Immediate Treatment for Rhabdomyolysis
Start aggressive intravenous fluid resuscitation with 0.9% normal saline at 1 liter per hour immediately upon diagnosis to prevent acute kidney injury and reduce mortality. 1
Initial Resuscitation Protocol
Fluid administration is the cornerstone of treatment and must begin without delay:
- Administer isotonic saline (0.9% NaCl) at 1000 mL/hour as soon as rhabdomyolysis is suspected 1
- Target urine output of 300 mL/hour once bladder catheterization is established 1
- For severe rhabdomyolysis (CK >15,000 IU/L), volumes greater than 6L per day may be required 2
- For moderate cases (CK <15,000 IU/L), 3-6L per day is typically sufficient 2, 3
- Early initiation is critical—delayed fluid resuscitation significantly increases the risk of acute kidney injury 2, 3, 4
The evidence strongly supports aggressive crystalloid resuscitation. A meta-analysis by the Eastern Association for the Surgery of Trauma found that intravenous fluid resuscitation decreased both the incidence of acute renal failure and need for dialysis 5. Historical data from crush syndrome patients demonstrates mortality reduction from nearly 100% to <20% with early vigorous fluid therapy 4.
Immediate Electrolyte Assessment and Monitoring
Check serum potassium and obtain an ECG immediately to identify life-threatening hyperkalemia:
- Monitor electrolytes (particularly potassium, calcium, phosphorus) every 6-12 hours 1
- Treat hyperkalemia aggressively with standard protocols if present 1
- Perform repeated bioassessments of plasma myoglobin, CK, and potassium 2, 3
- Avoid potassium-containing fluids during resuscitation 1
Discontinue Causative Agents
Immediately stop any medications or substances that may be causing or worsening rhabdomyolysis:
- Discontinue statins if drug-induced rhabdomyolysis is suspected 2
- Stop dietary supplements including red yeast rice, creatine monohydrate, wormwood oil, licorice, and Hydroxycut 2, 1
- Review and discontinue any other potentially nephrotoxic medications 2
What NOT to Do
Do not routinely use bicarbonate or mannitol—the evidence does not support these interventions:
- The Eastern Association for the Surgery of Trauma conditionally recommends against bicarbonate administration, as it does not improve acute renal failure rates or reduce dialysis need 5
- Mannitol similarly shows no benefit and is contraindicated in patients with oligoanuria 3, 5
- Osmotic diuretics may only potentially benefit patients with CK >30,000 U/L, but even this remains undefined and should only be used after adequate volume expansion 3
- Avoid NSAIDs for pain management due to nephrotoxic effects; use acetaminophen 500-1000 mg as first-line analgesia instead 2
Monitor for Compartment Syndrome
Maintain high suspicion for compartment syndrome, which can both cause and complicate rhabdomyolysis:
- Early signs include pain, tension, paresthesia, and paresis 2
- Late signs (pulselessness, pallor) indicate irreversible damage 2
- Perform early fasciotomy when compartment pressure exceeds 30 mmHg or differential pressure (diastolic BP minus compartment pressure) is <30 mmHg 2, 1
Duration of Treatment
Continue aggressive intravenous fluids until all of the following criteria are met:
- CK levels are decreasing 1
- Urine output remains adequate 1
- Electrolytes normalize 1
- Renal function stabilizes or improves 1
Indications for Dialysis
Initiate renal replacement therapy early for:
- Refractory hyperkalemia 1
- Severe metabolic acidosis 1
- Fluid overload 1
- Persistently elevated CK levels after 4 days of adequate hydration 1
Common pitfall: Waiting too long to start fluid resuscitation is the most critical error. Treatment should begin in the emergency department or even at the scene of injury for trauma patients, as early intervention is associated with better outcomes 4. The large volumes required (often >12L daily in severe cases) may seem excessive but are well-tolerated in young, carefully monitored patients 4.