Exam 5 Musculoskeletal

Lachman test

• Tests ACL

• Place the knee in 15 degree flexion and external rotation and grasp distal femur on the lateral side with one hand, the proximal tibia on the medial side with the other hand, and with the thumb of the tibial hand on the joint line, simultaneously pull the tibia forward and the femur back. Estimate the degree of forward excursion.

McMurray Test

• tests medial and lateral meniscus

• supine, grasp the heel and flex the knee, cup the other hand over the knee joint with your fingers and thumb along the medial joint line.

• From the heel, externally rotate the lower leg, then push on the lateral side to apply a valgus stress on the medial side of the joint; at the same time, slowly extend the lower leg in external rotation.

• The same maneuver with the internal rotation of the foot stresses lateral meniscus.

• If a click is felt or heard at the joint line during flexion and extension of the knee, or if the tenderness is noted along the joint line, you need to further assess the meniscus for a posterior tear.

Anterior drawer test

• tests ACL

• supine, hips flexed and knees flexed to 90 degrees and feet flat on the table

• cup your hands around the knee with your thumbs on the medial and lateral joint line and the fingers on the medial and lateral insertions of the hamstrings.

• Draw the tibia forward and observe if it slides forward like a drawer from under the femur.

• Compare the degree of forward movement with that of the opposite knee

Posterior drawer test

• tests PCL

• Position the patient and place your hand in the positions described for the anterior drawer test and push the tibia posteriorly and observe the degree of backward movement of the femur

Valgus knee

• tests MCL

• Abduction

• supine and the knees slightly flexed, move the thigh about 30 degrees laterally to the side of the table.

• Place one hand against the lateral knee to stabilize the femur and the other hand around the medial ankle.

• Push medially against the knee and pull laterally at the ankle to open the knee joint on the medial side.   

Varus knee

• tests LCL

• With the thigh and knee in the same position of the valgus knee test, change your position so you can place one hand against the medial surface of the knee and the other around the lateral ankle. Push laterally against the knee and medially at the ankle to open the knee joint on the lateral side.

Straight leg test

• Tests for lumbosacral radiculopathy and sciatica

• if the patient has low back pain that radiates down the thigh and leg (sciatica), test the straight leg raising on both sides in turn.

• supine position, raise the pt’s relaxed straightened leg, flexing the thigh at the hip.

• Some examiners first raise the leg with the knee flexed, then straighten the leg.

• Positive test is pain radiating into the ipsilateral (same) leg.

Tinel sign

• carpal tunnel syndrome

• Tests by tapping lightly over the course of the median nerve in the carpal tunnel

• + is aching and numbness in the median nerve distribution

Phalen sign

• carpel tunnel syndrome test

• compression of median nerve

• Ask the patient to hold the wrists in flexion for 60 seconds with the elbows fully extended

• Alternatively, you can ask the patient to press the back of the hands together to form right angles

• Numbness and tingling in the median nerve distribution within 60 seconds is +

Durkan test

• carpal tunnel syndrome test

• Direct, continual pressure over the patient’s carpal tunnel for 30 seconds elicits symptoms.

Hueston test

• tests for Dupuytren’s contractures

• Place hand and fingers prone on the table top

• + if hand is unable to lay flat

Thompson test

• achilles tendon rupture

• Have the patient prone and you squeeze the calf of the affected leg.

• + if there is no plantar flexion of foot

S/S cervical spinal stenosis

• Chronic neck pain

• Unilateral or bilateral upper limb pain often radiating

• Numbness of the hands

• Arm or hand clumsiness

• Loss of hand dexterity

• Progressive loss of fine motor function of the hands

• Weakness of the upper extremities and proximal lower extremities

• Decrease sensations of the arms or hands

• Gait disturbances or hyperreflexia

S/S lumbar spinal stenosis

• s/s are caused by direct mechanical compression or indirect vascular compression of the nerve roots or the cauda equina

• Neurogenic claudication

  • leg, back, or buttock pain precipitated by walking and relieved by sitting

• Pain may radiate down to the ankles and is associated with numbness, tingling and weakness.

• Taking a flexed posture reduces symptoms because it increases available space in the lumbar spinal canal.

• Decreased lumbar extension

• + Romberg sign

• Normal peripheral pulses

• Decreased proprioception

• A wide-based gait

• Reduced knee and ankle reflex

• Urinary incontinence

Rheumatoid arthritis (RA) S/S initial presentation

• initial presentation: Pain, swelling, warmth in one or more peripheral joints, frequently symmetric small joint involvement. Often associated with greater than one hour morning stiffness and constitutional symptoms such as fatigue, malaise, low grade fever, and weight loss occurring over periods of weeks to months

RA chronic, longstanding disease S/S

• May have swan neck deformity

• boutonniere and z thumb deformities

• ulnar deviation and subluxation of the MCP joints

• radial deviations of the wrist

RA extraarticular manifesations

• Sjogren’s syndrome

• rheumatoid nodules

• felty syndrome

• pulmonary disease

• neuromuscular disease

• cardiac disease

• ocular disease

• amyloidosis

• osteoporosis

RA initial lab tests

• Positive rheumatoid factor

• Anti CCP antibodies

• elevated sed rate and CRP

• CBC may have anemia of chronic disease

• Hypoalbuminemia

• Hypergammaglobulinemia

• ANA present in 20-30% of patients

• Inflammatory synovial fluid with > 2,000 PMNs polymorphonuclear neutrophils

RA diagnostic lab results

• Increased CRP

• + rheumatoid factor

• + ACPA

• Anemia

• Thrombocytosis

characteristic findings of RA of XR

• conventional radiography

  • Will show soft tissue swelling

  • symmetric joint space narrowing

  • periarticular erosions and deformities

  • periarticular osteopenia

Tx of RA pharmacologic ACUTE

• Early aggressive treatment with DMARDs (disease-modifying antirheumatic drugs) and/or biologics is associated with decreased progression of synovitis and bone erosions and decreased disability.

• Goal of therapy is to treat to a target of low disease activity or remission.

• Acute, general treatment: NSAIDs to control mild pain and mild inflammation (not disease modifying). Corticosteroids rapidly reduce inflammation until a DMARD can go into effect. Use lowest dose possible for the shortest duration of time.

Tx of RA pharmacologic CHRONIC

• DMARDs, nonbiologic

• Methotrexate is the first drug of choice

• hydroxychloroquine, sulfasalazine, leflunomide

  • Associated with toxicity, so close monitoring is required and generally require greater than 8 weeks to start taking effect

• DMARDs, biologic: Target cytokines and cells involved in the rheumatoid arthritis inflammatory response

  • Major side effects of a biologic are increased risk of infection and potential reactivation of tuberculosis

Non-pharmacologic tx of RA

• Educating the patient

• psychosocial intervention

• physical activity and exercise

• PT and OT

• proper nutrition

• diet

OA S/S

• pain generally with activity, stiffness, or gelling; Stiffness and gelling are usually short-lived and morning stiffness lasts less than 30 min.

• crepitus with motion

• Loss of function in joints

• Joint tenderness, swelling

• Bouchard and Heberden nodes

OA findings on XR

• plain xrays show:

  • joint space narrowing

  • subchondral sclerosis

  • new bone formation (osteophytes)

  • presence of cyst formation

OA nodes and where they are usually located

• Bouchard nodes: Usually in the middle joints of the fingers - proximal (PIP)

• Heberdens nodes: Joint closest to the tip of the finger - distal (DIP)

Management of OA

• Nonpharmacologic: Exercise, weight loss, pedometer steps count > 10,000 steps per day, and PT

• Pharmacologic: Acetaminophen, NSAIDs, topical diclofenac (reasonable choice for knee osteoarthritis), duloxetine, tramadol for severe pain unresponsive to other modalities, intraarticular steroid injections.

• Surgical management: Total joint replacement

Gout S/S

• abrupt and rapid eruption of pain, swelling, and erythema of a distal joint and/or periarticular soft tissue.

• Attacks often come on at night or early morning

• Metatarsal phalangeal joint (big toe) is the first affected in 50% of cases

• Other commonly affected joints are the ankles, heels, knees, wrists, and hands.

• The joint would be red, hot, swollen, and exquisitely tender.

Gout findings on XR

• early disease: no abnormal findings

• late disease: Associated with punched-out marginal erosions and over-hanging edges.

Diagnostic test with greatest value and what is expected

• presumptive diagnosis should be made with arthrocentesis with synovial fluid examination which will be cloudy with elevated WBCs and urate crystals may be present.

• uric acid may or may not be elevated at the time, but they were at some point.

• CBC will show leukocytosis & increased sed rate & CRP

Tx of gout

• acute and chronic treatment: NSAIDs, such as indomethacin, ibuprofen, naproxen, celecoxib (Celebrex), low-dose colchicine, intraarticular corticosteroid injection, or systemic corticosteroid therapy.

• treat hyperuricemia

  • Nonpharm therapy: D/C diuretic therapy and diet modification

    • however - rarely effective without urate-lowering therapy

  • Allopurinol: reevaluate serum uric acid after 4-6 weeks of starting

    • Goal uric acid: < 6

  • Febuoxidate

    • more potent than allopurinol

    • used if pt is allergic to allopurinol

  • Probenacid

    • Urico uric agent that can be used in pts with good renal function, but poor compliance d/t taking > 1x/day

low purine diet for gout

• decreased red meat, kidney, liver, yeast extract.

• Decreased shellfish, protein

• restrict alcohol intake.

septic arthritis s/s

• Hallmark: Acute onset of monoarticular joint pain, erythema, heat, and immobility

• Limited ROM of the joint & effusion with varying degrees of erythema & increased warmth around the joint.

• Single joint is affected in 89-90% of non-gonoccal arthritis.

Dx for septic arthritis

• Joint fluid analysis—most sensitive

  • leukocyte count of > 50,000 with > 80% PMNs

• Blood cultures are + in 35-50% of patients

• Serum

  • Increased WBC

  • increased sed rate

  • increased CRP

R/F septic arthritis

• age > 80

• Diabetes

• Total joint replacement

• Recent joint surgery

• Skin infection

• Recent intraarticular injection

• HIV

• IV drug use

• End stage renal disease

• Advanced hepatic disease

Pharmacologic management of septic arthritis

• aspirate the affected joint daily to remove necrotic material and also follow the WBC and C&S.

• ROM, exercise after the acute stage of inflammation.

• IV abx after joint aspiration gram stain

  • MSSA: Nafcillin, cefazolin

  • MRSA: Vancomycin with trough levels at 15-20

    • alternatives:daptomycin and linezolid

Cervical spine

• neck pain: patient presentation

• Especially with extension, limited ROM, referred unilateral interscapular pain

c-spine management

• Rest

• Soft or hard cervical collar for short period

• Heat or ice

• PT

• Avoid extreme ROM exercises in degenerative disk disease

• NSAIDs or oral steroids

• Muscle relaxants

• Analgesics

• Epidural steroid injection for radicular pain

• Chronic cervical spine problems: Acute modalities and nonoperative therapies fail after 6-12 weeks, or when there is evidence of functional neurologic deficits → Send that patient to surgical consult and also consider a nerve ablation for chronic pain in nonsurgical candidates.

Phases of frozen shoulder (adhesive capsulitis)

• Phase 1: Painful freezing phase—Gradual onset of severe pain that is usually worse at night and difficulty lying on the affected shoulder; Pain may last from 1 week to 10 months and there is minimal loss of motion.

• Phase 2: Frozen or intermediate phase—Characterized by shoulder stiffness and limited range of motion that may last up to 1 year. Pain usually improves and is often only present in terminal range of motion and at night. There is variable loss in the degrees of active and passive glenohumeral abduction and external rotation.

• Phase 3: Thawing or recovering—Gradual improvement of pain and increase in ROM lasting from 1-3 years. Long term ROM restrictions are possible.

Management of adhesive capsulitis

• Self-limiting

• 18-24 months to resolve without treatment

• PT with passive ROM and capsular stretching

• Intraarticular corticosteroid and lidocaine injection, which is most effective if done early.

• Late, without results from conservative treatment: shoulder manipulation under anesthesia or arthroscopic scapular release

XR finding on pt with repeated shoulder dislocations

• Hill-Sacks deformity: A groove in the posterolateral aspect of the humeral head and it may be seen in the prereduction or post reduction films.

  • caused by impaction of the humeral head against the glenoid rim after dislocation.

management of shoulder dislocation

• reduction using gradual, gentle application of pressure regardless of technique.

• Use intraarticular injection of lidocaine for pain reduction.

• Can use Stimpson maneuver where no assistant is required.

• Can also use scapular manipulation technique, or best of both

posterior shoulder dislocation

• Arm will be held in the sling position with adduction and internal rotation.

• Attempts at abduction and external rotation cause extreme pain.

anterior shoulder dislocation

• Shoulder is most common dislocation seen in the ED.

• Usually and anterior vs. posterior dislocation.

• Signs of anterior dislocation: Patient supports the injured extremity and leans to injured side while holding the arm in abduction and slight internal rotation. Shoulder looks rounded so compare sides.

Carpal tunnel syndrome (CTS) presentation, clinical tests, and management

• carpal tunnel is median nerve as it passes under the transverse carpal ligament at the level of the wrist.

• Pain and paresthesia in the volar or palmar aspect of thumb, index finger, middle finger, and radial half of the ring finger.

• Worse at night with awakenings from sleep being common.

• May have thenar atrophy in longstanding cases.

• Assess with Tinel, Phalen, and Durkan tests.

• Management: Use wrist braces or surgery for carpal tunnel release.

Dupuytrens contracture S/S, etiology

• isolated painless palmar nodules that eventually harden and progress into a cord that extends into the finger. As the cord enlarges it also contract, creating a flexion deformity usually seen at the metacarpal phalangeal or proximal phalangeal joints.

• Etiology is unknown but may have some genetic disposition and may also be immune-mediated.

Dupuytrens contracture management

• mild disease: Avoid repetitive movements, use padded gloves, PT

• moderate disease: Intralesional corticosteroid injection, percutaneous needle aponeurotomy, enzymatic fasciotomy by clostridium histolyticum collagenase injection for early, less severe cases.

• severe disease: surgery when the metacarpal phalangeal contracture > 30 degrees, the PIP > 20 degrees, or the Huesten test is +, or there is neurovascular damage to the finger.

Low back pain red flags

• major trauma

• minor trauma in elderly patient

• age < 20 or > 50

• History of signs of malignancy such as night pain, weight loss

• Recent fevers or chills

• History of drug use

• Immunocompromise

• Saddle anesthesia

• Urinary or bowel incontinence

• Progressive neurologic deficits

• Unrelenting pain

emergent diff dx of acute low back pain

• dissecting thoracic aneurysm

• Ruptured AAA

• Aortic dissection

• spinal infection

• Tumors

• Cauda equina syndrome

• Transverse myelitis

• Disk herniation causing neurologic impingement

clinical exam techniques - low back pain

• straight leg raise

• Reflexes

• Motor mobility

• Sensory and pain perception

management of back pain (without red flags)

• Mild moderate acute pain: NSAIDs, lidocaine patches, muscle relaxants in the short-term

• severe back pain: Nonopioid analgesics, second line: use opioids with caution; may need a parenteral dose of opioid in the ED and be put on oral NSAIDs/nonopioid analgesics; Limit quantity of opioids if prescribed

• chronic back pain: NSAIDs, Duloxetine, opioids are just as an adjunctive treatment, epidural glucocorticoid injections, heat, massage, acupuncture, yoga, and mindfulness; Avoid complete bed rest and try to remain active.

clinical findings in cauda equina syndrome

• low back pain

• Weakness in the bilateral lower extremities

• Saddle anesthesia

• Loss of voluntary bladder and/or bowel control often presenting as bladder retention and/or bowel incontinence.

Imaging in pts with low back pain

• nonspecific mechanical back pain: try conservative therapy before imaging.

• pts with red flags: Plain radiography or MRI if there is a high suspicion.

• pts with neuro s/s: MRI with urgent surgical consult.

• pts with radiculopathy, w/o serious or progressive neuro deficits: Plain radiography

• Spinal stenosis: MRI

sciatica s/s

• unilateral leg pain worse than low back pain

• pain radiating to foot or toes

• Numbness and paresthesia in the same distribution

• Straight leg raise induces more leg pain

• localized neuropathy emitted to one nerve root

• Most common cause is disk herniation from age-related changes

sciatica management

• Exercise minimally reduces the intensity of pain; individualized pain and ability to exercise must be considered

• Bed rest is not recommended

• PT and exercise therapy

• manual therapy with spinal immobilization

• ice or heat on the affected area for 20 minutes q2h & reducing pressure on the nerve root.

• there is no real definitive pharmacological treatment.

• May use acetaminophen, but other pharmacologic are not proven to work.

DDD s/s

• low back pain often worsened with coughing, activity, or sneezing.

• local lumbar lumbosacral tenderness.

• paresthesia, usually unilateral in the affected nerve’s distribution

• restricted low back motion.

• increased bending toward the affected side or flexion.

• Weakness and reflex changes.

• Positive straight leg raising if nerve root compression present.

DDD management

• Short course (3-5 days) limited physical activity for acute disk herniation with leg pain.

• Physical therapy

• percutaneous electrical nerve stimulation may be beneficial with chronic pain.

• Acupuncture is modestly effective

• NSAIDs

• Evidence suggests muscle relaxants are not effective

• analgesics only offer modest benefits

• Injection therapy for low back pain has limited clinical benefit

• surgery - considered if s/s do not improve w/ conservative management

Management of pt post-ORIF hip fx

• DVT Prophylaxis

• Pain management—remember that opioids have a high incidence of delirium and constipation

• With a preop iliac fascia compartment block, prophylactic antibiotic for 24 hours postop and rehab on the first day.

Hip dislocation s/s and management

• posterior hip dislocation (most common)—Shortened, internally rotated and adducted leg.

• anterior hip dislocation—Shortened, abducted, flexed at the hip, and externally rotated.

• Management: Reduction; Stimpson technique is the least traumatic, however, it may pose risk to the patient because the patient has to be prone.

Knee: ACL, PCL tear

• Patient will often hear an audible pop in the knee followed by severe pain and swelling

• Management:

  • Nonsurgical in older adults who do not participate in sports with activity modifications and NSAIDs.

  • PT for strengthening.

  • Surgery in younger patients w/ ACL reconstruction

• PCL tears: Rare

Knee: Meniscal tears

• May have pain and locking of the knee, swelling.

• Management

  • PT

  • NSAIDs

  • rest

  • arthroscopy with meniscectomy or a meniscus repair—mostly done in young adults.

Ottawa ankle rules

• point tenderness about the inferior posterior aspect of either malleolus to include the distal 6 cm of the lateral malleolus and/or inability to bear weight at the time of injury or clinical evaluation (4 independent steps).

ankle sprain presentation, tests, and management

• swelling

• ecchymosis

• tenderness to palpation should be assessed over the medial and lateral malleoli as well as the ligamentous structures around the ankle.

• Anterior drawer test to test the integrity of the interior tallow-fibular ligament.

• Manual squeeze test: The examiner compresses the tibia and fibula toward each other at the middle third of the anterior leg. Pain distally equals injury to the syndesmosis.

• Talar tilt test: tests the integrity of the anterior tallow-fibular ligament and the calcaneal-fibular ligament.

• Management: PRICE (Protection, Rest, Ice, Compression, Elevation); NSAIDs, exercise in 4-5 days.

Ankle sprain classification

• Grade 1: Sprain of the anterior of the tallow-fibular ligament, which include mild swelling and tenderness without joint instability.

• Grade 2: Anterior tallow-fibular ligament tear and a CFL calcaneofibular ligament sprain, which includes moderate swelling and tenderness, laxity with positive anterior drawer test.

• Grade 3: ATFL tear and CFL tear with severe swelling and tenderness, instability with an anterior drawer test and talar tilt test, and inability to bear weight.

Achilles tendon s/s, diagnostics, management

• PE: palpable defect in the distal third of the Achilles tendon; may have pain, ecchymosis, and edema; decreased plantar flexion against resistance (Thompson test).

• first test to do: Ultrasound

• Initial management: RICE with splint

• Nonop management: immobilization x 2 weeks, followed by the gradual advancement of weight bearing with a walking boot with heel wedges to prevent significant dorsiflexion, and PT

• Surgical: Ideally done within 7-14 days of injury; Want to reestablish the appropriate tendon length and ankle plantar flexion; PT

Scaphoid fx presentation, XR, management

• Break in the small bone in the wrist, with a fall on the outstretched hand.

• s/s: pain and tenderness in the area just below the base of the thumb, pressing over the anatomic snuff box puts pressure on the scaphoid bone.

• Positive pain—assume scaphoid fracture even if not shown on the Xray.

• Management: Thumb spica splint.

Initial management of open fx

• emergent orthopedic referral for irrigation, debridement

• treatment with antibiotics

• tetanus prophylaxis.

Splints

• thumb spica

• Know the indication for different splints based on fracture/condition (i.e., ulnar gutter, radial gutter, thumb spica, sugar tong, etc)

• Discharge instructions to a patient with a splint or cast

Suturing lip wounds

• thorough irrigation before suturing.

• Use 5-0 chromic

• In order to prevent a misaligned vermilion border, you want to put the first stitch at the vermilion cutaneous border.

Which side of a wound should be sutured first?

• Furthest from the NP

  • i.e., if right handed, suture right side first (furthest away and towards you)

• First suture for simple interrupted should be in the middle of the wound

technique to performing & necessary psi to irrigate a wound to remove bacteria & debris (and what is too much)

• wound irrigation is best achieved with large volume syringe (35 or 65 mL syringe) with an 18g or 19g catheter or needle to deliver irrigation volumes of at least 250 mL.

• Care must be taken to ensure that any method of irrigation is not exerting too much pressure

• Tissue damage can occur at 70 PSI

• Irrigation should continue until all visible loose particulate matter has been removed.

indications of layered closures (what and what not to suture)

• suture 3 basic layers

  • Fascia

  • Subcutaneous tissue

  • Skin

• closure of each individual layer obliterates the dead space which can fill with blood or exudate which can develop infection.

indications for staple wound closure

• linear laceration with straight sharp edges located on an extremity, the scalp, or trunk.

wounds that should be closed vs not closed

• Clinician should estimate the risk of infection prior to wound closure.

• if a wound is judged to be cleaned or rendered clean by scrubbing, irrigation, and debridement, the wound may be closed.

• if the wound remains contaminated despite the best of efforts, it should be left open to heal by secondary intention.

• if the status of the wound is uncertain, delayed primary closure is an option that should be considered.

Compartment syndrome

• Leg is most often affected, most often after a fracture.

• Dx: Direct intracompartmental pressure measurement.

  • confirmed when the difference between diastolic pressure and compartment pressure is < 30 mm/Hg.

• Fasciotomy is needed if:

  • absolute compartment pressure is > 30mmHg, or when the delta pressure (diastolic blood pressure minus compartment pressure) is < 30 mmHg

• peak interval between injury & onset of compartment syndrome: 15-30 hours

Compartment syndrome management

• Fasciotomy: Reduce the intracompartmental pressure and prevent tissue ischemia and necrosis.

• give analgesics

• Remove all dressing and casts

• Elevate the extremity to just above the level of the heart.

• Standard of care is emergency fasciotomy and debridement of nonviable tissue.

• definitive closure of the soft tissue envelope should be completed within about 7 days of the fasciotomy.

Arthrocentesis indications vs contraindications

• indications

  • dx of septic or crystal-induced arthritis

  • dx of a traumatic bony or ligamentous injury

  • installation of meds for acute or chronic arthritis.

  • relief of pain from hemi arthrosis

  • Determination of communication between a laceration and joint space.

• Contraindications (absolute and relative)

  • Absolute: Overlying cellulitis

  • Relative: Bleeding diaphysis

Bursitis tx and management

• swelling and redness of the affected joint with pain

• Management

  • NSAIDs

  • rest

  • avoidance of direct pressure or irritation of the bursitis and bursa

  • Local injection management is lidocaine and corticosteroid injection, but not more than 1 every 3 months

Olecranon bursitis presentation

oval swelling at the tip of the elbow, but it does not effect joint motion.

Epicondylitis RF

• repetitive lifting, playing tennis, hammering, playing golf.

• Can have medial or lateral epicondylitis

Rhabdo S/S

• Classic triad of symptoms

  • Muscle pain

  • weakness

  • dark urine from myoglobinuria

• Muscle tenderness is present in half of the cases

• Muscle swelling occurs after IV fluid repletion

• Muscular rigidity

• Fever

• Secondary to long-term statin administration: fatigue is nearly as common as muscle pain

• Oliguria or anuria with AKI

Rhabdomyolysis labs

• CK 5-10 x the ULN and typically peaks 24-72 hours after the initial insult

  • Levels > 15k are more likely associated with AKI. However, in patients with concomitant risk factors such as hypokalemia or volume depletion, CK levels as low as 5,000 may be associated with AKI.

• Myoglobin filtration into the urine produces a port wine color at concentration of 100-300 mg/dL.

• Assess K+, Ca2+, phosphorous, and uric acid

  • all of these are released from damaged muscle and may be elevated

Rhabdo management

• Aggressive fluid resuscitation with NS 200-1000 mL/hr to get UOP ≥ 200 mL/hr

• May need mannitol to enhance urine flow rates

• Correct electrolyte imbalances.

• May need CRRT.

• Identify the precipitating factor and D/C the toxin or drug if necessary.

• Maintain volume repletion until myoglobinuria stops or the plasma CK level decreases to less than 5,000 units/L.