What is the treatment for rhabdomyolysis?

Treatment of Rhabdomyolysis

Aggressive intravenous fluid resuscitation is the cornerstone of treatment for rhabdomyolysis, with a goal urine output of 300 mL/hour to prevent acute kidney injury. 1, 2

Initial Management

• Begin immediate aggressive IV fluid resuscitation:

  • For severe rhabdomyolysis (CK >15,000 IU/L): >6L of fluid per day 1, 2
  • For moderate cases: 3-6L of fluid per day 1, 2
  • Use isotonic saline as the primary resuscitation fluid 3
  • Early initiation is critical, as delayed treatment increases risk of acute kidney injury 1

• Monitor and correct electrolyte abnormalities:

  • Pay particular attention to potassium levels, as hyperkalemia can lead to life-threatening cardiac arrhythmias 1, 2
  • Monitor calcium, phosphorus, and magnesium levels 1
  • Obtain ECG to evaluate for cardiac effects of electrolyte disturbances 1

Laboratory Assessment

• Obtain baseline and serial measurements of:
  • Creatine kinase (CK) - the diagnostic gold standard 4
  • Plasma myoglobin - prognostic indicator 4
  • Complete electrolyte panel 1
  • Renal function tests (BUN, creatinine) 3
  • Liver function tests 1
  • Coagulation studies to evaluate for DIC 1

Monitoring for Complications

• Assess for compartment syndrome:

  • Early signs: pain, tension, paresthesia, and paresis 1, 2
  • Late signs: pulselessness and pallor (indicate irreversible damage) 1
  • Consider fasciotomy when compartment pressure exceeds 30 mmHg or when differential pressure (diastolic blood pressure – compartment pressure) is <30 mmHg 1

• Monitor for development of acute kidney injury:

  • Continue fluid therapy until CK levels decrease to <1,000 U/L 5
  • Consider renal replacement therapy for severe cases with refractory hyperkalemia, acidosis, or volume overload 3

Additional Interventions

• Consider urine alkalinization with sodium bicarbonate for patients who are acidotic 5

  • This may help prevent myoglobin precipitation in renal tubules 3

• Mannitol may be considered for patients not achieving target urine output despite adequate fluid resuscitation 5

  • However, evidence for improved outcomes with mannitol is limited 3

• Address the underlying cause of rhabdomyolysis:

  • Discontinue causative medications (particularly statins) 1, 2
  • Treat infections if present 1
  • Correct metabolic abnormalities 1

Special Considerations

• Avoid medications that can exacerbate rhabdomyolysis, particularly succinylcholine 1

• For rhabdomyolysis with myonecrosis, implement measures to prevent myoglobinuric renal failure:

  • Maintain adequate hydration 1
  • Consider forced diuresis 6
  • Urine alkalinization may be beneficial 6

• For exertional rhabdomyolysis, ensure proper calibration of training and conditioning, especially during transition periods 1, 2