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

Immediate Management of Rhabdomyolysis

Begin 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

Aggressive IV fluid resuscitation is the single most critical intervention and should be initiated without delay, as postponing treatment significantly increases the risk of acute kidney injury and worsens outcomes. 2, 3

Fluid Administration 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, urine output remains adequate, electrolytes normalize, and renal function stabilizes 1

The Eastern Association for the Surgery of Trauma meta-analysis demonstrated that aggressive IVFR decreased both the incidence of acute renal failure and need for dialysis, though the quality of evidence was very low. 5 Despite limited high-quality evidence, early and aggressive fluid resuscitation remains the universally agreed-upon cornerstone of treatment. 6

Electrolyte Monitoring and Management

Monitor potassium levels closely and correct hyperkalemia emergently, as it can precipitate life-threatening cardiac arrhythmias including pulseless electrical activity where external defibrillation may be ineffective. 2, 3

Monitoring Protocol

• Check electrolytes every 6-12 hours in severe cases, including potassium, calcium, and phosphorus 1, 3
• Perform repeated bioassessment including plasma myoglobin, CK, and potassium measurements 2
• Treat hyperkalemia aggressively with standard protocols 1
• Correct significant electrolyte abnormalities promptly, including hypocalcemia and hyperphosphatemia 3
• Assess for metabolic acidosis, which commonly occurs in severe rhabdomyolysis 3

Medication Review

Immediately discontinue any causative agents, particularly statins, which are a common cause of drug-induced rhabdomyolysis. 2

Medications and Supplements to Stop

• Statins (especially simvastatin 80 mg) 2
• Red yeast rice containing lovastatin 2, 1
• Creatine monohydrate 2, 1
• Wormwood oil, licorice, and Hydroxycut 2
• Any other prescription medications that may contribute to rhabdomyolysis 1

Compartment Syndrome Surveillance

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

Clinical Assessment

• Early signs: pain, tension, paresthesia, and paresis 2
• Late signs: pulselessness and pallor, which often indicate 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

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

Pain Management

Use acetaminophen as the preferred initial analgesic at 500-1000 mg, with a maximum daily dose of 4-6 grams, as it avoids nephrotoxic effects that are particularly problematic in rhabdomyolysis patients already at high risk for acute kidney injury. 2

Pain Management Algorithm

• First-line: Acetaminophen 500-1000 mg (onset 15-30 minutes) 2
• Avoid all NSAIDs (ibuprofen, ketoprofen, diclofenac, naproxen, mefenamic acid) due to gastrointestinal and renal toxicity 2
• For severe pain unresponsive to acetaminophen: oral morphine 20-40 mg for opioid-naive patients 2
• If acute kidney injury with eGFR <30 mL/min: use fentanyl or buprenorphine as the safest opioid choices 2

Interventions NOT Recommended

Do not routinely use bicarbonate or mannitol, as neither improves the incidence of acute renal failure or need for dialysis in patients with rhabdomyolysis. 5

The Eastern Association for the Surgery of Trauma conditionally recommends against treatment with bicarbonate or mannitol based on their meta-analysis. 5 While some sources mention these agents as potential adjuncts, the highest quality evidence does not support their routine use. 6

Critical Pitfalls to Avoid

• 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 3
• Failure to monitor and correct hyperkalemia can lead to pulseless electrical activity and cardiac arrest 2, 3
• Missing compartment syndrome, particularly in traumatic or severe exertional cases, can result in irreversible muscle and nerve damage 3