Emergency Management of Suspected Rhabdomyolysis
Do not give steroids routinely in rhabdomyolysis—they have no role in standard management and should only be considered for specific complications like inotrope-resistant shock in septic patients. 1
Immediate Fluid Resuscitation Protocol
Your current IV fluid bolus is correct, but you need to escalate aggressively:
- Start 0.9% normal saline at 1000 mL/hour immediately while awaiting CK results 2, 3, 4
- Target urine output of ≥300 mL/hour (approximately 3-5 mL/kg/hour for a 70 kg patient)—this is 6-10 times higher than standard oliguria thresholds 2
- Insert a bladder catheter now to monitor hourly urine output unless urethral injury is suspected 2, 3, 4
Fluid Volume Requirements Based on CK Level
Once CK results return, adjust your strategy:
- If CK >30,000 U/L (severe rhabdomyolysis): administer >6L per day 2
- If CK 5,000-30,000 U/L (moderate): administer 3-6L per day 2
- Continue aggressive fluids until CK levels decrease and urine output remains adequate 3
Critical Fluid Selection Points
Avoid these fluids entirely:
- No Lactated Ringer's, Hartmann's solution, or Plasmalyte A—potassium levels can spike markedly after reperfusion even with intact renal function 2, 3, 4
- No starch-based colloids—associated with increased acute kidney injury and bleeding 2, 4
- Use only 0.9% normal saline for initial resuscitation 2, 3
What NOT to Give (Common Pitfalls)
Steroids: No role in rhabdomyolysis management unless the patient develops inotrope-resistant shock from sepsis 1. The evidence shows steroids do not improve outcomes in rhabdomyolysis itself 1.
Bicarbonate for urinary alkalinization: Current evidence does not support routine bicarbonate use—aggressive fluid resuscitation alone is sufficient 2. Only give bicarbonate for life-threatening hyperkalemia or severe metabolic acidosis (pH <7.1), not for prophylactic urine alkalinization 2.
Mannitol: Not recommended routinely—studies show little benefit over crystalloid resuscitation alone and it is potentially nephrotoxic 2. May only benefit patients with CK >30,000 U/L, but even this is undefined 2.
Essential Monitoring Parameters
Order these labs every 6-12 hours in severe cases:
- CK levels (trend until decreasing) 2, 3
- Creatinine and BUN 3
- Potassium, calcium, and phosphorus—hyperkalemia is life-threatening and common 2, 3
- Urine myoglobin if available 2
- Urine pH (target approximately 6.5) 2
Additional Acute Management
Medication review: Immediately discontinue any statins, creatine supplements, or red yeast rice if the patient is taking them 3.
Compartment syndrome surveillance: Maintain high suspicion and check compartment pressures if there is any limb swelling or trauma—perform early fasciotomy if pressure >30 mmHg 3.
Hyperkalemia protocol: Have standard hyperkalemia treatment ready (calcium gluconate, insulin/dextrose, albuterol) as potassium can rise rapidly 2, 3.
When to Escalate Care
Consult nephrology early if:
- CK >30,000 U/L 2
- Refractory hyperkalemia despite treatment 3
- Oliguria persists despite adequate fluid resuscitation 2
- Creatinine rising despite fluids 3
- Fluid overload develops (pulmonary edema, hypoxia) 5, 6
Dialysis indications: Refractory hyperkalemia, severe metabolic acidosis, fluid overload despite conservative management, or persistently elevated CK after 4 days of adequate hydration 2, 3.
COVID-19 and Influenza Considerations
Since you're awaiting viral PCR results, be aware that both COVID-19 and influenza can cause severe rhabdomyolysis directly through viral myositis 7, 8, 5, 9, 6. However, this does not change your acute management—aggressive fluid resuscitation remains the cornerstone 7, 6.
Critical caveat for COVID-19 patients: If the patient has COVID pneumonia, fluid resuscitation must be more cautious to avoid worsening oxygenation and acute respiratory failure from fluid overload 5, 6. Monitor oxygen saturation closely and consider earlier ICU consultation if respiratory status deteriorates with fluids 6.