What is the treatment for rhabdomyolysis after high voltage electrocution?

Treatment of Rhabdomyolysis After High Voltage Electrocution

Aggressive intravenous fluid resuscitation with isotonic saline is the cornerstone of treatment for rhabdomyolysis following high-voltage electrocution, targeting a urine output of 300 mL/hour to prevent acute kidney injury and death from myoglobinuric renal failure. 1, 2, 3

Immediate Scene Safety and Initial Assessment

Before approaching the victim, ensure the power source is completely disconnected—never touch an electrocution victim while power is active, as all materials conduct electricity at high voltage 4. For high-voltage incidents involving fallen power lines, immediately notify emergency services and wait for trained personnel to secure the scene 4.

Once safe, assess for:

• Cardiopulmonary arrest (the primary cause of immediate death from electrocution), requiring CPR and defibrillation 4
• Cardiac arrhythmias including ventricular fibrillation, asystole, or ventricular tachycardia 4
• Respiratory arrest from brain injury or tetanic muscle contractions 4
• Thermal burns at entry/exit points and along the current pathway 4

Aggressive Fluid Resuscitation Protocol

Initiation and Volume

• Begin IV fluid resuscitation immediately upon diagnosis—delayed treatment significantly increases acute kidney injury risk and mortality 1, 5, 2
• Administer isotonic saline (0.9% NaCl) as the fluid of choice 1, 6
• For severe rhabdomyolysis (CK >15,000 IU/L), infuse >6L per day 1, 5, 6
• For moderate cases, use 3-6L per day 1, 5

Target Urine Output

• Maintain urine output at 300 mL/hour to facilitate myoglobin clearance and prevent renal tubular obstruction 1, 3, 7
• Place bladder catheter for hourly urine output monitoring 6
• Inadequate output (<300 mL/hour) indicates worsening kidney function requiring escalation 6

Monitoring During Resuscitation

• Monitor closely for fluid overload, particularly in patients with cardiac or renal compromise 1, 6
• Check electrolyte panels every 6-12 hours in severe cases 1, 6
• Perform serial CK, creatinine, and BUN measurements 1, 5, 6

Critical Electrolyte Management

Hyperkalemia Monitoring and Treatment

• Monitor potassium levels closely—hyperkalemia from muscle breakdown can precipitate life-threatening cardiac arrhythmias and sudden death 1, 5, 7
• Obtain ECG to identify hyperkalemic changes 7
• Correct significant hyperkalemia promptly to prevent cardiac arrest 1, 5, 6

Other Electrolyte Abnormalities

• Correct hypocalcemia and hyperphosphatemia, which commonly occur 1, 5, 6
• Assess for metabolic acidosis via arterial blood gas 1, 5
• Maintain urine pH at approximately 6.5 if possible 1, 6

Adjunctive Therapies and Medications

Diuretics (Selective Use Only)

• After ensuring adequate volume expansion, a furosemide challenge may help assess kidney function in select cases 1, 6
• Response to diuretics may predict successful recovery of kidney function 1, 6
• Do not use diuretics as first-line therapy or before adequate fluid resuscitation 6

Therapies NOT Recommended

• Bicarbonate administration does not improve outcomes and is conditionally recommended against 2
• Mannitol does not improve acute renal failure rates or dialysis need and is conditionally recommended against 2
• These agents lack strong evidence for benefit in rhabdomyolysis 3

Medication Review and Discontinuation

• Immediately discontinue any medications or supplements that may contribute to rhabdomyolysis, including statins, creatine monohydrate, red yeast rice, and other high-risk supplements 1, 5

Compartment Syndrome Surveillance

High-voltage electrical injuries carry significant risk for compartment syndrome, which both causes and complicates rhabdomyolysis 1, 5:

Early Signs (Reversible)

• Pain disproportionate to examination
• Muscle tension and swelling
• Paresthesias
• Paresis (weakness) 1, 5

Late Signs (Irreversible Damage)

• Pulselessness
• Pallor 1, 5

Surgical Intervention

• Perform early fasciotomy for established compartment syndrome 1, 5
• Consider fasciotomy when compartment pressure >30 mmHg or when differential pressure (diastolic BP – compartment pressure) is <30 mmHg 1, 5

Renal Replacement Therapy Indications

When to Initiate RRT

• If CK remains persistently elevated despite 4 days of adequate hydration, initiate RRT—this indicates severe rhabdomyolysis with significant risk of irreversible kidney damage 1, 6
• Early RRT initiation is associated with improved outcomes in severe cases 1, 6
• Consider RRT for:
  • Refractory hyperkalemia
  • Severe metabolic acidosis
  • Progressive acute kidney injury 1, 6

When to Discontinue RRT

• Consider discontinuation when urine output recovers adequately (>100 mL/day) 6
• Successful weaning is more likely with recovery of urine output 6

Supportive Care Measures

• Provide supplemental oxygen to address potential hypoxemia 1
• Support vital signs as needed 1
• Consider cooling measures if hyperthermia is present to protect against fulminating rhabdomyolysis 1
• Treat thermal burns appropriately with cooling (15-25°C tap water) and sterile dressings 4

Critical Pitfalls to Avoid

• Delaying fluid resuscitation is the most serious error—it significantly increases acute kidney injury risk and worsens outcomes 1, 5, 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 1, 5, 6
• Missing compartment syndrome, particularly in electrical injuries, can result in irreversible muscle and nerve damage requiring amputation 1, 5
• Delaying RRT initiation when indicated can lead to irreversible kidney damage and increased mortality 6

Special Considerations for Electrical Injuries

All victims of high-voltage electrical shock require medical assessment because the extent of internal injury may not be apparent from external examination 4. Electrical current traversing the body causes internal thermal burns along its pathway, with visible burns only at entry and exit points 4. The risk of severe rhabdomyolysis is substantial due to deep muscle injury from current passage and potential compartment syndrome development.