Rhabdomyolysis in Emergency Medicine Treatment & Management

  • Author: Sandy Craig, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Sep 21, 2011
 

Prehospital Care

Vigorous hydration with isotonic crystalloid is the cornerstone of therapy for rhabdomyolysis. Retrospective studies of patients with severe crush injuries resulting in rhabdomyolysis suggest that the prognosis is better when prehospital personnel provide fluid resuscitation.[40] Support of the intravascular volume increases the glomerular filtration rate (GFR) and oxygen delivery and dilutes myoglobin and other renal tubular toxins.

Immediately obtain intravenous access with a large-bore catheter.

Administer isotonic crystalloid 500 mL/h and then titrate to maintain a urine output of 200-300 mL/h.

Because injured myocytes can sequester large volumes of extracellular fluid, crystalloid requirements may be surprisingly large.

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Emergency Department Care

Assess ABCs and support as needed. Treat any underlying conditions, such as trauma, infection, or toxins. General recommendations for the treatment of rhabdomyolysis include fluid resuscitation and prevention of end-organ complications.

Patients with CK elevation in excess of 2-3 times the reference range, appropriate clinical history, and risk factors should be suspected of having rhabdomyolysis. Administer isotonic crystalloid 500 mL/h and titrate to maintain a urine output of 200-300 mL/h. In patients with CK ≥15,000 IU/L, higher volumes of fluid, on the order of 6 L in adults, are required.[41] (Consider central venous pressures or Swan-Ganz catheterization in patients with cardiac or renal disease. These invasive studies can assist in the assessment of the intravascular volume.) Repeat CK assay every 6-12 hours in order to determine peak CK level.

Acute renal failure develops in 30-40% of patients with rhabdomyolysis. Suggested mechanisms include precipitation of myoglobin and uric acid crystals within renal tubules, decreased glomerular perfusion, and the nephrotoxic effect of ferrihemate (formed upon dissociation of myoglobin in the acidic environment of the renal parenchyma). In a 1988 review, Ward suggested that predictors for the development of renal failure include peak CK level more than 6000 IU/L, dehydration (hematocrit >50, serum sodium level >150 mEq/L, orthostasis, pulmonary wedge pressure < 5 mm Hg, urinary fractional excretion of sodium < 1%), sepsis, hyperkalemia or hyperphosphatemia on admission, and the presence of hypoalbuminemia. Acute renal failure has occasionally developed in severely dehydrated patients with peak CK level as low as 2000 IU/L. To prevent renal failure, many authorities advocate urine alkalinization, mannitol, and loop diuretics.

Urinary alkalinization to prevent the development of acute renal failure in patients with rhabdomyolysis has been supported by animal studies and retrospective human studies, although prospective randomized human studies are lacking. Urinary alkalinization is recommended for patients with rhabdomyolysis and CK levels in excess of 6000 IU/L. Alkalinization should be considered earlier in patients with acidemia, dehydration, or underlying renal disease. A suggested regimen is 0.5 isotonic sodium chloride solution with one ampule of sodium bicarbonate administered at 100 mL/h and titrated to a urine pH higher than 7. After establishing an adequate intravascular volume, mannitol may be administered to enhance renal perfusion. Loop diuretics may be used to enhance urinary output in oliguric patients, despite adequate intravascular volume.

Treatment of hyperkalemia consists of intravenous sodium bicarbonate, glucose, and insulin; oral or rectal sodium polystyrene sulfonate (Kayexalate); and hemodialysis. Administer intravenous calcium chloride for patients who are hemodynamically compromised and hyperkalemic.

Hypocalcemia is noted early in the course of rhabdomyolysis and generally is not of clinical significance. Calcium supplementation is not recommended.

Compartment syndrome requires immediate orthopedic consultation for fasciotomy.

DIC should be treated with fresh frozen plasma, cryoprecipitate, and platelet transfusions.

Hyperuricemia and hyperphosphatemia rarely are of clinical significance and rarely require treatment.

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Consultations

Nephrologist

Indications for hemodialysis include hyperkalemia that is persistent despite therapy, severe acid-base disturbances, refractory pulmonary edema, and progressive renal failure.

Orthopedist

Consult an orthopedist in cases of suspected compartment syndrome.

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Contributor Information and Disclosures
Author

Sandy Craig, MD  Residency Program Director, Carolinas Medical Center; Associate Professor, Department of Emergency Medicine, University of North Carolina at Chapel Hill School of Medicine

Sandy Craig, MD is a member of the following medical societies: Alpha Omega Alpha and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Lance W Kreplick, MD, FAAEM, MMM  Medical Director of Hyperbaric Medicine, Fawcett Wound Management and Hyperbaric Medicine; Consulting Staff in Occupational Health and Rehabilitation, Company Care Occupational Health Services; President and Chief Executive Officer, QED Medical Solutions, LLC

Lance W Kreplick, MD, FAAEM, MMM, is a member of the following medical societies: American Academy of Emergency Medicine and American College of Physician Executives

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Tom Scaletta, MD  Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

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