RhabdomyolysisMANAGEMENT

MUSCULOSKELETAL AND RHEUMATOLOGIC PRESENTATIONS · 12 SECTIONS

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440 items

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01Approach to the Critical Patient/attcp36

Immediate priorities

›Time-critical stabilization

›Airway risk

›Depressed mental status

›Refractory hyperkalaemia arrhythmia risk

›Breathing risk

›Respiratory failure from acidosis

›Pulmonary oedema from aggressive fluids

›Circulation risk

›Shock from trauma heat sepsis

›Dysrhythmia from hyperkalaemia

›Immediate triggers

›If suspected compartment syndrome then emergent surgery consult

›If ECG changes with hyperkalaemia then treat hyperkalaemia before delays

›If anuric or rapidly rising potassium then nephrology for urgent kidney replacement therapy

›Early protective strategy

›Renal perfusion targets

›Mean arterial pressure 65 mmHg or higher

›Urine output goal 1 mL/kg/hour to 3 mL/kg/hour

›Monitoring setup

›Continuous ECG

›Strict intake output

›Core temperature if heat illness

›Etiology control

›If ongoing muscle compression then immediate release of compression

›If prolonged immobilization then pressure injury prevention and repositioning

›If toxin or medication trigger then discontinue agent

Key concepts

›Diagnostic and outcome frame

›Skeletal muscle necrosis with myoglobin release

›Acute kidney injury risk

›Hyperkalaemia risk

›Early fluids before established acute kidney injury

›Lower risk of dialysis

›Lower risk of renal failure

›Routine bicarbonate or mannitol

›No consistent benefit in outcomes

›Harm risk from alkalosis hypocalcaemia volume overload

02History/hx47

Presentation patterns

›Typical history clusters

›Dark urine

›Tea or cola colour

›May be absent despite severe disease

›Myalgia

›Proximal muscle groups

›Focal pain in compartment syndrome

›Weakness

›Difficulty standing or lifting

›New functional decline

›Systemic symptoms

›Fever

›Nausea vomiting

Causes and triggers

›Etiology categories

›Trauma and compression

›Crush injury

›Prolonged immobilization

›Exertional

›Intense unaccustomed exercise

›Sickle cell trait risk context

›Heat related

›Heat stroke

›Dehydration

›Seizure or agitation

›Generalized tonic clonic seizure

›Prolonged restraint

›Drugs and toxins

›Statins

›Antipsychotics with neuroleptic malignant syndrome

›Stimulants

›Metabolic and infectious

›Hypothyroidism

›Viral myositis

Risk factors and red flags

›High risk features

›Delayed presentation over 6 hours after insult

›Oliguria or anuria

›Syncope palpitations

›Severe muscle swelling or tight compartments

›Coexisting trauma bleeding risk

›Medication and comorbidity context

›Chronic kidney disease

›Heart failure

›Liver disease

›Concomitant nephrotoxins

›NSAID exposure

›ACE inhibitor or ARB

›Contrast exposure

03Physical Exam/exam30

Core exam domains

›Global severity

›Mental status

›Agitation or delirium

›Somnolence from toxins

›Hemodynamics

›Hypotension

›Tachycardia

›Temperature

›Hyperthermia

›Hypothermia in exposure

›Musculoskeletal focus

›Muscle tenderness

›Diffuse myalgia

›Focal pain out of proportion

›Swelling and firmness

›Tense compartments

›Rapidly expanding limb girth

›Neurovascular status

›Distal pulses

›Sensation deficits

›Motor weakness

›Compartment syndrome features

›Pain with passive stretch

›Paresthesia

›Pallor coolness

PITFALLS

›Common misses

›Normal urine colour does not exclude myoglobinuria

›Normal creatinine early does not exclude impending acute kidney injury

›Hypocalcaemia in early phase may be adaptive

›Over resuscitation in heart failure risk patients

04Differential Diagnosis/ddx27

Life threats and mimics

›Dangerous differentials

›Compartment syndrome

›ICD-10 T79.A0

›Limb threatening time dependent

›Heat stroke

›ICD-10 T67.0

›Encephalopathy plus hyperthermia

›Malignant hyperthermia

›Perioperative trigger context

›Rapid hypercapnia rigidity

›Neuroleptic malignant syndrome

›ICD-10 G21.0

›Rigidity autonomic instability

›Severe hyperkalaemia

›ECG changes

›Ventricular dysrhythmia

›Mimics of dark urine

›Haematuria from stones infection trauma

›Urine microscopy with RBC

›Haemoglobinuria from haemolysis

›Anaemia jaundice elevated LDH

›Porphyria and pigment disorders

›Episodic abdominal pain neurologic symptoms

Coding and terminology

›Primary diagnosis codes

›ICD-10 M62.82 rhabdomyolysis

›ICD-10 T79.6 traumatic ischaemic muscle injury

›SNOMED CT rhabdomyolysis concept

05Laboratory Tests/lt50

Core labs and interpretation

›Diagnostic confirmation

›Creatine kinase

›Diagnostic threshold commonly CK more than 5 times upper limit of normal

›Severity marker CK trend over time

›Urinalysis

›Heme positive with few or no RBC suggests myoglobin

›Specific gravity for hydration status

›Serum creatinine and urea

›Baseline comparison when available

›Early normal does not exclude later rise

›Electrolytes and metabolic risks

›Potassium

›Hyperkalaemia from cell lysis

›Immediate ECG correlation

›Calcium

›Early hypocalcaemia from calcium deposition

›Late hypercalcaemia during recovery

›Phosphate

›Hyperphosphataemia common

›Secondary hypocalcaemia contribution

›Bicarbonate

›Metabolic acidosis from lactate and renal failure

›Magnesium

›Arrhythmia risk when abnormal

›End organ injury markers

›AST ALT

›AST elevation may reflect muscle injury

›Disproportionate AST over ALT pattern

›Lactate

›Shock heat illness marker

›Coagulation studies

›DIC concern in severe trauma heat stroke

›Complication screening

›Complete blood count

›Infection or trauma bleeding context

›Glucose

›Hypoglycaemia or hyperglycaemia in critical illness

Trending strategy

›Repeat intervals

›CK every 6 hours to 12 hours until down trending

›Peak often at 24 hours to 72 hours after injury

›Electrolytes every 4 hours to 6 hours in severe cases

›Potassium priority

›Calcium and phosphate monitoring

›Creatinine and urine output

›Rising creatinine triggers escalation

›Oliguria triggers nephrology involvement

Test limitations

›Interpretation pitfalls

›Urine dip heme positive can reflect haemoglobin or myoglobin

›CK may be falsely low if delayed presentation after peak and washout

›AST ALT elevation may be misattributed to primary hepatic injury

06Diagnostic Tests/dt34

Scoring Systems

›Risk stratification tools

›McMahon score for acute kidney injury and dialysis risk

›Variables include age sex cause and early labs

›Higher score associated with higher dialysis and mortality risk

›KDIGO acute kidney injury staging

›Creatinine based criteria

›Urine output based criteria

MRI

›Soft tissue evaluation

›Indications

›Suspected myositis or pyomyositis

›Suspected necrotizing soft tissue infection extension

›Utility

›Muscle oedema and necrosis patterns

›Abscess detection

›Constraints

›Time and access limitations in unstable patients

›Trauma and deep tissue assessment

›Indications

›Crush injury with occult fracture concern

›Retroperitoneal muscle injury

›Suspected necrotizing soft tissue infection gas

›Contrast considerations

›Avoidable contrast exposure in evolving acute kidney injury when alternatives exist

›If contrast required then hydration strategy per institutional protocol

Ultrasound

›Point of care and complication assessment

›Volume status and cardiac function

›IVC assessment as adjunct

›Pulmonary B lines for fluid overload

›Renal ultrasound

›Hydronephrosis for postrenal cause of oliguria

›Baseline kidney size in chronic disease

›Limb assessment adjuncts

›DVT evaluation when immobilized

›Soft tissue fluid collections

07Disposition/dispo31

Level of care

›Admission criteria

›Acute kidney injury

›Rising creatinine

›Oliguria or anuria

›High risk electrolyte abnormalities

›Hyperkalaemia

›Symptomatic hypocalcaemia

›Severe CK elevation with systemic features

›CK very high with ongoing rise

›Metabolic acidosis

›Ongoing etiology risk

›Compartment syndrome concern

›Heat stroke

›Sepsis or severe infection

›ICU criteria

›Refractory hyperkalaemia

›ECG changes

›Need for temporizing measures or dialysis

›Shock requiring vasopressors

›Respiratory failure

›Need for continuous infusions or invasive monitoring

Discharge pathway

›Discharge eligibility

›Mild symptoms with improving course

›Stable creatinine

›Normal potassium

›Down trending CK

›Reliable oral hydration and follow up

›Follow up plan

›Repeat creatinine and electrolytes within 24 hours to 72 hours

›CK trend recheck when clinically indicated

›Medication review and trigger avoidance

08Treatment/t84

Immediate management

›Etiology directed actions

›Compression relief

›Remove constricting items

›If compartment syndrome suspected then emergent fasciotomy pathway

›Heat illness bundle

›Rapid cooling

›Temperature target below 39 C

›Seizure control

›Abort ongoing seizure

›Prevent recurrent seizures

›Toxin and medication reversal

›Discontinue offending agent

›Antidote when indicated by toxidrome

Fluid resuscitation

›Crystalloid strategy

›Initial fluid choice

›Isotonic crystalloid

›Balanced crystalloid consideration after large normal saline volumes

›Initial rate guidance

›Initiate 400 mL/hour and titrate to urine output goal

›Alternative starting range 200 mL/hour to 1000 mL/hour by severity and comorbidity

›Urine output targets

›Goal 1 mL/kg/hour to 3 mL/kg/hour

›Upper practical target up to 300 mL/hour

›Stop points and de escalation

›If pulmonary oedema then slow fluids and reassess

›If anuric despite resuscitation then nephrology for kidney replacement therapy evaluation

›Monitoring during fluids

›Electrolytes every 4 hours to 6 hours in severe cases

›Acid base trend for hyperchloraemic acidosis with normal saline

Electrolyte and acid base management

›Hyperkalaemia protocol

›If ECG changes or potassium severely elevated then immediate therapy

›Calcium gluconate IV 10 mL of 10 percent over 2 minutes to 5 minutes

›Repeat in 5 minutes to 10 minutes if ECG changes persist

›Continuous ECG monitoring

›Insulin regular IV 10 units plus glucose IV 25 g

›Repeat glucose checks every 30 minutes initially

›Hypoglycaemia prevention plan

›Salbutamol inhaled 10 mg to 20 mg nebulized

›Tachycardia and ischemia caution

›Sodium bicarbonate IV 50 mmol

›If severe metabolic acidosis with hyperkalaemia

›Not for routine alkalinization

›Potassium removal

›Loop diuretic if volume replete and producing urine

›Kidney replacement therapy if refractory or anuric

›Calcium abnormalities

›Early hypocalcaemia

›Avoid replacement if asymptomatic

›Replace if seizures tetany or arrhythmia

›Late hypercalcaemia during recovery

›Hydration

›Avoid routine calcium during early phase

›Hyperphosphataemia

›Dietary restriction

›Phosphate binders in admitted patients when persistent

›Metabolic acidosis

›Treat underlying shock

›Kidney replacement therapy if severe refractory acidosis

Urine alkalinization and diuresis

›Evidence aligned approach

›Routine bicarbonate infusion

›Not recommended for prevention of acute kidney injury in most patients

›Conditional recommendation against routine use in trauma guideline evidence

›Mannitol

›Not recommended routinely

›Hypovolaemia and renal hypoperfusion risk

›Selective bicarbonate consideration

›Class IIb recommendation for selected cases with severe metabolic acidosis and adequate volume status

›Target urine pH above 6.5 if used

›Stop if hypocalcaemia worsens or alkalosis develops

Kidney replacement therapy

›Dialysis triggers

›Refractory hyperkalaemia

›Refractory acidosis

›Refractory pulmonary oedema

›Uraemic complications

›Modality considerations

›Continuous therapy for haemodynamic instability

›Intermittent haemodialysis for stable patients

Evidence levels and recommendations

›Guideline based recommendations

›Aggressive isotonic fluid resuscitation early

›Class I recommendation by expert consensus

›EAST practice management guideline conditional recommendation for aggressive IV fluids

›Bicarbonate and mannitol routine use

›Class IIb only in selected circumstances

›EAST practice management guideline conditional recommendation against routine bicarbonate or mannitol

09Special Populations/sp32

Pregnancy

›Pregnancy considerations

›Maternal physiology

›Lower baseline creatinine

›Higher risk of pulmonary oedema with aggressive fluids

›Fetal considerations

›Continuous fetal monitoring when viable gestation and maternal instability

›Obstetrics involvement early

›Medication considerations

›Hyperkalaemia therapies acceptable with fetal monitoring

›Avoid hypotension from beta agonists in unstable patients

Geriatric

›Older adult considerations

›Higher baseline chronic kidney disease prevalence

›Lower threshold for nephrology involvement

›Lower tolerance for high volume fluids

›Medication triggers

›Statin associated myopathy risk

›Drug interactions increasing statin levels

›Disposition bias

›Admit more readily with modest CK plus comorbidity

Pediatrics

›Pediatric considerations

›Etiologies

›Viral myositis influenza

›Trauma and exertional

›Fluids

›Initiate isotonic crystalloid 10 mL/kg to 20 mL/kg bolus if hypovolaemic

›Maintenance plus deficit replacement with urine output targets

›Weight based hyperkalaemia dosing

›Calcium gluconate 0.5 mL/kg of 10 percent IV

›Maximum 20 mL

›Insulin regular 0.1 units/kg IV plus glucose 0.5 g/kg

›Nephrology consultation

›Early for rising creatinine or persistent oliguria

10Background/b42

Epidemiology

›Epidemiology snapshot

›Common causes

›Trauma and crush

›Exertional and heat related

›Drugs and toxins

›Seizures and agitation

›Acute kidney injury frequency

›Substantial risk in severe cases and high CK

›Risk increases with dehydration sepsis and delayed fluids

›Morbidity drivers

›Hyperkalaemia arrhythmia

›Acute kidney injury requiring dialysis

Pathophysiology

›Mechanisms

›Muscle cell disruption

›Potassium phosphate urate release

›CK release as biomarker

›Myoglobin mediated kidney injury

›Tubular obstruction with casts

›Direct tubular toxicity via oxidative injury

›Renal vasoconstriction and ischemia

›Volume depletion amplification

›Concentrated myoglobin in tubules

›Reduced renal perfusion

Therapeutic Considerations

›Rationale for fluids

›Dilution and clearance of myoglobin

›Increased urine flow reduces cast formation

›Improved renal perfusion lowers ischemic injury

›Timing dependence

›Early resuscitation before creatinine rise most beneficial

›Why bicarbonate is limited

›Theoretical benefit

›Reduced myoglobin precipitation at higher urine pH

›Evidence signal

›No consistent reduction in acute kidney injury or mortality

›Adverse effects including hypocalcaemia and alkalosis

›Why mannitol is limited

›Theoretical benefit

›Osmotic diuresis

›Free radical scavenging proposed

›Evidence signal

›No consistent outcome benefit

›Risk of volume depletion or osmotic nephrosis in susceptible patients

11Patient Discharge Instructions/pdi19

copy discharge instructions

›Discharge guidance

›Hydration plan

›Drink enough fluids to keep urine pale yellow

›Avoid alcohol and dehydration for 48 hours to 72 hours

›Activity guidance

›Avoid strenuous exercise until cleared

›Gradual return to activity after symptoms and labs improve

›Medication guidance

›Avoid NSAIDs unless clinician says otherwise

›Review statins and supplements with prescriber

›Return to emergency criteria

›Decreased urine output

›Worsening weakness

›Chest pain palpitations or fainting

›Severe muscle swelling or new severe limb pain

›Persistent vomiting inability to drink

›Fever or confusion

›Follow up tests

›Bloodwork for creatinine potassium and CK within 24 hours to 72 hours as directed

12References/r8

Clinical guidelines and consensus

›Guideline sources

›Eastern Association for the Surgery of Trauma practice management guideline for rhabdomyolysis management Am J Surg 2022

›American Association for the Surgery of Trauma Critical Care Committee clinical consensus document on rhabdomyolysis 2022

›KDIGO Clinical Practice Guideline for Acute Kidney Injury 2012

Evidence based sources

›Key evidence

›EAST guideline conclusion conditional recommendation for aggressive IV fluids and against routine bicarbonate or mannitol

›Consensus recommendations for urine output targeted fluids and monitoring from AAST clinical consensus document

›Observational evidence on bicarbonate and fluid volume limitations in rhabdomyolysis associated acute kidney injury

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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