What is the treatment for rhabdomyolysis?

Treatment of Rhabdomyolysis

The cornerstone of rhabdomyolysis treatment is aggressive fluid resuscitation with isotonic saline (0.9% NaCl) targeting a urine output of >300 mL/hour to prevent acute kidney injury. 1

Initial Management

Fluid Resuscitation

• Begin immediately with isotonic saline (0.9% NaCl) 1, 2
  • Avoid potassium-containing fluids like Lactated Ringer's 1
  • Do not delay fluid resuscitation while waiting for laboratory results 1
  • Target urine output: >300 mL/hour 1, 3
  • Continue IV fluids until creatine kinase (CK) levels decrease to <1,000 U/L 4

Electrolyte Management

• Monitor and correct electrolyte abnormalities:
  • Hyperkalemia: Treat urgently if present 1
  • Hypocalcemia: Address if symptomatic 1
  • Hyperphosphatemia: Monitor and correct as needed 1

Medication Management

• Discontinue all nephrotoxic medications 1
  • NSAIDs
  • ACE inhibitors/ARBs
  • Certain antibiotics
• Immediately stop any causative agents (e.g., statins) 1

Monitoring and Diagnostic Tests

Essential Laboratory Tests

• Serum CK (diagnostic threshold: at least 10× upper limit of normal) 1, 3
  • Monitor every 6-12 hours in acute phase 1
  • Peak levels typically occur 24-72 hours after muscle injury 1
• Plasma myoglobin (confirms muscle breakdown) 1
• Serum electrolytes 1
• Renal function tests 1
• Urinalysis (check for myoglobinuria - tea/cola-colored urine) 1
  • Positive for blood on dipstick but negative for RBCs on microscopy 1
• Consider coagulation studies (PT/PTT/INR) if DIC suspected 1

Complications Management

Acute Kidney Injury

• Consult nephrology for all cases with AKI 1
• Consider renal replacement therapy for: 1
  • Severe hyperkalemia
  • Acidosis
  • Volume overload
  • Uremic symptoms

Compartment Syndrome

• Monitor for signs: pain, tension, paresthesia, and paresis 1
• Measure compartment pressure if suspected
  • Threshold: >30 mmHg or differential pressure <30 mmHg 1
• Urgent surgical consultation for fasciotomy if confirmed 1

Controversial Interventions

While commonly mentioned in practice, there is limited high-quality evidence supporting:

• Bicarbonate-containing fluids 2, 3
• Mannitol 2, 3, 5
• Loop diuretics 2, 3

These interventions should be considered on a case-by-case basis rather than as routine practice.

Follow-up Care

• Follow up with primary care and/or nephrology within 1-2 weeks 1
• Monitor for recurrence symptoms 1
• Consider genetic counseling if hereditary disorder is suspected 1
  • Obtain detailed three-generation family history 1
  • Consider specific gene panels for:
    • Glycogen storage diseases
    • Fatty acid oxidation disorders
    • Mitochondrial disorders
    • Muscular dystrophies
    • Ion channelopathies

Common Pitfalls to Avoid

• Delaying fluid resuscitation while waiting for laboratory confirmation 1
• Using potassium-containing fluids for resuscitation 1
• Failing to recognize compartment syndrome (early or late finding) 1, 4
• Missing underlying causes that require specific treatment 6
• Discharging patients prematurely before adequate CK reduction 4
• Overlooking the need for genetic evaluation in recurrent cases 1, 6