What is the treatment for rhabdomyolysis?

Treatment of Rhabdomyolysis

Aggressive intravenous fluid resuscitation with isotonic saline is the cornerstone of treatment for rhabdomyolysis, targeting a urine output of 300 mL/hour, and must be initiated immediately upon diagnosis to prevent acute kidney injury and death. 1, 2

Immediate Fluid Resuscitation

Begin IV fluid resuscitation immediately upon diagnosis, as any delay significantly increases the risk of acute kidney injury and mortality. 1, 2

• Administer isotonic saline (0.9% NaCl) as the primary resuscitation fluid 1, 2
• Target urine output of 300 mL/hour to facilitate myoglobin clearance and prevent renal tubular obstruction 1, 3
• For severe rhabdomyolysis (CK >15,000 IU/L), infuse >6L of fluid per day 1, 4
• For moderate cases, use 3-6L per day 1, 4
• Monitor closely for fluid overload, particularly in patients with cardiac or renal compromise 1

The evidence consistently demonstrates that early and aggressive hydration is the single most important intervention, with delayed treatment associated with significantly worse outcomes 1, 2, 3.

Critical Electrolyte Management

Monitor potassium levels every 6-12 hours in severe cases, as hyperkalemia from muscle breakdown can precipitate life-threatening cardiac arrhythmias and sudden death. 1, 4

• Check complete electrolyte panels every 6-12 hours in severe cases 1
• Correct hyperkalemia promptly to prevent cardiac arrest 1, 2
• Address hypocalcemia and hyperphosphatemia, which commonly occur 1, 2
• Assess for metabolic acidosis through arterial blood gas analysis 1, 4
• Perform repeated bioassessment including plasma myoglobin, CK, and potassium measurements 1, 4

Medication Review and Discontinuation

Immediately discontinue any medications or supplements that may contribute to rhabdomyolysis. 1, 4

• Stop statins immediately if drug-induced rhabdomyolysis is suspected 4
• Discontinue creatine monohydrate, red yeast rice (contains lovastatin), wormwood oil, licorice, and Hydroxycut 4
• Cease the physical activity that triggered exertional rhabdomyolysis 1
• Avoid NSAIDs (ibuprofen, ketoprofen, diclofenac, naproxen) due to nephrotoxic effects 4

Monitoring for Compartment Syndrome

Maintain high suspicion for compartment syndrome, which can both cause and complicate rhabdomyolysis, particularly in traumatic or severe exertional cases. 1, 4

• Early signs include pain, tension, paresthesia, and paresis 1, 4
• Late signs include pulselessness and pallor, indicating irreversible damage 1, 4
• Perform early fasciotomy for established compartment syndrome 1, 4, 2
• Consider fasciotomy when compartment pressure exceeds 30 mmHg or when differential pressure (diastolic BP – compartment pressure) is <30 mmHg 4

Renal Replacement Therapy

Initiate RRT if CK remains persistently elevated despite 4 days of adequate hydration, as this indicates severe rhabdomyolysis with significant risk of irreversible kidney damage. 1, 2

• Early initiation of RRT is associated with improved outcomes in severe cases 1, 2
• Consider RRT for refractory hyperkalemia, severe metabolic acidosis, or progressive acute kidney injury 1
• Monitor renal function through serial creatinine and BUN measurements 1
• Assess urine output hourly with bladder catheterization; inadequate output (<300 mL/hour) suggests worsening kidney function 1
• Consider discontinuation of RRT when urine output recovers adequately (>100 mL/day) 1

Pain Management

Use acetaminophen as the first-line analgesic at 500-1000 mg (maximum 4-6 grams daily), as it avoids nephrotoxic effects that are particularly problematic in rhabdomyolysis patients. 4

• Reserve opioids for severe muscle pain unresponsive to acetaminophen 4
• Oral morphine is the opioid of first choice, starting at 20-40 mg for opioid-naive patients 4
• In patients with acute kidney injury (eGFR <30 ml/min), use fentanyl or buprenorphine as the safest opioid choices 4
• Provide round-the-clock dosing with rescue doses (10-15% of total daily dose) for breakthrough pain 4

Supportive Care

• Provide supplemental oxygen to address potential hypoxemia 1, 2
• Consider cooling measures if hyperthermia is present to protect against fulminating rhabdomyolysis 1, 2
• Support vital signs as needed 1
• Ensure rapid transport to a medical facility for severe cases 1

Common Pitfalls to Avoid

• Delaying fluid resuscitation is the most critical error, associated with higher risk of acute kidney injury and worse outcomes 1, 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, 4
• Missing compartment syndrome, particularly in traumatic or severe exertional cases, can result in irreversible muscle and nerve damage 1

Special Considerations for Athletes with Sickle Cell Trait

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. 1

Controversial Interventions

While bicarbonate and mannitol have been historically used, recent evidence suggests they do not possess strong evidence for improved outcomes 3. After ensuring adequate volume expansion, a diuretic challenge with furosemide may help assess kidney function in select cases, with response potentially predicting successful recovery 1.