Faisal Qadir, Yakoob Ahmadani, Qamar Masood.
Severe rhabdomyolysis due to drug overdose.
J Coll Physicians Surg Pak Jan ;14(7):436-7.

An 18-years old girl presented with a two day history of vomiting and loose motions in a state of drowsiness and hypotensive shock. She was experiencing difficulty in walking and extending the neck. It was noticed that in the last two months, she would not wake-up early for college, avoided breakfast and had lost weight. On examination she was afebrile. B.P. was 86/42 mmHg. She had shallow respiratory efforts, was diaphoretic and had hyporeflexia. An initial impression of drug overdose was made; gastric lavage was performed and IV fluids were given. Mechanical ventilation was commenced as she was retaining carbondioxide. Investigations revealed Hb 13 g/L, WBC count 12.6 x 109/L, normal coagulation profile and reticulocyte count, BUN 5.76 mmol/L, creatinine 53.31 mmol/L, ALT, 614 units/L, LDH, 4893 units/L, CPK 332667 units/L(rechecked), CK-MB 772 units/L, pH 7.17, paO2 70.4 mmHg, paCO2 62.6 mmHg, HCO3 23.1 mmol/L,O2 sat. 88%, serum aldolase 89.8 IU/L, urine myoglobin 11200 mg/dL and normal CXR and ECG. Urine for toxicology screen was positive for barbiturates, benzodiazepines and amphetamines and negative for opiates, cocaine and cannabinoids. Subsequent BUN and serum creatinine estimations reached a maximum of 19.44 mmol/L and 146.60 mmol/L respectively. Her FENa was <1%. With improvement in clinical status, she was gradually weaned off the mechanical ventilator. Aggressive I.V. fluid resuscitation was done with normal saline initially at the rate of 250 cc/hr. Urine alkalinization by administration of sodium bicarbonate( with daily measurement of urine pH) was carried out to achieve a urine pH greater than 6.5.

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