What is the treatment for exercise-induced rhabdomyolysis?

Treatment of Exercise-Induced Rhabdomyolysis

Aggressive intravenous fluid resuscitation is the cornerstone of treatment for exercise-induced rhabdomyolysis, with early initiation being critical to prevent acute kidney injury. 1

Immediate Management

Fluid Resuscitation

• Initiate early and aggressive IV fluid resuscitation immediately upon diagnosis, as delayed treatment significantly increases the risk of acute kidney injury 1
• Administer isotonic saline (0.9% NaCl) for volume expansion 2
• Target urine output of 300 mL/hour to facilitate myoglobin clearance and prevent renal tubular obstruction 3, 4
• For severe rhabdomyolysis (CK >15,000 IU/L), administer >6L of fluid per day; for moderate cases, use 3-6L per day 1
• Monitor closely for fluid overload, particularly in patients with cardiac or renal compromise 2

Supportive Care

• Provide supplemental oxygen to address potential hypoxemia 5
• Support vital signs as needed 5
• Consider cooling measures if hyperthermia is present to protect against fulminating rhabdomyolysis 5
• Ensure rapid transport to a medical facility for severe cases 5

Electrolyte Management

Critical Monitoring

• Monitor potassium levels closely, as hyperkalemia can precipitate life-threatening cardiac arrhythmias 1, 2
• Correct significant electrolyte abnormalities promptly, including hypocalcemia and hyperphosphatemia 2
• Perform repeated bioassessment including plasma myoglobin, CK, and potassium measurements 1
• Check electrolyte panels every 6-12 hours in severe cases 2

Metabolic Acidosis

• Assess for metabolic acidosis, which commonly occurs in severe rhabdomyolysis 1
• Maintain urine pH at approximately 6.5 if possible 2
• Avoid routine alkalinization with sodium bicarbonate, as evidence does not support its routine use 6

Medication Considerations

Diuretics

• Avoid routine use of loop diuretics or mannitol, as evidence does not support their routine administration 6
• After ensuring adequate volume expansion, a diuretic challenge with furosemide may help assess kidney function in select cases 2
• Response to diuretics may predict successful recovery of kidney function 2

Discontinue Offending Agents

• Immediately cease the physical activity that triggered the event 5
• Discontinue any medications or supplements that may contribute to rhabdomyolysis, including statins, creatine monohydrate, red yeast rice, and other high-risk supplements 1

Monitoring for Complications

Compartment Syndrome

• Maintain high suspicion for compartment syndrome, which can both cause and complicate rhabdomyolysis 1
• Early signs include pain, tension, paresthesia, and paresis; late signs include pulselessness and pallor (indicating irreversible damage) 1
• Perform early fasciotomy for established compartment syndrome 1
• Consider fasciotomy when compartment pressure exceeds 30 mmHg or when differential pressure (diastolic BP – compartment pressure) is <30 mmHg 1, 7

Acute Kidney Injury

• Monitor renal function through serial creatinine, BUN measurements 2
• Assess urine output hourly with bladder catheterization; inadequate output (<300 mL/hour) suggests worsening kidney function 2
• Check urinalysis for myoglobinuria (urine dipstick positive for blood without RBCs on microscopy) 4, 8

Advanced Interventions

Renal Replacement Therapy

• Initiate RRT if CPK remains persistently elevated despite 4 days of adequate hydration, as this indicates severe rhabdomyolysis with significant risk of irreversible kidney damage 2
• Early initiation of RRT is associated with improved outcomes in severe cases 2
• Consider RRT for refractory hyperkalemia, severe metabolic acidosis, or progressive acute kidney injury 2
• Avoid routine prophylactic RRT in the absence of clear indications 6
• Consider discontinuation of RRT when urine output recovers adequately (>100 mL/day) 2

Common Pitfalls to Avoid

• Delaying fluid resuscitation is associated with higher risk of acute kidney injury and worse outcomes 1, 2
• Inadequate fluid volume (using <6L/day in severe cases) may fail to prevent renal complications 1
• Failure to monitor and correct hyperkalemia can lead to pulseless electrical activity and cardiac arrest 5, 2
• Missing compartment syndrome, particularly in traumatic or severe exertional cases, can result in irreversible muscle and nerve damage 1, 7
• Routine use of mannitol or bicarbonate alkalinization lacks evidence and should be avoided 6

Special Considerations for Athletes

For athletes with sickle cell trait experiencing collapse, this represents a medical emergency requiring immediate cessation of activity, supplemental oxygen, IV hydration, and possible cooling, as metabolic insult with lactic acidosis and hyperkalemia can lead to pulseless electrical activity where external defibrillation may be ineffective 5