What is the treatment for rhabdomyolysis (muscle breakdown) with aspirin (acetylsalicylic acid) toxicity?

Treatment of Rhabdomyolysis with Aspirin Toxicity

Aggressive intravenous fluid resuscitation is the cornerstone of treatment for rhabdomyolysis associated with aspirin toxicity, with hemodialysis strongly recommended for severe cases with altered mental status, respiratory distress, or high salicylate levels.

Initial Management

• Immediately consult with a medical toxicologist, clinical toxicologist, or regional poison center to facilitate rapid and effective therapy for this potentially life-threatening condition 1

• Administer aggressive intravenous fluid resuscitation (IVFR) as the primary treatment to prevent acute kidney injury, with a goal urine output of 300 mL/h 2, 3

• Provide at least 12 L daily of intravenous fluids in severe cases to stabilize circulation and mobilize edema fluids sequestered in injured muscles 4

Specific Interventions for Aspirin Toxicity

• Administer sodium bicarbonate for two purposes:

  1. To alkalinize the urine (target pH 7.5-8.0), which reduces renal tubular reabsorption and promotes renal excretion of salicylate 1
  2. To produce alkalemia, which minimizes passage of salicylate into the central nervous system 1

• Perform gastrointestinal decontamination in selected patients after acute overdose to limit further absorption 1

Indications for Hemodialysis

Hemodialysis is strongly indicated in any of the following circumstances:

• Altered mental status due to salicylate toxicity 1
• Acute respiratory distress syndrome requiring supplemental oxygen 1
• Failure of standard therapy despite appropriate interventions 1
• High salicylate concentrations regardless of symptoms:

  • 7.2 mmol/L (100 mg/dL) in patients with normal renal function 1

  • 6.5 mmol/L (90 mg/dL) in patients with impaired kidney function 1

• Severe acidemia (pH <7.20) even in the absence of other indications 1

Extracorporeal Treatment Options

• Intermittent hemodialysis is the preferred modality for removing salicylates from circulation 1

• If hemodialysis is unavailable, acceptable alternatives include:

  • Hemoperfusion 1
  • Continuous renal replacement therapies (less effective but can be used if other options aren't available) 1
  • Exchange transfusion in neonates 1

Management of Rhabdomyolysis

• Monitor serum creatine kinase, potassium, and renal function closely 1

• Continue aggressive fluid resuscitation to prevent myoglobinuric renal failure and severe dysrhythmias 2, 5

• Urine alkalinization (already being performed for salicylate toxicity) may help protect against the nephrotoxic effects of myoglobinemia 4

• Monitor for and treat compartment syndrome if present, which may require surgical intervention 2, 3

Important Considerations and Pitfalls

• Do not administer NSAIDs (except for the aspirin already causing toxicity), as they can increase the risk of mortality, reinfarction, hypertension, heart failure, and myocardial rupture 1

• Evidence does not support the routine use of mannitol for rhabdomyolysis 2, 3

• In refractory cases with persistently elevated creatine kinase despite fluid therapy, high-dose corticosteroids may be considered, though evidence is limited 6

• Carefully monitor fluid balance, especially in patients with pre-existing cardiac or renal conditions, as aggressive fluid resuscitation can lead to volume overload 4

• Early initiation of renal replacement therapy should be considered if there are signs of acute kidney injury not responding to conservative management 1