What is the immediate treatment for rhabdomyolysis (muscle breakdown disease)?

Immediate Treatment for Rhabdomyolysis

Initiate aggressive intravenous fluid resuscitation with isotonic saline immediately upon diagnosis, targeting a urine output of 300 mL/hour, as this is the cornerstone of treatment and early initiation is critical to prevent acute kidney injury and death. 1, 2, 3

Initial Resuscitation and Fluid Management

Begin IV fluid resuscitation without delay, as postponing treatment significantly increases the risk of acute kidney injury and mortality. 2, 3, 4

• Administer isotonic saline (0.9% NaCl) as the fluid of choice for volume expansion. 2, 3
• For severe rhabdomyolysis (CK >15,000 IU/L), infuse >6L per day; for moderate cases, use 3-6L per day. 1, 2
• Target urine output of 300 mL/hour to facilitate myoglobin clearance and prevent renal tubular obstruction. 2, 5
• Place a bladder catheter for hourly urine output monitoring; inadequate output (<300 mL/hour) suggests worsening kidney function. 2
• Monitor closely for fluid overload, particularly in patients with cardiac or renal compromise. 2

Critical Electrolyte Monitoring and Correction

Monitor potassium levels immediately and repeatedly, as hyperkalemia from muscle breakdown can precipitate life-threatening cardiac arrhythmias and sudden cardiac arrest. 1, 2, 3

• Obtain an ECG immediately to identify cardiac manifestations of hyperkalemia. 6
• Check complete electrolyte panel including potassium, calcium, phosphorus, and magnesium. 1
• Perform repeated bioassessment including plasma myoglobin, CK, and potassium measurements. 1
• Check electrolyte panels every 6-12 hours in severe cases. 2
• Correct significant hyperkalemia, hypocalcemia, and hyperphosphatemia promptly. 1, 2, 3
• Assess for metabolic acidosis, which commonly occurs in severe rhabdomyolysis. 2

Medication Management

Immediately discontinue any causative agents, including statins, succinylcholine, and high-risk supplements. 7, 1, 2

• Stop all statins and other prescription medications that may contribute to rhabdomyolysis. 1
• Discontinue dietary supplements including red yeast rice (containing lovastatin), creatine monohydrate, wormwood oil, licorice, and Hydroxycut. 1, 2
• Avoid succinylcholine in all myopathic patients due to risk of worsening rhabdomyolysis and hyperkalemia. 7
• After ensuring adequate volume expansion, consider a diuretic challenge with furosemide to assess kidney function in select cases, though this is not first-line therapy. 2

Compartment Syndrome Surveillance

Maintain high suspicion for compartment syndrome, which can both cause and complicate rhabdomyolysis, particularly in trauma or severe exertional cases. 1, 2, 3

• Early signs include pain, tension, paresthesia, and paresis. 1
• Late signs include pulselessness and pallor, which often indicate irreversible damage. 1
• Perform early fasciotomy for established compartment syndrome. 1, 2, 3
• Consider fasciotomy when compartment pressure exceeds 30 mmHg or when differential pressure (diastolic BP – compartment pressure) is <30 mmHg. 1, 2

Supportive Care

• Provide supplemental oxygen to address potential hypoxemia. 2, 3
• Consider cooling measures if hyperthermia is present to protect against fulminating rhabdomyolysis. 2, 3
• Cease the physical activity that triggered the event immediately. 2
• Support vital signs as needed. 2

What NOT to Do: Avoiding Common Pitfalls

Do not routinely use bicarbonate or mannitol, as neither improves outcomes in rhabdomyolysis and may cause harm. 4, 5, 8

• The Eastern Association for the Surgery of Trauma conditionally recommends against treatment with bicarbonate or mannitol based on meta-analysis showing no benefit for acute renal failure or dialysis need. 4
• There is little evidence beyond animal studies to support routine use of bicarbonate-containing fluids, mannitol, or loop diuretics. 8
• Delaying fluid resuscitation is associated with higher risk of acute kidney injury and worse outcomes. 2, 3
• Inadequate fluid volume (using <6L/day in severe cases) may fail to prevent renal complications. 2
• Failure to monitor and correct hyperkalemia can lead to pulseless electrical activity and cardiac arrest. 2

Advanced Interventions for Severe Cases

Initiate renal replacement therapy (RRT) if CK remains persistently elevated despite 4 days of adequate hydration, as this indicates severe rhabdomyolysis with significant risk of irreversible kidney damage. 2, 3

• Early RRT initiation is associated with improved outcomes in severe cases. 2, 3
• Consider RRT for refractory hyperkalemia, severe metabolic acidosis, or progressive acute kidney injury. 2
• Consider discontinuation of RRT when urine output recovers adequately (>100 mL/day). 2

Special Considerations

For high-voltage electrocution victims, ensure the power source is completely disconnected before approaching to prevent further injury. 3

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. 2