predecessor-version":[{"id":4998,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4530\/revisions\/4998"}],"up":[{"embeddable":true,"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/pages\/4912"}],"wp:attachment":[{"href":"https:\/\/edren.org\/ren\/wp-json\/wp\/v2\/media?parent=4530"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
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