UMEM Educational Pearls

Category: Toxicology

Title: Hyperemesis Cannabinoid Syndrome

Keywords: Hyperemesis, Cannabinoid (PubMed Search)

Posted: 10/18/2018 by Kathy Prybys, DO (Emailed: 10/19/2018) (Updated: 10/19/2018)
Click here to contact Kathy Prybys, DO

Despite the well established antiemetic properties of marijuana, Cannabinoid Hyperemesis Syndrome (CHS) is a distinct under recognized syndrome characterized by severe cyclic vomiting and refractory abdominal pain. CHS can be divided into three phases with varying time lags: pre-emetic or prodromal, hyperemetic, and recovery phase. The hyperemetic phase consists of paroxsyms of overwhelming incapacitating nausea and vomiting.The underlying mechanism of the hyperemesis in CHS is not well understood but appears to be associated with cummulative and toxic effects of Δ9-tetrahydrocannabinol (Δ9-THC) in predisposed patients.
 
Diagnostic criteria include:
  • History of regular cannabis use at least weekly for any duration of time.
  • Compulsive hot water bathing multiple times per day for symptom relief which is mediated by the TRPV capsaicin receptors.
  • Resolution of symptoms with cannabis cessation.
  • Prior nonrevealing extensive diagnostic work up.

 

CHS Treatment:

  • Definitive and most effective treatment is to stop cannabinoid use which provides complete relief within 7–10 days.
  • Temporary relief occurs with hot water bathing, Capsaicin topical cream, Haldol administration, and fluid resuscitation.

Bottom line: Patient education should be provided on the paradoxical and recurrent nature of the symptoms of CHS to discourage relapse of use often stemming from false preception of beneficial effects of cannabis on nausea. 

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Category: Orthopedics

Title: Concussion question parents will ask you

Keywords: Concussion, return to play, school, head injury (PubMed Search)

Posted: 10/13/2018 by Brian Corwell, MD (Updated: 10/19/2018)
Click here to contact Brian Corwell, MD

You have successfully diagnosed a concussion, explained everything to the parents, closed the encounter, reached for the doorknob and….

“What about school?”

 

An athlete should not return to play until they have successfully returned to school

Several studies have demonstrated that intense cognitive stimulation and intense intellectual stimulation result in worsening symptoms

                -school work, TV, videogames, texting

Attempt to limit cognitive activity to the point where it begins to reproduce or worsen symptoms!

Step 1: 24 to 48 hours of rest

Step 2: Daily at home activities that do not increase symptoms. Starting with 5 – 10 minutes and gradually build up to a goal of tolerating 30 minutes of cognitive activity without worsening symptoms.

                Home work, reading assignments, other cognitive activities

Step 3: Attempt Return to school (will not be completely symptoms free!) with either part time, partial days, or with extended breaks. Goal of tolerating an entire school day without symptoms.

Most students recover fully within 4 weeks and adjustments can then be discontinued. Others with ongoing symptoms may require ongoing academic modifications (extra time for tests, papers, etc).

Suggested examples of adjustments:  Shortened days, 15 minute break for every 30 minutes of instruction, providing class notes, tutoring, decreasing course expectations, decreasing exposure to classes which exacerbate symptoms, no computer work, untimed tests and quizzes, lunch in a quiet place.

 

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Category: Neurology

Title: Early Dual Antiplatelet Therapy for Stroke Prevention?

Keywords: stroke, TIA, antiplatelet, aspirin, clopidogrel, POINT, CHANCE (PubMed Search)

Posted: 10/10/2018 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

Takeaways

Does using a combination of aspirin and clopidogrel decrease your patient’s risk of recurrent stroke after a minor ischemic stroke or high risk TIA event?

  • The recent international Platelet-Oriented Inhibition in New TIA and Minor Stroke (POINT) trial compared 4881 patients receiving aspirin/clopidogrel vs. aspirin/placebo within 12 hours of symptom onset.
    • Patients who received DAPT had a lower rate of major ischemic events at 90 days compared to aspirin/placebo (5.0% vs. 6.5%, p=0.02).
    • However, patients who received DAPT had a higher rate of major hemorrhage compared to aspirin/placebo (0.9% vs. 0.4%, p=0.02).
  • A similar Chinese study, the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial, compared 5170 patients receiving DAPT vs. aspirin/placebo within 24 hours also found lower rate of stroke (8.2% vs. 11.7%, p<0.001) but similar rates of moderate/severe hemorrhage (0.3% vs. 0.3%, p=0.73).
  • Major differences between these two trials are the population studied and the duration of DAPT, as POINT utilized DAPT for 90 days while CHANCE utilized DAPT for 21 days.

Bottom Line: The use of DAPT in minor ischemic stroke and high risk TIA reduces the risk of recurrent stroke.  However, the duration of DAPT may affect the risk of major hemorrhage.

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Category: Critical Care

Title: High Velocity Nasal Insufflation

Keywords: High flow nasal cannula, acute respiratory failure, hypoxia, hypercarbia, non-invasive ventilation (PubMed Search)

Posted: 10/9/2018 by Kami Hu, MD (Updated: 10/19/2018)
Click here to contact Kami Hu, MD

We know that high flow nasal cannula is an option in the management of acute hypoxic respiratory failure without hypercapnea. A newer iteration of high flow, "high velocity nasal insufflation" (HVNI), may be up-and-coming.

According to its makers (Vapotherm), it is reported to work mainly by using smaller bore nasal cannulae that deliver the same flows at higher velocities, thereby more rapidly and repeatedly clearing dead space, facilitating gas exchange and potentially offering ventilatory support. 

In an industry-sponsored non-inferiority study published earlier this year:

  • 204 adult patients in 5 EDs
  • Any acute respiratory failure deemed by the treating physician to require non-invasive positive pressure ventilation (NPPV)
  • Patients randomized to either NPPV (bilevel positive airway pressure) or HVNI
  • Rate of HVNI treatment failure (26%) and intubation @ 72 hours (7%) fell within predefined noninferiority margins
  • Rates of PCO2 clearance were similar between HVNI and NPPV groups
  • The study was not powered to detect differences between different etiologies for respiratory failure
  • Authors concluded that HVNI is noninferior to NPPV for all-comer respiratory failure.

Bottom Line: 

The availability of a nasal cannula that helps with CO2 clearance would be great, and an option for patients who can't tolerate the face-mask of NPPV would be even better.

HVNI requires more investigation with better studies and external validation before it can really be considered noninferior to NPPV, but it certainly is interesting. 

 

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Clonidine is an alpha-2 agonist commonly used to treat hypertension. Clonidine can also be used to mitigate symptoms of opioid withdrawal as it easily crosses the blood brain barrier and reduces sympathetic effects.

When using clonidine for acute withdrawal or blood pressure control, oral tablets are the preferred route.  Clonidine transdermal patches have slow absorption and take 2-3 days for the effect to be seen.  Once removed, clonidine patches can provide therapeutic levels for up to 20 hours.

Bottom Line: If clonidine is needed acutely for your patient, select oral tablets and titrate to effect.

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Category: Neurology

Title: Must transverse myelitis be symmetrical?

Keywords: weakness, sensory symptoms, MRI, LP (PubMed Search)

Posted: 9/26/2018 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

Although transverse myelitis classically presents with bilateral and symmetric symptoms, it may be “partial” - symptoms would be asymmetric, or specific only to particular anatomic tracts.
In patients with risk factors (e.g. recent infection, history of autoimmune disease or cancer) and subacute ascending weakness/sensory symptoms, perform a thorough neurological exam, and obtain a gadolinium-enhanced MRI of the entire spine and/or lumbar puncture if you suspect transverse myelitis. 

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Category: Orthopedics

Title: Medial Elbow Instability

Keywords: thrower, insability (PubMed Search)

Posted: 9/23/2018 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

25yo baseball pitcher presents with medial elbow pain. He felt a painful “pop” and could not continue to throw (due to loss of speed and control). Mild paresethesias in 4th and 5th digits.

 

What physical examination maneuvers can you do at the bedside to assist in the diagnosis?

               Exam opposite elbow first to establish baseline and to assist patient relaxation and understanding.

Flexing elbow to 20 to 30 degrees unlocks the olecranon

  1. Valgus stress test – flex elbow with forearm/hand supinated. Apply valgus stress test and note for laxity/firm endpoint.

https://www.youtube.com/watch?v=KXQxH0UTn-8

  1. Milking maneuver – Here the valgus stress is created by pulling on the patient’s thumb with the forearm supinated and elbow flexed to 90°. Note instability, pain, or apprehension.

https://www.youtube.com/watch?v=4sa9goJ4afs

or

https://www.youtube.com/watch?v=SwigwaZxBXE

  1. Moving valgus stress test – Similar to the milking maneuver, the valgus stress test is applied while the elbow is ranged through full flexion and extension. Note instability, pain, or apprehension in mid range (between 70 and 120 degrees)

https://www.youtube.com/watch?v=OnkkHpG3Dqg

 


Originally described a Dr. West in 1841 – it is a rare (~1200 cases annually)  seizure disorder in young kids, generally less than 1 year old.  Very subtle appearance, often with only bending forward or ‘jerking’ of the extremities as opposed to Brief Resolved Unexplained Event (BRUE) or tonic-clonic in description.  The spasms can be thought of as a syndrome, where 70% of those have an undiagnosed rare metabolic/genetic disease.

A prompt evaluation, including labs, EEG, MRI, metabolic and genetic studies is vital in helping to establish a diagnosis which can have a profound impact on the patients prognosis. Examples might include Tuberous Sclerosis, Pyridoxine Dependent Seizures among over 50 others.

Bottom line: In pediatric patients less than 1 year old who present to the Emergency Department with a description of spasm-like episodes, consider Infantile Spasms on the differential, and consult your friendly neighborhood Pediatric Neurologist for help in determining a proper disposition.

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Category: Pediatrics

Title: Ibuprofen use and infants

Keywords: Fever, pain control, ibuprofen, acetaminophen (PubMed Search)

Posted: 9/21/2018 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

Ibuprofen is an effective antipyretic and analgesic and children.  In the US, ibuprofen is not used in children less than 6 months due to safety concerns involving adverse GI effects, risk of renal failure, increased risk of necrotizing infections and Rey syndrome.   The British National Formulary, however, does provide dosing guidance for infants aged 1-3 months.
This study was a retrospective review looking at infant's age less than 6 months who were prescribed ibuprofen or acetaminophen.  The rate of adverse GI and renal events were compared between both the ibuprofen and acetaminophen group. 
GI adverse events were mild including vomiting, moderate with abdominal pain and gastritis. Renal adverse events included acute or chronic renal failure.
GI and renal adverse events were not higher in infants younger than 6 months who are prescribed ibuprofen compared to those age 6-12 months.  Adverse events were increased in children younger than 6 months to her prescribed Motrin compared to acetaminophen alone.
Bottom line: Remain cautious about adverse GI and renal events in children age less than 6 months when using ibuprofen compared to acetaminophen.  However, there is no difference in adverse events when ibuprofen is used in children younger than 6 months compared with those older than 6 months.

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Category: Toxicology

Title: A Bad Natural "High"

Keywords: Anticholinergic, Plant (PubMed Search)

Posted: 9/20/2018 by Kathy Prybys, DO
Click here to contact Kathy Prybys, DO

Question

A 19 year old male presents confused and very agitated complaining of seeing things and stomach pain. His friends report he ingested a naturally occurring plant to get high a few hours ago but is having a "bad trip".  His physical exam :

Temp 100.3, HR 120, RR 14, BP 130/88. Pulse Ox 98%.

Skin: Dry, hot , flushed

HEENT: Marked mydriasis 6mm

Lungs: Clear

Heart: Tachycardic

Abdomen: Distended tender suprapubic with absent bowel sounds,

Neuro: Extremely agitated pacing, no muscular rigidity.

What has he ingested and what is the treatment?

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Sedating Mechanically Ventilated Patients

  • Providing appropriate analgesia and sedation to mechanically ventilated patients is of paramount importance.
  • In a recent systematic review and meta-analysis, Stephens et al. assessed the impact of deep sedation within the first 48 hours of initiation of mechanical ventilation.
  • In 9 studies that included over 4,500 patients, deep sedation within the first 48 hours of initiation of mechanical ventilation was associated with increased mortality, increased ICU LOS, and increased frequency of delirium.
  • Take Home Points
    • When possible, target lighter levels of sedation in mechanically ventiilated patients.
    • Though no universally accepted definition of light sedation exists, most studies use a RASS of -2 to +1

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Category: Pediatrics

Title: CDC Guideline on Mild Traumatic Brain Injury Among Children

Keywords: Concussion, minor head injury, traumatic brain injury, mTBI (PubMed Search)

Posted: 9/14/2018 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Takeaways

The Centers for Disease Control and Prevention recently released guidelines on the diagnosis and management of mild traumatic brain injury (mTBI**) among children. From 2005-2009, children made almost 3 million ED visits for mTBI. Based on a systemic review of the literature, the guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI.

Key Recommendations:

1. Do not routinely image patients to diagnose mTBI (utilize clinical decision rules to identify children at low risk and high risk for intracranial injury (ICI), e.g. PECARN)

2. Use validated, age-appropriate symptoms scales to diagnose mTBI

3. Assess evidence-based risk factors for prolonged recovery.  No single factor is strongly predictive of outcome.

4. Provide patients with instructions on return to activity customized with their symptoms (see CDC Resources below)

5.  Counsel patients to return gradually to non-sports activities after no more than 2-3 days of rest.

 

A wealth for information and tools for provder and families can be found at:

www.cdc.gov/HEADSUP (including evaluation forms and care plans for providers)

www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html

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Category: Toxicology

Title: Anaphylatoid reaction to IV N-acetylcysteine

Keywords: anaphylactoid reaction, IV NAC (PubMed Search)

Posted: 9/13/2018 by Hong Kim, MD, MPH (Emailed: 9/14/2018)
Click here to contact Hong Kim, MD, MPH

Analphylatoid reaction is caused by non-IgE mediated histamine released. Intravenous N-acetylcysteine (NAC) infusion is well known to cause analphylatoid reaction. However, it’s incidence is unknown.

Recently, a large retrospective study of all patients who received 21-hour IV NAC in 34 Canadian hospitals (1980 to 2005) was performed. 

Anaphylactoid reaction was documented in 528 (8.2%) of 6455 treatment courses

  • Cutaneous reaction (urticarial, pruritus and angioedema) occurred in 398 (75.4%)
  • Systemic reaction (respiratory symptoms or hypotension): 34 (6.4%)
  • Both reactions: 96 (18.2%)

Over 90% patients developed analphylatoid reaction within 5 hours.

Onset of reaction: 

  • 1stNAC dosing (150 mg/kg over 1 hour): 133/528
  • 2ndNAC dosing (50 mg/kg over 4 hours): 371/528
  • 3rdNAC dosing (100 mg/kg over 16 hours): 24/528

Administered medication for treatment

  • Antihistamine: 371
  • Beta-2 agonist: 15
  • Epinephrine: 10
  • Corticosteroids: 7

Patient characteristics that were associated with higher incidence of Anaphylactoid reaction includes

  • Female
  • Single acute ingestion
  • Low serum acetaminophen level.

 

Bottom line

  1. Anaphylactoid reaction to NAC is uncommon
  2. Cutaneous symptoms are most common
  3. Female, single acute ingestion and low serum acetaminophen levels are associated with incidence of anaphylactoid reaction. 

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Category: Critical Care

Title: Sodium Bicarbonate in Severe Metabolic Acidosis

Keywords: acidosis, acidemia, sodium bicarbonate, shock (PubMed Search)

Posted: 9/11/2018 by Kami Hu, MD
Click here to contact Kami Hu, MD

The recently published BICAR-ICU study looked at the use of bicarb in critically ill patients with severe metabolic acidemia...

  • Multicenter, open-label, RCT, 26 French ICUs
  • Adult patients with pH < 7.2 not secondary to hypercapnia, serum bicarb < 20 not due to bicarb wasting process 
  • SOFA score > 4 or lactate > 2
  • No bicarb versus 4.2% sodium bicarb infusion titrated to pH >7.3
  • Primary outcome: Composite measure of 28-mortality and presence of any organ failure at 7 days post-randomization
  • Secondary outcomes: Need for/length of life support measures (renal-replacement, vasopressors, mechanical ventilation), SOFA score after enrollment, electrolyte effects, occurrence of ICU-acquired infections, and ICU length of stay
  • Major findings:
    • No difference in primary outcome overall
    • No difference in pressor-free days, days off RRT, dialysis dependence at ICU discharge, ICU LOS
    • Bicarb group had less need for RRT during ICU stay (35 vs 52%, p=0.0009)
    • In patients with AKI and AKIN score 2-3*, the bicarbonate group had a decrease in both 28-day mortality (46 vs 63%, p=0.0166) and presence of any organ failure at day 7 (66 vs 82%, p=0.0142)
  • Limitations:
    • Unblinded
    • A quarter of the control group actually received bicarb
    • No data regarding vent settings, ABGs to r/o ventilation effects on pH
    • 4.2% is not a standard concentration of bicarb used in the U.S.

Bottom Line

Consider administration of sodium bicarbonate for your critically ill ED patients with severe metabolic acidosis and AKI, especially if acidosis &/or renal function is not improved with usual initial measures (such as IVF, etc).

 

 

*Acute Kidney Injury Network Staging Criteria

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Category: Orthopedics

Title: Froment's Sign

Keywords: Ulnar nerve (PubMed Search)

Posted: 9/9/2018 by Brian Corwell, MD (Updated: 10/19/2018)
Click here to contact Brian Corwell, MD

Froment’s Sign

Tests for motor weakness of the Ulnar nerve

Patient asked to hold piece of paper in both hands, grasping with the thumb and radial side of index finger of both hands

Examiner then pulls on the paper

Test is positive if patient flexes the thumb IP join in an attempt to hold onto paper

 

https://handlab.com/resources/wp-content/uploads/2014/04/June-2013-No25.jpg

 


Does Lactated Ringer's Raise Serum Lactate?

  • Intravenous fluid administration is a cornerstone of resuscitation and the treatment of many critically ill ED patients.
  • Recent publications have suggested that balanced crystalloid solutions may be better than 0.9% normal saline (NS) for select conditions.
  • Lactated Ringer's (LR) is a common balanced crystalloid solution often used for fluid resuscitation in critically ill patients.
  • AS LR contains approximately 28 mmol/L of sodium lactate, the question of whether LR elevates serum lacate is frequently asked.
  • In a recent small, randomized, double-blind, controlled trial, investigators randomized healthy volunteers to receive 30 ml/kg of either 0.9% NS or LR. The authors report no statistical difference in the mean serum lactate when comparing LR to 0.9% NS.

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Many elderly patients have thin skin making suture repair of lacerations difficult. Consider using Steri-Strips™ in combination with sutures to close fragile skin tears.

1. Apply Steri-Strips™ perpendicular to the wound in order to approximate skin edges.

2. Place sutures through both the applied Steri-Strips™ and skin and knot the suture.

This technique will help prevent the suture from tearing the skin as the tension of the suture will be distributed across the surface area of the Steri-Strips™.

 

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Takeaways

The Centers for Medicare and Medicaid Services (CMS) require broad spectrum antibiotics to be administered within 3 hours of presentation of sepsis to be in compliance with the sepsis measure. 

 

Not only do the antibiotics that are chosen determine compliance with this measure, but the order in which antibiotics are given can also significantly affect compliance. 

 

According to CMS, for combination antibiotic therapy, both antibiotics must be started within the three hours following presentation; however, they do not need to be completely infused within this time frame. 

 

Combination therapy typically includes a monotherapy antibiotic (see list in detailed information below) plus vancomycin (daptomycin or linezolid could also be used). 

 

So which antibiotic should be given first? 

 

If a monotherapy antibiotic is given first within the 3 hours of presentation, then compliance for the sepsis measure is met.  These antibiotics cover a broader range of bacteria and are typically infused over ~30 minutes, which allows plenty of time for your second antibiotic to be initiated.  

 

If vancomycin is given first, compliance with this measure can become difficult. First, vancomycin has a narrower spectrum of activity and is not a monotherapy antibiotic. Second, vancomycin infusion rates range from 1 to 2 hours.  Given that antibiotics are usually given after sepsis is flagged, this infusion rate only gives a short period of time for the second antibiotic to be initiated. Thus, vancomycin should almost always be the second antibiotic infused. 

 

In addition, patients may also have limited intravenous access or antibiotics may not be compatible with resuscitation fluids.  All of these factors together must be considered when trying to gain compliance with this measure. 

 

Take-Home Point: 

Administer monotherapy antibiotics (e.g. piperacillin/tazobactam and cefepimeprior to administering vancomycin in your septic patients to improve compliance with the sepsis measure. 

 
 

 

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  • Migraine diagnosis should only be made after other serious intracranial diagnoses have been ruled out.
  • Pediatric migraine is a difficult diagnosis to make before the age of 7 years, due to communication difficulties
  • Avoid opiates and barbiturates. They have not proven to be effective, and have been shown to decrease the effectiveness of future triptan treatments. 
  • First line treatment for mild to moderate migraines is acetaminophen and/or NSAID's.  The addition of caffeine, has been shown to potentiate the analgesic effects of both.
  • First line treatment for moderate to severe migraines is triptans.
  • Most pediatric migraines presenting to the ED, are severe migraines that have failed the above abortive home treatments and have persisted for 24+ hours.  These patients often require intravenous therapy.
  • Dopamine receptor antagonist, specifically Prochlorperazine, 0.15mg/kg, 10mg max, has demonstrated the greatest effectiveness. Consider administration with diphenhydramine, 1mg/kg, 50mg max to prevent dystonic reactions.
  • Concomitant dexamethasone, 0.6mg/kg, 20mg max administration has been shown to decrease acute recurrence.
  • If prochlorperazine fails, other alternatives include Sumatriptan, 5-20mg IN, 50-100mg PO and lidocaine, 0.5mL of 4% solution IN.
  • IVF hydration, and reduction of light and sound stimuli may be helpful.

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Category: Toxicology

Title: Muscle weakness

Keywords: Weakness (PubMed Search)

Posted: 8/2/2018 by Kathy Prybys, DO (Emailed: 8/31/2018) (Updated: 8/31/2018)
Click here to contact Kathy Prybys, DO

Takeaways

 A 68 year old male presents to the ED complaining of weakness to his legs. He states today his yard chores took him over 2 hours to complete instead of the usual 15-20 minutes due need to take frequent breaks for rest due to leg pain. He denied any chest pain or shortness of breath. Past medical history included hypercholesteremia, HTN,  and CAD. He is taking aspirin and recently started on rosuvastatin.

His physical exam was unremarkable.

Results showed normal EKG and CBC. Bun was 70, Creatinine was 3.4, and CPK of 1025.

This patient has statin induced rhabdomyolysis and acute renal failure.

Take Home Points:

  • Rhabdomyolysis is characterized by muscle necrosis which causes the release of myoglobin into the bloodstream.
  • Clinical manifestations can range from asymptomatic elevation of CPK to life-threatening cases with extremely high CPK levels, electrolyte imbalance, and acute renal failure.
  • Classic triad is: muscle aches and pains, weakness, and tea-colored urine.
  • Numerous recreational drugs, pharmaceuticals, and toxins can alter myocyte function. Ethanol, statins, and cocaine in particular have high risk to cause rhabdomyolysis.
  • 50% of cases of statin-induced-rhabdomyolysis were due to drug interactions.

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