Rhabdomyolysis following spinal cord injury: case report

Rhabdomyolysis in Acute Spinal Cord Injury Presenting With Nausea and Vomiting as Chief Complaints: A Case Report

Dealing with complications is crucial in the management of patients with spinal cord injury (SCI). We describe a case of rhabdomyolysis in SCI without apparent soft tissue injury, presenting with nausea and vomiting as chief complaints. Given that gastrointestinal discomfort is common in SCI, this case highlights the need to consider rhabdomyolysis as a potential cause of unexplained nausea and vomiting in SCI, and indicate the value of regular check-up of creatine kinase level in SCI patients. Early diagnosis and treatment can prevent acute renal failure that can occur with rhabdomyolysis and minimize the potential threat of declined renal function in SCI patients.

Rhabdomyolysis caused by a potential sitagliptin-lovastatin interaction

A 75-year-old woman with diabetes mellitus, hypertension, and hyperlipidemia came to the emergency department with generalized and upper-extremity weakness; she had experienced a fall 2 months earlier. On admission, her drug therapy included lovastatin 40 mg/day, controlled-release diltiazem 240 mg/day, and glimepiride 1 mg/day. Nineteen days earlier, sitagliptin 100 mg/day had been started; it was discontinued 2 weeks later, and glimepiride was begun. A cardiology consultation performed on the day of admission determined that a markedly elevated creatine kinase-myocardial band isoenzyme level and borderline-high troponin I level were diagnostic of rhabdomyolysis secondary to statin use. Because the patient had been taking lovastatin for the past 12 years, the possibility that the rhabdomyolysis may have been caused by a drug interaction between lovastatin and a concomitant drug was evaluated. As it had been 10 months since her last dosage adjustment of diltiazem, it was unlikely that the statin-induced rhabdomyolysis was precipitated by diltiazem. Use of the Drug Interaction Probability Scale to determine the strength of a lovastatin-sitagliptin interaction indicated a possible association (score of 4). Multiple drug interactions have been reported with lovastatin. To our knowledge, however, this is the first case report of a possible sitagliptin-lovastatin interaction that may have caused rhabdomyolysis. Studies must be performed to further evaluate the in vivo effect of sitagliptin on the cytochrome P450 3A4 enzyme system and to elucidate other mechanisms that may potentiate such a drug-drug interaction. In the meantime, however, clinicians should be aware of this possible drug interaction.

Recovery from a psychotropic drug overdose tends to depend on the time from ingestion to arrival, the Glasgow Coma Scale, and a sign of circulatory insufficiency on arrival

PURPOSE

The aim of this study was to investigate which factors on arrival correlate with the duration of unconsciousness induced by a psychotropic drug overdose.

BASIC PROCEDURE

Patients were 175 consecutive intubated patients unconscious due to psychotropic drug overdose. They were divided into 2 groups, an "early" group in which the patients were extubated within 2 days from hospitalization, and a "delayed" group who were not extubated within 2 days.

MAIN FINDINGS

Glasgow Coma Scale (P = .001) scores in the early group were higher than those in the delayed group. The estimated time from ingestion to admission (P < .0001), creatine kinase level (P < .01), number of cases demonstrating shock (P < .05), shock index (P < .0001), and heart rate (P = .001) in the early group were smaller than those in the delayed group. Two subjects in the delayed group died of pneumonia and pulmonary embolism.

PRINCIPAL CONCLUSIONS

Delayed arrival from ingestion, a low level of unconsciousness, and a sign of circulatory insufficiency in a patient with a psychotropic drug overdose were risk factors of a delayed recovery and death.

Continuous renal replacement therapy in patients following traumatic injury

In critically injured patients, the incidence of acute renal failure has been reported to occur in as many as 31% of patients. The use of CRRT modalities for patients following traumatic injuries is becoming more common, albeit slowly, and this therapy may impact upon long-term recovery of renal function and mortality. Historical studies investigating the early use of intermittent dialysis reported significant improvement in survival in patients who were dialyzed earlier and more vigorously than in control subjects. Early trauma patients also showed improved survival following war injuries when dialyzed prophylactically. Although there is a growing acceptance in favor of earlier renal replacement therapy, the published consensus and the practice in many centers has been to dialyze/filter relatively ill rather than relatively healthy patients. The R Adams Cowley Shock Trauma Center (STC) in Baltimore, Maryland, USA, admits over 8,000 trauma patients each year. Within the STC, a program of continuous renal replacement therapy was established in the early 1980's. We review both historical and current literature on the use of renal replacement therapies after traumatic injury, and suggest some future areas of investigation and indications for these modalities.