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    Rhabdomyolysis – Treatment

    Critical Care / Resuscitation, Environmental Injuries / Exposures, Metabolic / Endocrine, Urological

    Last Updated Dec 05, 2020
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    • Rhabdomyolysis can result from a variety of traumatic and non-traumatic mechanisms that cause muscle injury and release intracellular muscle constituents into the circulation.
    • Can result in life threatening acute renal failure, electrolyte and metabolic abnormalities, fluid shifts and disseminated intravascular coagulation (DIC).
    • Early recognition and appropriate resuscitation can therefore be lifesaving.
    • Many patients will likely need to be admitted for treatment and monitoring of potential complications. Depending on your setting, much of the initial management may occur in the ED.
    • See the Rhabdomyolysis – Diagnosis for presentation details.

    Recommended Treatment

    Management Overview

    1. Finding and treating the underlying cause,
    2. Prevention of renal failure, and
    3. The management of life or limb-threatening complications (may require intubation; cardiac arrest from hyperkalemia, hypocalcemia and acidosis).
    4. Essentially if the kidney function is normal and the CK is less than 5K, give a couple of liters NS and forget about it.
    5. If the eGFR is 30 – 60, or CK 5K to 10K recheck after a few litres NS, and values are improving, can discharge home in 6 – 12 hours assuming no other problems.
    6. If the eGFR of CK doesn’t improve after recheck, admit.
    7. If eGFR is less than 30 or CK > 10K, may as well admit since that isn’t going to get better in 12 hours.
    8. Use bicarb for elevated K or acidosis and such patients should be admitted.

    More specifically

    Volume Administration

    • Volume expansion (bordering on hypervolemia) is critical to avoiding myoglobin-induced acute renal failure.
    • Initiate aggressive fluid resuscitation early in treatment:
      • Choice of crystalloid type is controversial.
      • One recommended approach is to start volume repletion with normal saline at an initial rate from 200 to 1500 ml per hour depending on severity of rhabdomyolysis.
      • Target fluid rate to achieve a urine output of approximately 3 ml/kg/hr
      • Regularly check a serum pH to monitor for an iatrogenically induced hyperchloremic metabolic acidosis if using a large volume of normal saline.
      • Consider switching to Ringers Lactate or Plasmalyte after 2-4 litres fon saline.
      • IV fluids should be continued until CK concentration decreases to less than 1000 U/L.


    • Bicarbonate administration is considered because urine alkalization, in theory, prevents heme-protein precipitation with Tamm-Horsfall proteins. There is no clear clinical evidence however that an alkaline diuresis is more effective than a saline diuresis in preventing AKI.
    • Probably more benefit for hyperkalemia/acidosis.
    • Check urine pH. If less than 6.5, consider urine alkalization with the following:
      • Sodium bicarbonate (150 mL [3 amps] of 8.4 percent sodium bicarbonate mixed with 1 L of 5 percent dextrose) via an intravenous line separate from that used for the isotonic saline infusion. The initial rate of infusion is 200 mL/hour; the rate is adjusted to achieve a urine pH of >6.5.
      • Bicarbonate may be given only if hypocalcemia is not present, arterial pH is less than 7.5 and serum bicarbonate is less than 30 mmol/L.
    • If bicarbonate is given, the arterial pH and serum calcium should be monitored every two hours during the infusion.

    Additional Medications

    • Hyperkalemia: calcium gluconate/chloride, insulin-dextrose, B-2 agonists, NaHCO3.
    • Loop diuretics may be indicated if volume overload is present.
    • Administration of mannitol is not routinely recommended. If given, it should only be administered after volume replacement and avoided in patient with oliguria.
    • May need hemodialysis but plasma exchange has not been shown to be beneficial.


    • Regularly monitor electrolytes for potentially life-threatening abnormalities.
    • Monitor for compartment syndrome in affected extremities.
    • Monitor for signs and symptoms of disseminated intravascular coagulation.

    Consider Renal Replacement Therapy

    • As with non-rhabdomyolysis related causes of renal failure, monitor for indications for emergent dialysis including
      • Uncorrectable metabolic acidosis
      • Life-threatening hyperkalemia and other electrolyte disturbances despite medical management
      • Manifestations of uremia, and anuria or oliguria
      • Fluid overload.

    Criteria For Hospital Admission


    • Most patients with rhabdomyolysis will likely require admission for parenteral fluid resuscitation, monitoring for complications as outlined above and treatment of coexisting injuries.


    • Most patients with rhabdomyolysis will recover sufficient kidney function to be dialysis independent, and many recover to normal or near normal kidney function.
    • The McMahon score for Rhabdomyolysis can be used as a predictive tool for morality and AKI

    Criteria For Safe Discharge Home

    • The kidney function is normal and the CK is less than 5K, give a couple of litres NS and can discharge assuming underlying cause addressed.
    • If the eGFR is 30 – 60, or CK 5,000-10,000:
      • recheck after a few litres NS, and if values are improving, can discharge home in 6 – 12 hours assuming no other problems.

    Quality Of Evidence?


    Intravenous fluid resuscitation.


    Choice of crystalloid, adjunct therapeutics (mannitol).


    Related Information

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