What is the treatment for rhabdomyolysis?

Treatment of Rhabdomyolysis

Aggressive intravenous fluid resuscitation with isotonic saline (0.9% NaCl) is the cornerstone of rhabdomyolysis management, targeting a urine output of >300 mL/hour to prevent acute kidney injury. 1, 2, 3

Diagnosis and Initial Assessment

• Diagnostic criteria: Serum creatine kinase (CK) at least 10 times the upper limit of normal
• Key laboratory tests:
  • Serum CK (monitor every 6-12 hours in acute phase)
  • Plasma myoglobin (rises earlier than CK but has shorter half-life)
  • Urinalysis (positive for blood on dipstick but negative for RBCs on microscopy)
  • Serum electrolytes and renal function tests
  • Coagulation studies if DIC suspected 1

Fluid Resuscitation Protocol

1. Initial Management:

   • Begin immediate IV fluid resuscitation with 0.9% NaCl (isotonic saline)
   • Target urine output: >300 mL/hour
   • Do not delay fluid resuscitation while waiting for laboratory results 1, 3

2. Fluid Selection:

   • Use isotonic saline (0.9% NaCl) as initial fluid of choice
   • Avoid potassium-containing fluids (e.g., Lactated Ringer's) 1

Electrolyte Management

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

Renal Protection Measures

1. Nephrotoxic Medications:

   • Discontinue all nephrotoxic medications including:
     • NSAIDs
     • ACE inhibitors/ARBs
     • Certain antibiotics
     • Statins (if causative) 1

2. Nephrology Consultation:

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

Compartment Syndrome Management

• Monitor for signs: pain, tension, paresthesia, and paresis
• Measure compartment pressure (threshold >30 mmHg)
• Obtain urgent surgical consultation for fasciotomy if compartment syndrome confirmed 1, 4

Controversial Interventions

• Bicarbonate and Mannitol: Current evidence does not support routine use of these agents
  • The Eastern Association for the Surgery of Trauma conditionally recommends against treatment with bicarbonate or mannitol 2
  • One retrospective study suggested mannitol may benefit only patients with marked CK elevations (>30,000 U/L), but true benefit remains undefined 5

Monitoring and Follow-up

• Monitor CK levels every 6-12 hours until declining
• Follow electrolytes and renal function closely
• Follow up with nephrology within 1-2 weeks after discharge 1

Special Considerations

• For recurrent rhabdomyolysis, consider genetic testing for underlying disorders
• In cases of statin-induced rhabdomyolysis, immediately discontinue the medication
• For exertional rhabdomyolysis, proper training and adequate hydration are preventive measures 1

Common Pitfalls to Avoid

1. Delaying fluid resuscitation while waiting for laboratory confirmation
2. Using potassium-containing fluids for resuscitation
3. Continuing nephrotoxic medications
4. Missing compartment syndrome requiring fasciotomy
5. Failing to monitor for and treat electrolyte abnormalities, especially hyperkalemia

The mortality rate of rhabdomyolysis is approximately 10% and significantly higher in patients who develop acute renal failure 6. With early recognition and aggressive fluid resuscitation, mortality in muscle crush syndrome has been reduced from nearly 100% to <20% over the past 70 years 3.