What are the immediate steps for managing a diagnosis of rhabdomyolysis?

From the Guidelines

The immediate management of rhabdomyolysis should focus on aggressive intravenous fluid resuscitation with normal saline at an initial rate of 1-2 L/hour, adjusted based on the patient's cardiovascular status and urine output, as recommended by recent guidelines 1. The goal of this approach is to maintain urine output at 200-300 mL/hour to prevent acute kidney injury by diluting nephrotoxic myoglobin and preventing its precipitation in renal tubules. Simultaneously, electrolyte abnormalities must be addressed, particularly hyperkalemia, which can cause cardiac arrhythmias, with the use of calcium, insulin with glucose, sodium bicarbonate, or potassium-binding resins as needed for severe hyperkalemia 1. Some considerations include:

• Urine alkalinization with sodium bicarbonate (maintaining urine pH >6.5) may be considered to reduce myoglobin toxicity, though this remains controversial.
• Continuous cardiac monitoring is essential, especially with significant electrolyte disturbances.
• Creatine kinase levels should be monitored daily until declining, along with renal function tests and electrolytes.
• The underlying cause of rhabdomyolysis must be identified and treated, whether it's trauma, medication, infection, or other factors.
• In severe cases with acute kidney injury, renal replacement therapy may be necessary. Key diagnostic markers include plasma myoglobin and creatine phosphokinase (CPK) levels, with CPK levels above 75,000 IU/L associated with a high incidence of newly formed acute kidney injury 1. Pain management with appropriate analgesics and discontinuation of any potentially causative medications are also important components of immediate care. Monitoring for compartment syndrome, especially in patients with severe limb trauma, is crucial, with clinical signs such as pain, tension, paraesthesia, paresis, and increased compartmental pressure being indicative of this condition 1. Early fasciotomy may be necessary in cases of established compartment syndrome. Overall, the management of rhabdomyolysis requires a multifaceted approach that prioritizes fluid resuscitation, electrolyte management, and monitoring for complications such as acute kidney injury and compartment syndrome.

From the Research

Immediate Steps for Managing Rhabdomyolysis

The immediate steps for managing a diagnosis of rhabdomyolysis include:

• Aggressive intravenous fluid resuscitation (IVFR) to improve outcomes of acute renal failure (ARF) and lessen the need for dialysis 2
• Early diagnosis and prompt management with fluid resuscitation, initiation of renal replacement therapy (RRT), and elimination of causative agents can help prevent complications 3
• Hospitalisation with aggressive intravenous fluid (IVF) resuscitation and correction/prevention of electrolyte abnormalities 4
• Optimal crystalloid selection is still debated, but immediate, aggressive intravenous volume expansion is indicated to prevent myoglobinuric renal failure 5
• Early vigorous fluid resuscitation with ≥12 l daily intravenous infusion of alkaline solution started at the scene of injury can stabilize the circulation, mobilize edema fluids, correct hyperkalemia and acidosis, and protect against the nephrotoxic effects of myoglobinemia and hyperuricosuria 6

Key Considerations

• The treatment of rhabdomyolysis remains controversial, with debate persisting regarding the benefit of further therapy including aggressive IVFR, urine alkalization with bicarbonate, and the use of mannitol 2
• The main pathophysiology of renal injury is due to vasoconstriction, intraluminal casts, tubular obstruction, and direct myoglobin toxicity 3
• Rhabdomyolysis can be complicated by acute renal failure, compartment syndrome, cardiac dysrhythmias via electrolyte abnormalities, and disseminated intravascular coagulopathy 4
• The overall prognosis for rhabdomyolysis is favourable when treated with early and aggressive IVF resuscitation, and full recovery of renal function is common 4