Think of rhabdomyolysis and you'll think of an elevated creatine kinase (CK). The condition ranges from an asymptomatic period to a life-threatening condition with a hugely associated rise in CK which can also be accompanied by electrolyte disturbance, renal failure and disseminated intravascular coagulation.
Rhabdomyolysis is caused by a breakdown in skeletal muscle and occurs most commonly following trauma, very often that can be due to a 'long-lie' when a patient is unable to get off a floor until help arrives after a prolonged period. There are other causes including drugs, muscle enzyme deficiencies, electrolyte abnormalities and more.
The presentation itself is pretty vague and suspicion of the disease needs to be pretty high. Patients can experience weakness, myalgia and the dark'coca-cola urine', the diagnosis is then confirmed with a serum elevation in CK.
The big concern with Rhabdomyolysis is the hit the kidneys take. Acute kidney injury is due to the heme pigment that is released from myoglobin and haemoglobin and is nephrotoxic. Early aggressive fluid rehydration aims to minimise ischaemic injury, increase urinary flow rates and thus limit intratubular cast formation. Fluids also help eliminate excess K+ that may be associated. But have a think about the management in your ED, how high does that CK need to be to require i.v. fluids and admission to hospital?
Here's a few facts we need to know:
A lot of the evidence and knowledge surrounding rhabdomyolysis is from humanitarian disasters; earthquakes, terrorism along with observational cohorts, but at the end of the day we need to work with what we've got.
Have a listen to the podcast and see what you think, the application of the evidence base may change your practice.
Bench-to-bedside review: Rhabdomyolysis -- an overview for clinicians. Huerta-Alardín AL. Crit Care. 2005
Creatine kinase MB isoenzyme in dermatomyositis: a noncardiac source. Larca LJ. Ann Intern Med. 1981
Rhabdomyolysis: an evaluation of 475 hospitalized patients. Melli G. Medicine (Baltimore). 2005
Serum creatine kinase as predictor of clinical course in rhabdomyolysis: a 5-year intensive care survey. de Meijer AR. Intensive Care Med. 2003
Prevention and treatment of heme pigment-induced acute kidney injury (acute renal failure). Paul M Palevsky. UpToDate. 2015
Epistaxis is an extremely common presentation to both Prehospital Emergency Services and Emergency Departments. The vast majority are benign and self limiting but every once in a while a catastrophic bleed will come our way.
Whilst not necessarily the most attention grabbing of topics a sound understanding of the management is key to excellent care.
In this podcast Rob talk us through the management of epistaxis, all the way from causes and presentation, right the way through to resuscitative management and latest evidenced based treatment.
References & Further Reading
BMJ overview paper & management flowchart
Routine coagulation screening in the management of emergency admission for epistaxis; is it necessary? Thaha MA. J Laryngol Otol 2000
Front-line epistaxis management: let's not forget the basic. E C Ho. J Laryngol Otol 2008
Serious spontaneous epistaxis and hypertension in hospitalized patients.Page C. Eur Arch Otorhinolaryngol. 2011
Welcome back to Papers of the Month. February holds a diverse number of topics on some really interesting areas of practice.
We kick off with a snap shot systematic review from the Annals of Emergency Medicine on the effect of Amiodarone or Lignocaine on the outcome from refractory VF or VT arrests, are drugs losing more favour yet again in cardiac arrest.
Next up is a pilot study following the surgical theme of minimal intervention for appendicitis, can antibiotics safely be used in a particular cohort of patients to prevent the need for surgery? And moreover could this be even safer than the traditional surgical cure?
Last up we cover a paper looking at the survival from traumatic cardiac arrest and consider the bias that may occur by reporting those resuscitation attempts that are of limited duration in with the whole cohort; are we painting a overly negative picture of the prognosis of traumatic cardiac arrest?
As ever we would highly encourage you to go and read the papers yourselves, these are only our takes on the literature and we would love to hear your thoughts below.
References & Further Reading
In Patients With Cardiac Arrest, Does Amiodarone or Lidocaine Increase Meaningful Survival? Hunter BR. Ann Emerg Med
Antibiotics-First Versus Surgery for Appendicitis: A US Pilot Randomized Controlled Trial AllowingOutpatient Antibiotic Management. Talan DA. Ann Emerg Med. 2016 Dec
Resuscitation attempts and duration in traumatic out-of-hospital cardiac arrest. Beck B. Resuscitation 2017 Feb