What is the immediate management for rhabdomyolysis (muscle breakdown) in a patient involved in a road traffic accident?

Immediate Management of Rhabdomyolysis in Road Traffic Accident Victims

Begin aggressive intravenous fluid resuscitation with 0.9% normal saline at 1 liter per hour immediately upon patient contact, even before extrication if possible, to prevent acute kidney injury and reduce mortality. 1, 2

Pre-Hospital and Early Management

Fluid Resuscitation Protocol

Start fluid resuscitation as early as possible—ideally before or during extrication from the vehicle:

• Establish IV access in an accessible limb; if venous access cannot be obtained, insert an intra-osseous needle in a lower limb 1
• Infuse 0.9% normal saline at 1000 mL/hour during the initial extrication phase 1
• Reduce infusion rate by at least 50% (to ≥500 mL/hour) if extrication takes longer than 2 hours 1
• Target urine output of 300 mL/hour once bladder catheterization is established 2, 3

Critical Fluid Selection

Avoid potassium-containing fluids (Lactated Ringer's, Hartmann's solution, Plasmalyte A) entirely in trauma patients with suspected crush injury, as reperfusion of injured limbs causes massive potassium release that can precipitate fatal cardiac arrhythmias even with normal renal function. 1

Avoid starch-based fluids, which increase acute kidney injury and bleeding risk. 1

Hospital Management Algorithm

Immediate Actions (First 6 Hours)

• Continue 0.9% saline at 3-6 liters per day for moderate rhabdomyolysis; increase to >6 liters per day for severe cases (CK >15,000 IU/L) 4, 2
• Insert bladder catheter (unless urethral injury suspected) to monitor hourly urine output 1
• Obtain immediate labs: CK, potassium, calcium, phosphorus, creatinine, BUN, arterial blood gas 4, 2
• Perform ECG to identify hyperkalemia-induced cardiac changes 4, 5

Electrolyte Management

Monitor potassium every 6-12 hours in severe cases, as hyperkalemia is the most immediately life-threatening complication:

• Hyperkalemia can cause pulseless electrical activity and cardiac arrest where external defibrillation is ineffective 2
• Treat hyperkalemia aggressively with standard protocols (calcium gluconate, insulin/glucose, albuterol) 4, 2
• Monitor for hypocalcemia but avoid aggressive calcium replacement unless symptomatic, as calcium can precipitate in damaged muscle 4
• Assess for metabolic acidosis with serial blood gases 2

Monitoring Protocol

Check the following at presentation and serially:

• CK levels (diagnostic threshold: >10x upper limit of normal; severe: >15,000 IU/L) 4, 3
• Electrolytes (potassium, calcium, phosphorus, magnesium) every 6-12 hours 4, 2
• Renal function (creatinine, BUN) every 12-24 hours 1, 4
• Urinalysis for myoglobinuria (brown/tea-colored urine, positive for blood without RBCs) 4
• Urine output hourly via catheter 2, 3

Compartment Syndrome Surveillance

Maintain high suspicion for compartment syndrome, which both causes and complicates rhabdomyolysis in trauma patients:

Early Warning Signs (Reversible)

• Pain out of proportion to examination 4, 2
• Muscle tension and swelling 4, 2
• Paresthesias 4, 2
• Paresis (weakness) 4, 2

Late Signs (Irreversible Damage)

• Pulselessness 4, 2
• Pallor 4, 2

Perform early fasciotomy when:

• Compartment pressure exceeds 30 mmHg 4, 2
• Differential pressure (diastolic BP minus compartment pressure) is <30 mmHg 4, 2

Controversial Interventions

Bicarbonate Administration

Do not routinely use bicarbonate for urine alkalinization. Current evidence shows no benefit over aggressive saline resuscitation alone, and large bicarbonate doses can worsen hypocalcemia. 1, 6 Use bicarbonate only to correct severe metabolic acidosis (pH <7.1). 2

Mannitol Administration

Do not routinely administer mannitol. Despite theoretical benefits (diuresis, antioxidant effects, reduced compartment pressure), evidence shows no additional benefit over crystalloid resuscitation alone, and mannitol is potentially nephrotoxic. 1, 6 Consider mannitol only as a diuretic challenge after adequate volume expansion if urine output remains inadequate. 2

Renal Replacement Therapy Indications

Initiate dialysis early for:

• Refractory hyperkalemia despite medical management 1, 4
• Severe metabolic acidosis unresponsive to treatment 1, 2
• Fluid overload with pulmonary edema 1
• Persistently elevated CK after 4 days of adequate hydration 2
• Anuria or severe oliguria with rising creatinine 1

Early initiation of renal replacement therapy is associated with improved survival in trauma-associated acute kidney injury. 1

Volume Titration Considerations

Individualize fluid volumes based on:

• Time under entrapment: More fluid needed for delayed rescue, but use conservative approach (3-6 L/day) if patient presents days later with established anuria to avoid hypervolemia 1
• Patient demographics: Reduce fluid volumes for elderly patients, children, and those with low body mass 1
• Volume status: Increase fluids for hypotension, bleeding, third-spacing; decrease for signs of fluid overload, especially in anuria 1
• Environmental factors: Less fluid needed in cold environments 1

Common Pitfalls to Avoid

• Delaying fluid resuscitation is the single most important error—early aggressive fluids prevent acute kidney injury and improve survival 1, 2, 6
• Using inadequate fluid volumes (<6 L/day in severe cases) fails to prevent renal complications 2
• Missing hyperkalemia can result in sudden cardiac arrest 4, 2
• Failing to recognize compartment syndrome leads to irreversible muscle and nerve damage 4, 2
• Using potassium-containing fluids can precipitate fatal arrhythmias 1

Medication Review

Discontinue any medications or supplements that may worsen rhabdomyolysis:

• Statins 4
• Creatine monohydrate 4
• Red yeast rice 4

Duration of Treatment

Continue intravenous fluids until:

• CK levels decrease to <1,000 U/L 3
• Urine output remains adequate (>300 mL/hour) without support 2
• Electrolytes normalize 4
• Renal function stabilizes or improves 4