Ashley AdamsPosted Date:November 30, 2020 11:25 AMStatus:Published
The patient in this scenario is displaying the clinical manifestations of rhabdomyolysis, which is the breakdown of muscle from various causes which leads to the shift of intracellular components into vascular and extracellular compartments(McCance & Huether, 2018). Clinical signs include pain, weakness, and tea-colored urine (myoglobinuria) along with elevated serum K+ and creatine kinase (CK) levels (Hocagil et al., 2019). While the roommate in the scenario does not know how long the patient was in the unresponsive state, lack of oxygen and energy to the muscle tissue in a dependent state can rapidly lead to ischemia and necrosis (Hocagil et al., 2019).
At the cellular level, anoxia leads to the cessation of aerobic metabolism and reduced generation of ATP, ultimately causing the failure of the NA+-K+ pump (McCance & Huether, 2018). Na+ accumulates in the ICF while K+ accumulates in the ECF, causing the cell to swell and damaging the cell membrane, while increased calcium in the ICF leads to further cell damage (McCance & Huether, 2018). If oxygenation is not restored quickly, cell death will occur (McCance & Huether, 2018).
The patient is presenting with the symptoms of hyperkalemia, marked by the elevated serum K+ levels and EKG abnormalities. Common EKG alterations in hyperkalemia are prolonged PR intervals, wide QRS complexes, and ST segment depression (Roberts, 2020). Left uncorrected, severe dysrhythmias may occur up to and including ventricular fibrillation and cardiac arrest (McCance & Huether, 2018).
While much more specific research is needed, early studies are pointing to a correlation between genetics and substance abuse or addiction disorders (Hancock et al., 2018). Several replicable genomic variables have been identified among individuals with various addictive disorders that could lead to early and targeted prevention measures (Hancock et al., 2018).
In this scenario, different patient demographics could lead to different causes of rhabdomyolysis. In addition to tissue ischemia, rhabdomyolisis can result from the ingestion of certain drugs and toxins, trauma such as a crush injury, physical overexertion, infections, and metabolic imbalances (McCance & Huether, 2018).
Hancock, D. B., Markunas, C. A., Bierut, L. J., & Johnson, E. O. (2018). Human genetics of addiction: New insights and future directions. Current Psychiatry Reports, 20(2). https://doi.org/10.1007/s11920-018-0873-3
Hocagil, H., İzci, F., Hocagil, A., Tatli, M., Sözen, S., & Akkaya hocagil, T. (2019). Detection of rhabdomyolysis in patients admitted to emergency department due to drug overdose as a suicide attempt: A propective original clinical study. Turkiye Klinikleri Journal of Medical Sciences, 39(3), 237–244. https://doi.org/10.5336/medsci.2018-64073
McCance, K. L., & Huether, S. E. (2018). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Mosby.
Roberts, D. M. (2020). Metabolic complications of poisoning. Medicine, 48(3), 169–172. https://doi.org/10.1016/j.mpmed.2019.12.005
Sara AndrewsPosted Date:November 30, 2020 6:27 PMStatus:Published
At first glance, the necrosis discovered in the patient’s greater trochanteric area and forearm could be attributed to his unconscious state and prolonged pressure to bony prominences with resulting rhabdomyolysis. However, the case scenario does not indicate the amount of time the patient was lying unconscious on the floor. Opioid overdose is suspected given the patient regained consciousness after administration of the opiate receptor antagonist naloxone (Schiller &Goyal, 2020). Within 3-5 minutes, opioid overdose results in hypoxia and death (Schiller & Goyal, 2020), therefore increasing the probability that necrosis was present prior to the overdose ( as a result of tissue damage related to drug abuse) and not the result of an extended period of unconsciousness, rhabdomyolysis, or pressure on bony prominences.
Musculoskeletal and vascular injury are the most common complications of toxicity related to opioid abuse (Delaney, Stanley & Bolster, 2020); specifically, necrotizing fasciitis related to soft tissue injury from needle puncture to the vessel wall or infection (Delaney, Stanley & Bolster, 2020). Further, studies show that opioid abuse results in damage to microvasculature structures resulting in decreased blood flow and ischemic death to tissues and bone (Wu, Song, Ni, & Dai, 2015).
Hyperkalemia is defined as potassium levels greater than 5.0 (McCance & Heuther, 2019). The patient in the case scenario presented to the ED with a serum potassium level of 6.5. Hyperkalemia is common in trauma since tissue damage caused by ischemic muscle cells release intracellular potassium to extracellular space (Wu, Song, Ni, & Dai, 2015). When extracellular potassium ratios exceed intracellular, the cell membrane becomes depolarized, “excitable” and “irritable”, manifested by tall T-waves and longer PR intervals on the ECG (McCance & Huether, 2019).
The crux of the problem and solution lies in the disease of addiction itself. Amid rising opioid use and overdose-related deaths, genetics, specifically D2 (dopamine) receptors is shown to have a significant role in 23-54% of opioid use disorders (Crist, Reiner, & Berrettini, 2019). Genome studies using brain tissue from the prefrontal cortex have revealed specific shared genetic loci linked to illicit drug addiction (Hancock, Markunas, Bierut, & Johnson, 2018). These studies provide valuable data and promise for developing effective treatments against the opioid epidemic and its heavy burden on the fabric of our social and healthcare systems.
Crist, R. C., Reiner, B. C., & Berrettini, W. H. (2019). A review of opioid addiction
genetics. Current Opinion in Psychology, 27, 31–35. https://doi-
Delaney, F. T., Stanley, E., & Bolster, F. (2020). Retrieved November 30, 2020, from https://eds-a-ebscohost-com.ezp.waldenulibrary.org/eds/detail/detail?vid=4
Genes matter in addiction. (2008, June). Retrieved November 30, 2020, from https://www.apa.org/monitor/2008/06/genes-addict
Hancock, D., Markunas, C., Bierut, L., & Johnson, E. (2018, March 5). Human Genetics of Addiction: New Insights and Future Directions. Retrieved November 30, 2020, from https://www.ncbi.nlm.nih.gov/pubmed/29504045
McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in
adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier
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