eMedicine Specialties > Pediatrics: General Medicine > Rheumatology

Rhabdomyolysis: Follow-up

Author: Eyal Muscal, MD, Assistant Professor, Section of Pediatric Rheumatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital
Coauthor(s): Marietta Morales de Guzman, MD, Assistant Professor, Department of Pediatrics, Baylor College of Medicine; Consulting Staff, Section of Pediatric Rheumatology, Department of Pediatrics, Texas Children's Hospital, Ben Taub General Hospital; Renee Wilson, MD, Clinical Assistant Instructor, Department of Emergency Medicine, SUNY-Downstate and Kings County Hospital; Binita R Shah, MD, FAAP, Professor of Clinical Pediatrics and Emergency Medicine, SUNY Health Science Center at Brooklyn, Director of Pediatric Emergency Medicine, Depts of Emergency Medicine and Pediatrics, Kings County Hospital Center
Contributor Information and Disclosures

Updated: Dec 8, 2008

Follow-up

Further Inpatient Care

  • In general, patients with rhabdomyolysis should be admitted for observation and correction of fluid and electrolyte imbalances.
  • Provide patients with adequate hydration and record urine output. Assess for development of acute renal failure and need for dialysis.
  • Monitor cardiac function and check and correct electrolyte levels, as indicated.
  • Monitor creatine kinase (CK) levels to show resolution of rhabdomyolysis.

Further Outpatient Care

  • Once well-hydrated, patients with normal renal function, normal electrolyte levels, alkaline urine, and an isolated cause of muscle injury may be discharged and monitored as outpatients.

Inpatient & Outpatient Medications

  • Adequate hydration is required, and no specific outpatient medications are needed. Inciting myotoxic agents should be stopped.

Transfer

  • The patient should be initially stabilized, and life-threatening electrolyte abnormalities should be corrected. Once stabilized, the patient may be transferred if the hospital is not equipped to provide the critical care monitoring and specialized orthopedic procedures.
  • In natural disasters, patients often have to be evacuated out of affected areas and transported to locations that can provide dialysis services.5

Deterrence/Prevention

  • Once identified, the patient must avoid any preventable inciting cause of rhabdomyolysis. 
  • Exercise should be reduced or avoided if this is the cause or exacerbating factor of rhabdomyolysis.
  • Alcohol should be avoided.
  • Overdose of drugs such as narcotics, sedative hypnotics, or any other drug known to cause immobilization and, hence, pressure necrosis should be avoided. Proper mental health and drug rehabilitation services should be offered to individuals with substance use disorders.
  • Use of stimulants (eg, cocaine, amphetamines, ecstasy) should be discouraged.
  • Compliance with seizure and asthma medications may reduce status epilepticus, status asthmaticus, or both.
  • Risky behavior that results in trauma should be avoided.

Complications

  • Electrolyte abnormalities are prominent features of rhabdomyolysis. Hyperphosphatemia, hyperkalemia, hypocalcemia, hyperuricemia, and hypoalbuminemia have been reported.
  • Compartment syndrome may be a complication of or the inciting cause of rhabdomyolysis. Measure compartment pressures if muscle injury has occurred and perform a fasciotomy if the pressure is more than 30 mm Hg.5
  • Acute renal failure and disseminated intravascular coagulation are the most severe complications of rhabdomyolysis.

    • If rhabdomyolysis is not adequately treated, approximately one-third of adult patients develop renal failure. This figure may be significantly lower in children.2
    • Renal failure may also develop in patients treated with optimal measures.
    • If renal failure and electrolyte abnormalities are not addressed, death can occur from causes such as cardiac arrhythmias (and hyperkalemic cardiac arrest) and seizures.

Prognosis

  • Implementation of the treatment modalities above (see Treatment) has reduced morbidity and mortality. In a 10-year retrospective pediatric review, only 13 of 191 (6%) of patients died. Nine of these patients presented in cardiopulmonary arrest and could not be resuscitated.2
  • Rapid intervention and appropriate supportive therapies of rhabdomyolysis-related renal failure improve outcomes in traumatic crush injuries. The ability of medical response teams to provide aggressive hydration and dialysis services enhances survival in large-scale natural disasters such as earthquakes. If treatment modalities are implemented early, many patients completely recover.

Patient Education

  • Educate patients about the causes of rhabdomyolysis and its prevention.
  • Provide genetic counseling for families with inherited muscle enzyme and energy substrate deficiencies.
  • Educate high-school and college athletes about proper hydration and signs of dehydration and heat-related injuries.

Miscellaneous

Medicolegal Pitfalls

  • Patients may present without any obvious history or physical sign of rhabdomyolysis. The physician must be aware of the subtle presentation and keep the diagnosis in mind. Failure to consider this diagnosis could result in the most severe complication of rhabdomyolysis, pigment-associated renal failure.
  • Rhabdomyolysis accounts for 5-25% of cases of renal failure in adult patients. Rates in pediatric patients are unknown.

Special Concerns

  • Consider rhabdomyolysis in cases of child abuse, drug-overdoses, heat-related events and pediatric orthopedic injuries.
 


More on Rhabdomyolysis

Overview: Rhabdomyolysis
Differential Diagnoses & Workup: Rhabdomyolysis
Treatment & Medication: Rhabdomyolysis
Follow-up: Rhabdomyolysis
References
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References

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Further Reading

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Keywords

rhabdomyolysis, muscle weakness, myalgia, dark urine, myoglobinuria, sarcolemma, acute renal failure, myoglobin-induced acute renal failure, nephrotoxicity, malignant hyperthermia, crush injury, disseminated intravascular coagulation, cellular membrane injury, muscle cell hypoxia, ATP depletion, myoglobin-induced acute renal failure, hyperphosphatemia, hyperkalemia, hypocalcemia, hyperuricemia, hypoalbuminemia, viral myositis, renal insufficiency, diabetic ketoacidosis, compartment syndromes, Epstein-Barr virus, parainfluenza, cytomegalovirus, herpes family viruses varicella, human immunodeficiency virus, HIV, tularemia, Legionella infection, Salmonella species, neuroleptic malignant syndrome, hyperglycemic hyperosmolar nonketotic syndrome, cocaine, respiratory failure, status asthmaticus

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Contributor Information and Disclosures

Author

Eyal Muscal, MD, Assistant Professor, Section of Pediatric Rheumatology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital
Eyal Muscal, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Rheumatology, and Clinical Immunology Society
Disclosure: Nothing to disclose.

Coauthor(s)

Marietta Morales de Guzman, MD, Assistant Professor, Department of Pediatrics, Baylor College of Medicine; Consulting Staff, Section of Pediatric Rheumatology, Department of Pediatrics, Texas Children's Hospital, Ben Taub General Hospital
Marietta Morales de Guzman, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Rheumatology, and Texas Pediatric Society
Disclosure: Nothing to disclose.

Renee Wilson, MD, Clinical Assistant Instructor, Department of Emergency Medicine, SUNY-Downstate and Kings County Hospital
Renee Wilson, MD is a member of the following medical societies: Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Binita R Shah, MD, FAAP, Professor of Clinical Pediatrics and Emergency Medicine, SUNY Health Science Center at Brooklyn, Director of Pediatric Emergency Medicine, Depts of Emergency Medicine and Pediatrics, Kings County Hospital Center
Binita R Shah, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Barry L Myones, MD, Associate Professor, Departments of Pediatrics and Immunology, Pediatric Rheumatology Section, Baylor College of Medicine; Director of Research, Pediatric Rheumatology Center, Texas Children's Hospital
Barry L Myones, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American College of Rheumatology, American Heart Association, American Society for Microbiology, Clinical Immunology Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

David D Sherry, MD, Director, Clinical Rheumatology, Attending Physician, Pain Management, The Children's Hospital of Philadelphia; Professor of Pediatrics, University of Pennsylvania
David D Sherry, MD is a member of the following medical societies: American College of Rheumatology and American Pain Society
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

Chief Editor

Herbert S Diamond, MD, Professor of Medicine, Temple University School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital
Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa
Disclosure: medifocus Honoraria Review panel membership; health dialogs Honoraria Consulting; Merck, Amgen, Biogen, Zimmer, Wyeth, Johnson&Johnson, Stryker, Medtronic, Zimmer.Abbott,  Ownership interest Other; West Penn Allegheny Health System Consulting fee Consulting; Alpharma Honoraria Consulting; Proctor&Gamble Grant/research funds Independent contractor

 
 
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