Rhabdomyolysis
Publication Date: January 24, 2022
Last Updated: March 14, 2022
Trauma patients
Rhabdomyolysis should be suspected in patients with a large burden of traumatic injury involving muscular tissue, especially patients with crush injuries involving the extremities or mangled extremities. Patients with vascular injuries or muscle ischemia with subsequent reperfusion are also at higher risk for rhabdomyolysis.
Metabolic etiologies
Rhabdomyolysis should be suspected in any patient with a medical condition causing increased metabolic demands on myocytes in excess of the available supply of ATP. This may result from extreme exertional demands on skeletal muscle from exercise, exogenous agents such as drugs or toxins, genetic defects or myopathies affecting the muscle cell, and infections.
Clinical findings
Rhabdomyolysis presentation may vary from asymptomatic to commonly implicated clinical features, including acute muscle weakness, pain/tenderness, and swelling (dolor, tumor) of the affected extremity or body region.12 Darkened (tea-colored) urine may be an additional common finding. A low threshold of clinical suspicion in the proper laboratory and historical context is warranted to initiate appropriate therapy.
Laboratory findings
The most commonly implicated variables include elevated serum concentrations of CK (>5× the upper limit of normal or >1000 IU/L), myoglobin, lactate dehydrogenase (LDH), potassium, creatinine, and aspartate aminotransferase (AST). Elevated urine myoglobin provides additional evidence. A low threshold of suspicion in the proper clinical context is warranted to initiate appropriate therapy. A strategy for disease monitoring with serial CK measurement should be additionally undertaken. Interval CK values should be followed until a peak concentration is identified (typically at 24–72 hours), discontinued once the CK is reliably downtrending.
Management
- Either lactated Ringer’s solution or saline (0.9% or 0.45%) is an acceptable fluid for resuscitation in rhabdomyolysis. A starting rate of 400 mL/hour can be initiated, with goal-directed therapy of urine output of 1 mL/kg/hour to 3 mL/kg/hour, and up to 300 cc/hour.
- Clinical studies evaluating the efficacy of sodium bicarbonate and/or diuretic use (mannitol, loop diuretics) for prevention of rhabdomyolysis-induced AKI are limited by a lack of appropriate control groups, standardized definitions, retrospective design, and low statistical power. Given these significant limitations, the use of sodium bicarbonate or diuretics for prevention of AKI in rhabdomyolysis is not recommended.
- Hyperkalemia, hyperphosphatemia, and hypocalcemia are electrolyte abnormalities most commonly encountered when treating rhabdomyolysis. Correcting biochemical equilibrium and electrolytes during rhabdomyolysis should proceed meticulously to avoid complications from treatment. Hyperkalemia is the electrolyte abnormality that requires timely correction to reduce risk of cardiac arrhythmia.
- There is no role for RRT (either continuous (CRRT) or intermittent) in rhabdomyolysis to prevent AKI. The utilization of RRT in patients with rhabdomyolysis should be based on traditional indications for AKI and the degree of renal impairment.
- In patients with rhabdomyolysis who develop AKI and need RRT, either CRRT or intermittent RRT should be used based on the degree of renal impairment and the clinical status of the patient. There are no recommendations regarding RRT modalities (filtration vs. diffusion), filter type (low vs. high cut-off membranes), or high-flow versus low-flow dialysis.
Outcomes
- Clinicians should monitor for a variety of complications, ranging from an asymptomatic elevation of muscle protein to an accumulation of electrolyte imbalances, edema, and toxic cellular components. Morbidity can present early or late, including hyperkalemia, hepatic dysfunction, cardiac dysfunction, AKI, acute renal failure (ARF), disseminated intravascular coagulation (DIC), and compartment syndrome. AKI is the most common systemic complication of rhabdomyolysis and is responsible for most of the morbidity and mortality associated with rhabdomyolysis.
- The risk of AKI, RRT, and/or in-hospital mortality in patients with rhabdomyolysis can be estimated using admission demographic, clinical, and laboratory variables. Risk prediction scores may not directly influence treatment; however, they may be useful in estimating prognosis and setting expectations. As no single laboratory value is sufficient to predict the course of rhabdomyolysis, a combined index of metrics, the McMahon Score (table 1), may be calculated at admission for prognostication.3 A score greater than or equal to 6 is predictive of a need for high-volume fluid resuscitation, RRT, and death.
Rhabdomyolysis consensus summary
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| Problem | Recommendations/findings |
| Populations at risk | Large burden of injury involving muscle. Vascular injury or muscle ischemia. Extreme exertional demands/toxins. |
| Clinical findings | May be asymptomatic. Acute muscle weakness. Pain/tender/swelling involved extremity. |
| Laboratory findings | CK >5× upper limit of normal or >1000 IU/L. Elevated myoglobin, LDH, K+, Cr, and AST. |
| Fluid management | LR or NaCl (0.9 or 0.45%) initiated at 400 cc/hour. |
| Urine output goals | 1–3 cc/kg/hour. Up to 300 cc/hour. |
| Diuretic/bicarbonate therapy | Diuretics not recommended. Bicarbonate not recommended. |
| Electrolyte abnormalities | Elevated K+ and phosphate. Decreased calcium. |
| Renal replacement therapy | No role for RRT in AKI prevention. Rhabdo with AKI: CRRT or intermittent RRT. No recommendation on RRT modalities. |
| Complications of rhabdomyolysis | AKI. DIC. Compartment syndrome. |
| Predictors of AKI development | Based on demographic and clinical laboratory variables. McMahon Score for RRT need. |
Recommendation Grading
Overview
Title
Rhabdomyolysis
Authoring Organization
American Association for the Surgery of Trauma
Publication Month/Year
January 24, 2022
Last Updated Month/Year
August 28, 2024
Document Type
Consensus
Country of Publication
US
Document Objectives
Rhabdomyolysis is a condition characterized by primary (mechanical) or secondary (metabolic) skeletal muscle injury, resulting in cell death and release of potentially toxic substances into circulation. Management often centers on prevention or treatment of the primary complication of the condition, acute kidney injury (AKI). Here we briefly review the causes, diagnosis, management, and outcomes of rhabdomyolysis.
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Emergency care, Hospital, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Management
Diseases/Conditions (MeSH)
D012206 - Rhabdomyolysis
Keywords
Rhabdomyolysis
Source Citation
Kodadek L, Carmichael Ii SP, Seshadri A, Pathak A, Hoth J, Appelbaum R, Michetti CP, Gonzalez RP. Rhabdomyolysis: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open. 2022 Jan 27;7(1):e000836. doi: 10.1136/tsaco-2021-000836. PMID: 35136842; PMCID: PMC8804685.
Supplemental Methodology Resources
Methodology
Number of Source Documents
122
Literature Search Start Date
December 31, 2005
Literature Search End Date
November 30, 2015