What is the immediate management for a patient diagnosed with rhabdomyolysis?

Immediate Management of Rhabdomyolysis

Initiate 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 and Fluid Management

The cornerstone of rhabdomyolysis treatment is early, aggressive fluid resuscitation—delays significantly increase the risk of acute kidney injury and worsen outcomes. 2, 1, 3

Fluid resuscitation protocol:

• Start 0.9% normal saline at 1000 mL/hour immediately upon patient contact 1
• Target urine output of 300 mL/hour once bladder catheterization is established 1, 3, 4
• For severe rhabdomyolysis (CK >15,000 IU/L), administer >6L of fluid per day 2, 3
• For moderate cases, use 3-6L per day 2, 3
• Avoid potassium-containing fluids and starch-based fluids 1
• Continue IV fluids until CK levels decrease below 1,000 U/L, urine output remains adequate, electrolytes normalize, and renal function stabilizes 1, 4

The evidence strongly supports aggressive fluid resuscitation: a meta-analysis by the Eastern Association for the Surgery of Trauma found that IVFR decreased the incidence of acute renal failure and need for dialysis, though the quality of evidence was very low due to predominantly retrospective studies. 5 Despite this limitation, the clinical consensus is clear—early vigorous fluid resuscitation with ≥12L daily has reduced mortality from nearly 100% to <20% in crush syndrome cases over the past 70 years. 6

Electrolyte Monitoring and Management

Monitor electrolytes every 6-12 hours, with particular attention to potassium, as hyperkalemia can precipitate life-threatening cardiac arrhythmias. 2, 1, 3

• Check plasma myoglobin, CK, and potassium repeatedly 2
• Monitor calcium, phosphorus, and magnesium levels 1
• Treat hyperkalemia aggressively with standard protocols 1
• Assess for metabolic acidosis, which commonly occurs in severe cases 2, 3
• Perform ECG and cardiac troponin to rule out cardiac involvement 2

Critical pitfall: Failure to monitor and correct hyperkalemia can lead to pulseless electrical activity and cardiac arrest, particularly in patients with sickle cell trait where external defibrillation may be ineffective. 3

Medication Review

Immediately discontinue any causative agents or medications that may worsen rhabdomyolysis. 2, 1, 3

Stop the following:

• Statins and other prescription medications 2
• Red yeast rice containing lovastatin 2, 1, 3
• Creatine monohydrate 2, 1, 3
• Wormwood oil, licorice, and Hydroxycut 2
• All NSAIDs (ibuprofen, ketoprofen, diclofenac, naproxen, mefenamic acid) due to nephrotoxic effects 2

Pain Management

Use acetaminophen as the preferred initial analgesic at 500-1000 mg (maximum 4-6 grams daily) to avoid nephrotoxic effects of NSAIDs. 2

• Acetaminophen has onset of action in 15-30 minutes and avoids nephrotoxicity 2
• Reserve opioids for severe muscle pain unresponsive to acetaminophen 2
• If opioids are needed, use oral morphine 20-40 mg for opioid-naive patients 2
• In patients with acute kidney injury (eGFR <30 mL/min), use fentanyl or buprenorphine as the safest opioid choices 2

Compartment Syndrome Surveillance

Maintain high suspicion for compartment syndrome, which can both cause and complicate rhabdomyolysis. 2, 3

• Early signs: pain, tension, paresthesia, and paresis 2
• Late signs: pulselessness and pallor (indicating irreversible damage) 2
• Perform early fasciotomy when compartment pressure exceeds 30 mmHg or when differential pressure (diastolic BP – compartment pressure) is <30 mmHg 2, 1, 3

Renal Replacement Therapy Indications

Initiate dialysis early for specific indications rather than waiting for complete renal failure. 1, 3

Indications for RRT:

• Refractory hyperkalemia 1, 3
• Severe metabolic acidosis 1, 3
• Fluid overload 1
• Persistently elevated CK levels after 4 days of adequate hydration 1, 3
• Progressive acute kidney injury 3

Early initiation of RRT is associated with improved outcomes in severe cases. 3

Adjunctive Therapies: What NOT to Use

Do not routinely use sodium bicarbonate or mannitol for rhabdomyolysis treatment. 5

The Eastern Association for the Surgery of Trauma conditionally recommends against bicarbonate or mannitol, as neither improved the incidence of acute renal failure or need for dialysis in their meta-analysis. 5 However, sodium bicarbonate may be considered for patients who are acidotic 4, and mannitol may be used if urine output is not at goal after adequate fluid resuscitation 4. These represent salvage therapies rather than routine interventions.

Additional Supportive Measures

• Provide supplemental oxygen to address potential hypoxemia 3
• Consider cooling measures if hyperthermia is present 3
• Support vital signs as needed 3
• Ensure rapid transport to a medical facility for severe cases 3