2. › Introduction
› Patient Profile
› Disease background
› Admission
› Nutrition Care Process
› Summary and Reflection
3. › Exertional rhabdomyolysis is a muscle
injury the results in the lysis of skeletal
muscle and the release of celllular
components into the circulation
› In severe cases can lead to death
› Rhabdomyolysis affects 1/10,000
people in the US per year
(Boutaud and Robert, 2010 and Stella and Shariff, 2012)
4. › 28 year old African American Male
› Admission: 9/03/12 Discharge: 9/13/12
› Initial DX: heat exhaustion and cramps
› Admit through ER from soccer
tournament
› PMH: heat exhaustion requiring IV fluids
2 at soccer tournament 2 years prior
› Family HX: insignificant
› Single, lives with roommate
5. › Native to Florida where he currently
lives
› Has been a Civil Servant for >4 years in
the Air Force as a Systems Engineer
› Currently completing his
undergraduate degree
› Position: Right back
› Been playing soccer for 23 years
6. › Ht: 71 in - 6’ 11”
› Wt: 91.17 kg – 200 lbs
› No previous wt gain/loss
› No difficulty swallowing/chewing or BM
› Denies any substance abuse
› Previously healthy individual
7. › Numbers 11: 31-35
› 1812 during Napoleon’s rein
› 1941 during WWII after the Blitz of
London referred to as “crush syndrome”
(Elsayed and Reilly, 2010)
8. › Breakdown of skeletal muscle resulting
in the release of intracellular contents
› Leakage of contents can become
severe and life threatening
(Khan, 2009)
9. › Acute Renal Failure: abrupt decrease in
renal function sufficient enough to result
in retention of nitrogenous waste and
disrupt fluid and electrolyte homeostasis
(Anderson, 2009)
10. › Illicit drug use, alcohol abuse, muscle
disease, trauma, seizures and immobility
› Sporadic strenuous exercise can cause
exertional rhabdomyolysis
› Excess heat increases risk
› Hypokalemia
› Hyponatremia
(Bruso, 2010)
11. › Myocyte is muscle cell
› Sarcomlemma is a thin membrane that
encloses striated muscle fibers and
electrochemical gradients
› Intercellular Na is maintained at 10 mEq/L by
active transport
› Interior of cell is negatively charged and can
pull Na to interior for Ca exchange
(Khan, 2009)
12. › Low levels of intracellular Ca allows for
increased actin-myosin muscle
contraction
› Na/K-ATPase pump and Ca-ATPase
pump
› Every electrochemical pump requires
ATP
› ATP depletion = Pump dysfunction
resulting in rhabdomyolysis
(Kahanov et al, 2012)
13. › Destruction of myocytes
› Dysfunction of the electrochemical
pumps located in the sacrolemma
membrane
› Altered ATP = Na in cytoplasm =
intracellular Ca
› Proteases and phospholipases activate
= destruction of myofibrillar cytoskeletal
membrane proteins
(Bosch, 2009 and Khan 2009)
14. › Muscle cell breaks
down, K, aldolase, phosphorus, myoglo
bin, creatine kinase, lactate
dehydrogenase, urate, apsertate
dehydrogenase are released into
circulation
› >100 g of muscle breaks down -
myoglobin releases into the circulation
› myoglobin leads to renal tubular
obstruction, nephrotoxicity, and ARF
(Khan, 2009)
15. › Muscle damage can increase from 2-12
hrs after injury
› Peak values at 24-72 hrs
› Creatine Kinase (CK) 5 x normal value is
accepted for dx
› Myoglobin might become visible in the
urine
(Kahanov et al, 2012)
16. › Hypovolaemia: fluid into necrotic
muscle
› Compartment syndrome: ischemia and
swelling
› Hepatic dysfunction
› Lactic acidosis
› Acute Renal Failure ~ 33% of
rhabdomyolysis
(Kahanov et al, 2012)
17. › Depends on underlying cause
› If treated early and aggressively, good
prognosis
› 80% have recovered renal function
› 1,500 die of rhabdomyolysis per year
(Thoenes, 2010)
19. Article Sport/Event Suspect Cause Diagnosis Outcome
Bruso, 2010 161 km ultra
marathon
over hydration 5 cases of
rhabdomyolysis
3 with ARF
Full recovery
Casares and
Marull, 2008
Heavy weight
leg workout
Unconditioned
muscle group
Exertional
Rhabdo
CK 1,454,952
8 days after d/c CK <
1,000
Stella and
Shariff, 2012
Recreational
swimming
Unconditioned Ecertional rhabdo
CK 112,400
Full recovery
Thoenes,
2010
Spin class Strenuous
repetitive exercise
Exertional rhabdo
myoglobinuria
Full recovery
Kuklo et al,
2000
Army Physical
Fitness test
Strenuous exercise
Dehydration
undernourished
Myoglobinuria
Acidosis
AR insuffieciency
Elevated CK
Multisystem failure
expired
Katerina et
al, 2006
246-km
continuous
running race
Continuous muscle
strain
39 possible
rhabdomyolysis
Not reported on
Parmar et al,
2012
Spin class Sudden increase in
training /s proper
training
2 cases of
rhabdomyolysis
Lab values within normal
limits at F/U
Kahanov et
al, 2012
Div I NCAA
football
Eccentric exercise Rhabdomyolysis Increased CK for 18 days
6 week recovery period
20. › Pt initial diagnosis was heat exhaustion
with cramps, then later the primary
diagnosis changed to Rhabdomyolysis
with Acute Renal Failure
› Pt was hospitalized for 10 days
› Pt expressed a lack of understanding
related to his condition
21. › Pt was treated with aggressive
hydration and electrolyte replacement
› Made a gradual recovery
› 3rd day- decreased muscle
cramps, soreness
› 4th day- CK began to trend down
› 7th day- ARF was resolved
› 10th day- CK 1106
25. 9/01/12
• 79-98˚F
• 66%
average
humidity
• 10 mph
average
wind
speed
9/02/12
• 77-99˚F
• 60%
average
humidity
• 11 mph
average
wind
speed
9/03/12
• 76-99˚F
• 60%
average
humidity
• 10 mph
average
wind
speed
26. › Water intoxication
› < 135 mEq/L of sodium in the blood
› Excessive water intake
› Osmotic imbalance
(Bruso et al, 2010)
27. › Facilitates rehydration
› Sustains the thirst drive
› Promotes retention of fluids
› More rapidly restores lost plasma
volume during rehydration
(Bruso et al, 2010)
28. › Exercise Associated Hyponatremia (EAH)
› Facilitates rhabdomyolysis through
changes in intracellular K or Ca
concentration resulting in hypotonic cell
swelling
› Lysis from exertion and thermal strain =
spacing of fluids = facilitates EAH
(Bruso et al, 2010)
29. › risk of opportunistic infections
› Damaged tissues caused by free
radicals after exercise can lead to
incomplete recovery
(Maughan, 2002)
30. › Higher average energy deficit = higher
body fat percentage
› rate of protein catabolism
› ↓ immune function
(Deutz et al, 2000 and Maughan, 2002)
31. › Oxidation of fat and CHO for energy
› Body stores of CHO are relatively low
› Glycogen stores deplete during
strenuous exercise
› CHO not replenished = decrements in
training response
(Maughan, 2002)
32. › Low-CHO diet = difficulty in sport
performance compared to high-CHO
diet
› Low-CHO diet risk of injury and
susceptibility to minor infections
› High-CHO might be difficult to achieve
due to daily practicalities of most
athletes
(Maughan, 2002)
33. › Adequate dietary CHO before exercise
and regular CHO ingestion during
exercise to minimize stress hormones
that have negative effect on immunity
› Maintaining adequate dietary CHO
intake is a priority
(Maughan, 2002)
34. › Inadequate carbohydrate intake
related to food and nutrition
knowledge deficit and increased
energy needs due to physical activity
as evidence by estimated
carbohydrate intake less than
recommended amounts and
verbalized report of incomplete
knowledge
› Basic sport nutrition education was
given
35. › >23 years as a soccer player with no
nutritional guidance?!
› Could this have been avoided with
proper dietary habits and nutrition?
› Who is responsible?
36. Anderson, R. & Barry, D. (2004). Clinical and laboratory diagnosis of acute renal failure. Best Practice & Research
Clinical Anesthesiology. 18(1): 1-20.
Bosch, X., Poch, E., & Grau, J. (2009). Rhabdomyolysis and acute kidney injury. The New England Journal of
Medicine. 361(1): 62-74.
Bruso, J., Hoffman, M., Rogers, I., Lee, L., Towle, G., & Hew-Butler, T. (2010). Rhabdomyolysis and hyponatremia:
A cluster of five cases at the 161-km 2009 Western States Endurance Run. Wilderness & Environmental
Medicine. 21: 303-308.
Capacchione, J., & Muldoon, S. (2009). The relationship between exertional heat illness, exertional
rhabdomyolysis, and malignant hyperthermia. Anesthesia Research Society. 109(4): 1065-1069.
Casares, P. & Marull, J. (2008). Over a million creatine kinase due to a heavy work-out: A case report. Cases
Journal. 1(173): 1-4.
Deutz, R., Benardot, D., Martin, D., & Cody, M. (2000). Relationship between energy deficits and body
composition in elite female gymnast and runners. Medicine and Science in Sports and Exercise. 659-678.
Falvo, M. & Bloomer, R. (2006). Review of exercise-induced muscle injury: Relevance for athletic populations.
Research in Sports Medicine. 14: 65-82.
Hannah-Shmouni, F., McLeod, K., & Sirrs, S. (2012). Recurrent exercise-induced rhabdomyolysis. Canadian
Medical Associations Journal. 184(4): 426-430.
Huerta-Alardin, A., Varon, J., & Marik, P. (2005). Bench –to-bedisde review: Rhabdomyolysis- an overview for
clinicians. Critical Care. 9: 158-169.
Kahanov, L., Eberman, l., Wasik, M., & Alvey, T. (2012). Exertional rhabdomyolysis in a collegiate American
football player after preventive cold water immersion: A case report. Journal of Athletic Training. 47(2): 228-
232.
Khan, F. (2009). Review: Rhabdomyolysis: A review of the literature. The Netherlands Journal of Medicine. 67(9).
Kulko, T., Tis, J., Moores, L., & Schaefer, R. (2000). The American Journal of Sports Medicine. 28(1): 117.
Maughan, R. (2002). Plenary lecture: The athlete’s diet: Nutritional goals and dietary strategies. The Nutritional
Society. 61:87-96
Parmar, S., Chauhan, B., DuBose, J., & Blake, L. (2012). Rhabdomyolysis after spin clas? The Journal of Family
Practice. 61(10): 584-586.
Skenderi, K., Kavouras, S., Anastasiou, C., Yiannakouris, N., & Matalas, A. (2006). Exertional rhabdomyolysis
during a 246-km continuous running race. Americn College of Sports Medicine. 1054-1056.
