What is the treatment for rhabdomyolysis in a 14-year-old patient?

Treatment of Rhabdomyolysis in a 14-Year-Old Patient

Aggressive intravenous fluid resuscitation with isotonic saline is the cornerstone of treatment for rhabdomyolysis in a 14-year-old, with the goal of achieving diuresis greater than 300 mL/hour to prevent acute kidney injury. 1

Initial Management

1. Fluid Resuscitation

   • Begin with isotonic saline (0.9% NaCl) as the initial fluid of choice 1
   • Avoid potassium-containing fluids due to risk of hyperkalemia 1
   • Target urine output >300 mL/hour 1, 2
   • Fluid requirements are typically higher than maintenance, with aggressive hydration needed to mobilize sequestered fluids from damaged muscle 3

2. Laboratory Monitoring

   • Measure serum creatine kinase (CK) levels (diagnostic threshold: at least 10× upper limit of normal) 1
   • Monitor electrolytes, particularly potassium, calcium, and phosphate 1
   • Check renal function (BUN, creatinine) 1
   • Obtain urinalysis to assess for myoglobinuria 1
   • Consider ECG to evaluate for cardiac effects of electrolyte abnormalities 1

Electrolyte Management

1. Hyperkalemia

   • Urgent correction if present to prevent cardiac arrhythmias 1
   • Standard hyperkalemia protocols apply (calcium gluconate, insulin with glucose, sodium bicarbonate, beta-agonists)

2. Calcium Abnormalities

   • Correct hypocalcemia only if symptomatic 1
   • Monitor for late hypercalcemia during recovery phase 4

Nutritional Support

For a 14-year-old patient, protein requirements are 1.5-2.0 g/kg/day 5. This is particularly important as adolescents are in a developmental growth phase with increased requirements compared to adults.

Special Considerations

1. Avoid Nephrotoxic Medications

   • Discontinue NSAIDs, ACE inhibitors/ARBs, and certain antibiotics 1
   • Avoid medications that may worsen muscle injury

2. Diuretics and Mannitol

   • Current evidence does not support routine use of mannitol or loop diuretics 5, 2
   • Mannitol may only be beneficial in cases with marked CK elevations (>30,000 U/L), but benefits remain undefined 5
   • Mannitol is contraindicated in patients with oligoanuria 5

3. Urine Alkalinization

   • Evidence for bicarbonate administration is limited and controversial 2
   • Not routinely recommended based on current evidence

Monitoring for Complications

1. Acute Kidney Injury

   • Monitor urine output, creatinine, and BUN closely 1
   • Consider nephrology consultation for all cases with AKI 1
   • Consider renal replacement therapy for severe hyperkalemia, acidosis, volume overload, or uremic symptoms 1

2. Compartment Syndrome

   • Monitor for signs of compartment syndrome (pain, tension, paresthesia, paresis) 1
   • Remove tight dressings and avoid limb elevation if suspected 1
   • Obtain urgent surgical consultation for fasciotomy if confirmed 1
   • Fasciotomy is indicated with intracompartmental pressures ≥30 mmHg in normotensive patients with positive clinical findings 1

Follow-up Care

1. Monitor for Recovery

   • CK levels typically peak 24-72 hours after injury 1
   • Continue fluid therapy until CK levels are trending down
   • Consider genetic evaluation for recurrent cases 1

2. Prevention of Recurrence

   • Identify and address underlying cause
   • Education on proper hydration, especially during exercise 1
   • Gradual return to physical activity with appropriate training regimens 1

Pitfalls and Caveats

1. Fluid Overload Risk: While aggressive fluid resuscitation is essential, monitor for signs of fluid overload, especially in patients with pre-existing cardiac or renal conditions.

2. Delayed Presentation: The classic triad of myalgia, muscle weakness, and pigmenturia is present in less than 10% of cases 1, so maintain high clinical suspicion.

3. Underlying Causes: Always investigate and address the underlying cause of rhabdomyolysis (exertional, crush injury, medications, infections, genetic disorders).

4. Pediatric Considerations: Remember that nutritional requirements are higher in adolescents compared to adults due to ongoing growth and development 5.