Increased Myoglobin

[18G]

I had a patient that was involved in an MVC the other morning. Patient had some ETOH onboard and had no complaints in the fields. I noted some decreased (L) breath sounds but didn't think too much of it since the patient had absolutely no complaints, no chest wall markings, SpO2 was normal, no interior vehicle damage, no point tenderness noted when I palpated the chest, and also due to the noise level in the patient compartment of the ambulance which made it kinda difficult to hear. Pt. was stable in the field with PE pretty unremarkable.

A few hours later we get called to transport same 43 y/o male pt. to a trauma center for a (L) sided pneumothorax with a 40% involvement and rib fracture (7th) who had a chest tube and was getting a liter bolus of NSS with orders to follow with more fluid at 125mL/hr. Pt. was normtensive and had no issue with blood pressure. RN stated pt. had no urine output since time he arrived at the ED which was abotu 3-4hrs ago. The nursing staff never gives great reports during transfer of care on IFT.

While looking at the lab results I noted a increase in patients myoglobin level (295 I believe it was). I am familiar with increases in myoglobin as it presents with crush injuries, severe burns, or other injuries that result in a lot of tissue/muscle destruction. But this patient did not seem to fit that category.

Given the high myoglobin level and decreased urine output I knew there was concern for renal failure which was reason for the fluid administration.

What would have probably caused the increased myoglobin level in a patient such as described? Underlying muscle injury in the chest?

 

[Veneficus]

I had a patient that was involved in an MVC the other morning. Patient had some ETOH onboard and had no complaints in the fields. I noted some decreased (L) breath sounds but didn't think too much of it since the patient had absolutely no complaints, no chest wall markings, SpO2 was normal, no interior vehicle damage, no point tenderness noted when I palpated the chest, and also due to the noise level in the patient compartment of the ambulance which made it kinda difficult to hear. Pt. was stable in the field with PE pretty unremarkable.

A few hours later we get called to transport same 43 y/o male pt. to a trauma center for a (L) sided pneumothorax with a 40% involvement and rib fracture (7th) who had a chest tube and was getting a liter bolus of NSS with orders to follow with more fluid at 125mL/hr. Pt. was normtensive and had no issue with blood pressure. RN stated pt. had no urine output since time he arrived at the ED which was abotu 3-4hrs ago. The nursing staff never gives great reports during transfer of care on IFT.

While looking at the lab results I noted a increase in patients myoglobin level (295 I believe it was). I am familiar with increases in myoglobin as it presents with crush injuries, severe burns, or other injuries that result in a lot of tissue/muscle destruction. But this patient did not seem to fit that category.

Given the high myoglobin level and decreased urine output I knew there was concern for renal failure which was reason for the fluid administration.

What would have probably caused the increased myoglobin level in a patient such as described? Underlying muscle injury in the chest?

Firstly, don't worry about the pneumo, most pneumos show up over time so it probably wasn't significant enogh when you saw him to even show up on the best physical exam.

As for the myoglobin, there are all kinds of chronic disease processes that cause catabolic states which break down muscle. While diffuse blunt injury is very capable of producing enough myoglobin to shut down kidneys, I wouldn't rule out that he wasn't perfectly healthy before this. He also could have had deep focal injuries that could cause similar.

You mentioned his chest exam, but what about his abd.? Was he wearing a seatbelt? Was he assaulted prior to driving home?




I once saw a 56 year old who was stopped at a light and was rear ended by another car with a speed estimated by LE to be about 5-10 MPh. At the hospital the guy had no complaints, no obvious injuries and his CXR came back with a diaphragmatic herniation with his liver almost totally in his thorax. He got to go right to surgery.

 

[Aidey]

How long was he sitting in the car before someone called 911?

 

[18G]

The accident had happened just moments before the Truck from my station came up on it while responding to a fire call. Guy was not seat belted and was found down between the seat and the dash (not entrapped or confined) by the FD. When I got there he was sitting upright on the passenger side talking to First Responders. MVC happened during a snow storm.

Patient had no significant PMH and abd was benign on exam.

 

[mycrofft]

Maybe pre-extant?

http://en.wikipedia.org/wiki/Rhabdomyolysis
Severe and prolonged malnutrition especially with exertion, immobilization (crush from inability to redistribute pressure), and especially meth use. ETOH-ism..don't know. Statin drugs.

This was urine myoglobin??

 

[18G]

No, not urine as ED staff reported that pt. had no urine output during ED admission.

 

[J. Burdett]

Sounds interesting..... Maybe he had some meth or coke on board? Could've been hyperpyrexic induced rhabdo... Then again the ED probably would've caught that...

 

[usafmedic45]

High doses of ETOH and muscle trauma will both cause cause myoglobin release. It does not even have to be "tissue destruction" like a lot of people think of. A closed fracture of the thigh or tib/fib or even multiple rib fractures could easily spike the myoglobin. As someone else pointed out, one has to wonder how long this guy was down before you found him.

Maybe he had some meth or coke on board? Could've been hyperpyrexic induced rhabdo...

Hoof beats my dear newbie....

 

[rhan101277]

I once saw a 56 year old who was stopped at a light and was rear ended by another car with a speed estimated by LE to be about 5-10 MPh. At the hospital the guy had no complaints, no obvious injuries and his CXR came back with a diaphragmatic herniation with his liver almost totally in his thorax. He got to go right to surgery.

I brought in a 18 y/o pt in a minor MVC, middle rear passenger. Speed was enough to damage bumper and shatter brake lights. No intrusion, all windows intact. All 3 pt in backseat had cervical collar.

She complained of LLQ and LUQ abdominal pain, she was tachycardic but normotensive. I figure she could be anxious but I started an IV w/ 500cc NS TKO. Got to ER and Dr was going to do a vertical x ray or something, just enough to get a side view of the c-spine and thorax I guess. They didn't do a bedside ultrasound or anything.

I know it is probably a minor seat belt injury but he was talking with another doctor who was asking about he might try this/that (a house officer). He said it was ok but he didn't want to get into a serial imaging goose chase.