From the Guidelines
Rhabdomyolysis (rhabdo) is characterized by muscle pain, weakness, and dark urine, and requires immediate medical attention to prevent serious complications such as acute kidney injury and electrolyte imbalances, as evidenced by studies showing that elevated CPK levels and myoglobin can lead to reduced glomerular filtration rate and increased mortality 1. The classic triad of rhabdomyolysis includes:
- Muscle pain
- Weakness
- Dark urine (tea or cola-colored) due to myoglobin release from damaged muscle cells Patients often experience severe muscle tenderness, swelling, and stiffness, particularly in the shoulders, thighs, lower back, and calves. Systemic symptoms may include:
- Fever
- Nausea
- Vomiting
- Confusion
- Extreme fatigue Some patients develop complications like acute kidney injury, which can manifest as decreased urine output. Electrolyte abnormalities, particularly elevated potassium levels, may cause heart rhythm disturbances. Monitoring creatine kinase levels, kidney function, and electrolytes is essential during treatment, and a repeated bio-assessment combining plasma myoglobin, plasma creatine phosphokinase (CPK) and kalaemia measurements is probably recommended to detect acute kidney injury in patients suffering from post-traumatic acute rhabdomyolysis after limb traumatic injury 1. Rhabdomyolysis occurs when muscle breakdown releases intracellular contents into the bloodstream, which can be triggered by trauma, extreme exercise, medications (particularly statins), infections, or prolonged immobility. Early recognition and treatment are crucial to prevent permanent kidney damage and other serious complications. Treatment typically involves aggressive IV fluid administration (often normal saline at 1-2 L/hour initially, then adjusted based on response) to prevent kidney damage. Bladder catheterisation to monitor hourly urine output and urine pH, which should be maintained at 6.5, is also recommended 1.
From the Research
Rhabdomyolysis Signs and Symptoms
- Rhabdomyolysis is a medical condition caused by muscle breakdown leading to potential renal damage, resulting in significant morbidity and mortality if not rapidly identified and treated 2
- The condition can cause the release of numerous intracellular molecules, including potassium, calcium, phosphate, uric acid, and creatinine kinase into the bloodstream 2
- Common signs and symptoms include:
- Myalgias (muscle pain)
- Muscle weakness
- Dark-colored urine
- Non-specific symptoms such as nausea and vomiting
- Severe disease may result in:
- Renal failure
- Electrolyte derangements
- Liver disease
- Compartment syndrome
- Disseminated intravascular coagulation
Diagnosis
- The diagnosis of rhabdomyolysis is often determined with an elevated creatinine kinase greater than five times the upper-limit of normal 2
- A creatine kinase level at least 10 times the upper limit of normal is typically considered diagnostic, as is myoglobinuria 3
- Additional testing is needed to evaluate for potential causes, electrolyte abnormalities, and acute kidney injury (AKI) 4
Treatment
- Treatment includes addressing the underlying etiology, as well as aggressive intravenous hydration with a goal urine output of 300 mL/h 2
- Early and aggressive fluid resuscitation to restore renal perfusion and increase urine flow is agreed on as the main intervention for preventing and treating AKI 4
- Sodium bicarbonate can be used for patients who are acidotic, and mannitol can be used for those whose urine output is not at goal 3
- Significant electrolyte abnormalities may be present and must be managed to avoid cardiac arrhythmias and arrest 3
- Compartment syndrome can develop as an early or late finding and requires decompressive fasciotomy for definitive management 3