Date sent: Fri, 23 Feb 1996 16:56:54 +0100 Send reply to: Philippe Le Conte From: Philippe Le Conte Subject: ck levels and intramuscular injection To: Multiple recipients of list EMED-L Recently, a 41 years old man was admitted to the ED for acute chest pain which was resolved spontaneously. An intramuscular injection was done before his admission. The ECG did not showed a myocardial infarction. The CK levels were elevated (normal range X3) but it was attributed to the IM injection. After 12 hours and a new ECG, this patient was discharged from the ED. Two months later, his cardiologist tell us that echocardiography show a posterior myocardial infarction that probably occured when the patient was admitted in our ED. Thus, the question is : are CK and MB fraction modified by an IM injection? I have found only two references on medline (1 and 2) that show opposite conclusions. I would be happy to have your opinion about this question Thank you in advance (1) [Changes in creatine kinase activity in serum following intramuscular injection] AU: Surber-C; Dubach-UC; Forgo-I SO: Klin-Wochenschr. 1988 Feb 1; 66(3): 96-102 AB: The effect of intramuscular injections of two multivitamin preparations, two excipient preparations without vitamins, and a placebo preparation (glycine 2.5%) on serum creatine kinase activity (S-CK) in ten healthy volunteers (three female, seven male) aged between 23 and 25 years was investigated. One of the multivitamin preparations contained no lidocaine, the other 1% lidocaine. The one excipient formulation was isoosmotic, while the other contained added saline to bring it to the same degree of hyperosomolarity as the multivitamin formulation without lidocaine. The formulations were administered by deep ventrogluteal injection by means of a standardized injection technique. Blood samples were taken before and 6, 12, 24 and 48 h after injection. Following the administration of all the formulations except that of the glycine 2.5%, a marked increase in S-CK activity (1260 I.U./l) was observed 12 h after injection (normal range: male: 47-243 I.U./l, female: 39-226 I.U./l). The relative standard deviation for the 12 h S-CK value was 66.4-97.3%. On applying a threeway analysis of variance to the parameter S-CKmax, no significant differences (alpha = 5%) were found between the effects of the multivitamin and excipient formulations. There was a difference between these and glycine 2.5%, however. There were significant differences between individual volunteers but no significant differences based on the sequence in which the injections were given. With regard to the parameter S-CK AUC (area under the curve, trapezoidal rule), a significant difference (alpha = 5%) was observed only between glycine 2.5% and the multivitamin formulation containing 1% lidocaine; (2) Serum creatine kinase after intramuscular injections. AU: Konikoff-F; Halevy-J; Theodor-E SO: Postgrad-Med-J. 1985 Jul; 61(717): 595-8 AB: Serum creatine kinase (CK) activity was measured after intramuscular injections in 44 patients hospitalized for non-cardiac reasons. The drugs injected were: diazepam, dipyrone, metoclopramide, meperidine, pentazocine and procaine penicillin. Only 3 out of 44 patients (7%) demonstrated significant elevation of CK levels following the intramuscular injections. In these 3 patients the elevation was mainly due to a rise of the MM-isoenzyme fraction with MB levels increased in one patient. These findings do not justify the common clinical notion of regarding intramuscular injections as a frequent cause of serum CK elevation. It is concluded that high CK serum values in a patient with chest pain should always be considered with utmost suspicion, disregarding the possible effects of a previous intramuscular injection. Philippe Le Conte, MD, PhD Emergency Department University Hospital Nantes, France