What is the treatment for rhabdomyolysis?

Treatment of Rhabdomyolysis

Aggressive IV fluid resuscitation with isotonic saline is the cornerstone of rhabdomyolysis treatment, targeting a urine output of 200-300 mL/hour until creatine kinase levels decrease to <1,000 U/L. 1

Initial Management

Fluid Resuscitation

• Begin with isotonic saline at rates sufficient to achieve urine output of 200-300 mL/hour (approximately 6L/day for severe cases)
• Continue IV fluids until CK levels decrease to <1,000 U/L
• Monitor fluid status closely to prevent volume overload, especially in elderly patients or those with cardiac/renal compromise

Laboratory Monitoring

• Check CK, electrolytes, BUN, creatinine every 4-6 hours initially
• Monitor for and correct electrolyte abnormalities:
  • Hyperkalemia (potentially life-threatening)
  • Hypocalcemia (early)
  • Hyperphosphatemia
  • Metabolic acidosis

Electrolyte Management

• Hyperkalemia: Treat urgently if severe or with ECG changes using:

  • Calcium gluconate for cardiac membrane stabilization
  • Insulin with glucose
  • Sodium bicarbonate (if acidotic)
  • Consider dialysis for refractory cases

• Hypocalcemia: Generally, do not correct unless symptomatic (tetany, seizures) as calcium supplementation may promote calcium-phosphate deposition in damaged muscles

Renal Protection Strategies

• The Eastern Association for the Surgery of Trauma conditionally recommends against routine use of sodium bicarbonate and mannitol due to limited evidence 1
• Consider early nephrology consultation for:
  • Significantly elevated CK levels
  • Signs of developing acute kidney injury
  • Need for potential renal replacement therapy

Compartment Syndrome Management

• Perform regular neurovascular assessments
• Measure compartment pressures if clinically suspected
• Consider surgical consultation for decompressive fasciotomy if:
  • Compartment pressure >30 mmHg
  • Differential pressure (diastolic BP - compartment pressure) <30 mmHg 1

Renal Replacement Therapy

• Indications for dialysis:
  • Life-threatening hyperkalemia unresponsive to medical management
  • Severe acidosis
  • Volume overload unresponsive to diuretics
  • Uremic symptoms
• Intermittent hemodialysis provides rapid clearance of potassium and may be preferred for patients with severe AKI despite fluid resuscitation 1

Addressing Underlying Causes

• Identify and treat the underlying cause:
  • Discontinue causative medications (statins, particularly when used with CYP3A4 inhibitors) 2
  • Treat infections if present
  • Manage metabolic disorders
  • Address traumatic injuries

Common Pitfalls and Caveats

1. Delayed recognition: CK levels may not peak until 24-72 hours after muscle injury
2. Inadequate fluid resuscitation: Most common preventable cause of AKI in rhabdomyolysis
3. Overzealous calcium supplementation: May worsen muscle and kidney damage
4. Missing compartment syndrome: Can develop as an early or late complication
5. Drug interactions: Be aware that statins combined with certain medications (macrolides, azole antifungals, calcium antagonists, etc.) significantly increase the risk of rhabdomyolysis 2

By following this algorithmic approach to rhabdomyolysis management with emphasis on aggressive fluid resuscitation, electrolyte monitoring and correction, and addressing underlying causes, the risk of complications—particularly acute kidney injury—can be significantly reduced.