Rhabdomyolysis - Revision history

Danbot: Strip excess bold

2026-03-22T09:31:45Z

Strip excess bold

← Older revision		Revision as of 09:31, 22 March 2026
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	==Background==		==Background==
	*Breakdown of skeletal muscle releasing intracellular contents into the circulation		*Breakdown of skeletal muscle releasing intracellular contents into the circulation
	*Key toxins: ~~'''~~myoglobin~~'''~~ (nephrotoxic), creatine kinase (CK), potassium, phosphate, uric acid		*Key toxins: myoglobin (nephrotoxic), creatine kinase (CK), potassium, phosphate, uric acid
	*~~'''~~Acute kidney injury (AKI)~~'''~~ occurs in 15-40% of cases<ref name="bosch">Bosch X, et al. Rhabdomyolysis and acute kidney injury. ''N Engl J Med''. 2009;361(1):62-72. PMID 19571284.</ref>		*Acute kidney injury (AKI) occurs in 15-40% of cases<ref name="bosch">Bosch X, et al. Rhabdomyolysis and acute kidney injury. ''N Engl J Med''. 2009;361(1):62-72. PMID 19571284.</ref>
	*Overall mortality ~5%; higher with AKI, DIC, or [[Compartment syndrome\|compartment syndrome]]		*Overall mortality ~5%; higher with AKI, DIC, or [[Compartment syndrome\|compartment syndrome]]

	==Etiology==		==Etiology==
	*~~'''~~Trauma / Crush injury~~'''~~ (most common worldwide)		*Trauma / Crush injury (most common worldwide)
	*'''Exertional''' (exercise, seizures, agitation, status epilepticus)		*'''Exertional''' (exercise, seizures, agitation, status epilepticus)
	*~~'''~~Drug/toxin-induced~~'''~~		*Drug/toxin-induced
	**Statins (especially with interacting drugs)		**Statins (especially with interacting drugs)
	**[[Cocaine toxicity\|Cocaine]], [[Amphetamine toxicity\|amphetamines]], MDMA, [[Ethanol toxicity\|alcohol]]		**[[Cocaine toxicity\|Cocaine]], [[Amphetamine toxicity\|amphetamines]], MDMA, [[Ethanol toxicity\|alcohol]]
	**[[Neuroleptic malignant syndrome\|NMS]], [[Serotonin syndrome]], [[Malignant hyperthermia]]		**[[Neuroleptic malignant syndrome\|NMS]], [[Serotonin syndrome]], [[Malignant hyperthermia]]
	*~~'''~~Prolonged immobilization~~'''~~ (found down, intraoperative)		*Prolonged immobilization (found down, intraoperative)
	*[[Hypokalemia]], [[Hypophosphatemia]], [[Hyponatremia]]		*[[Hypokalemia]], [[Hypophosphatemia]], [[Hyponatremia]]
	*[[Heat stroke]]		*[[Heat stroke]]
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	==Clinical Features==		==Clinical Features==
	*Classic triad: ~~'''~~myalgias, weakness, dark urine~~'''~~ (tea/cola-colored)		*Classic triad: myalgias, weakness, dark urine (tea/cola-colored)
	**Full triad present in <10% of cases		**Full triad present in <10% of cases
	*Muscle tenderness, swelling, and stiffness		*Muscle tenderness, swelling, and stiffness
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	==Evaluation==		==Evaluation==
	*~~'''~~Creatine kinase (CK)~~'''~~ — diagnostic marker		*Creatine kinase (CK) — diagnostic marker
	**CK >5x upper limit of normal (typically >1,000 U/L) diagnostic		**CK >5x upper limit of normal (typically >1,000 U/L) diagnostic
	**CK >5,000 U/L: significant risk of AKI		**CK >5,000 U/L: significant risk of AKI
	**Peak CK at 24-72 hours; monitor serial levels		**Peak CK at 24-72 hours; monitor serial levels
	*~~'''~~Urinalysis~~'''~~: urine dipstick positive for "blood" but no RBCs on microscopy (myoglobinuria)		*Urinalysis: urine dipstick positive for "blood" but no RBCs on microscopy (myoglobinuria)
	*~~'''~~BMP~~'''~~: potassium (may be severely elevated), creatinine, BUN, calcium, phosphate, bicarbonate		*BMP: potassium (may be severely elevated), creatinine, BUN, calcium, phosphate, bicarbonate
	*~~'''~~CBC, LDH, uric acid, coagulation studies~~'''~~		*CBC, LDH, uric acid, coagulation studies
	*~~'''~~ECG~~'''~~ — evaluate for [[Hyperkalemia\|hyperkalemia]] changes (peaked T waves, wide QRS)		*ECG — evaluate for [[Hyperkalemia\|hyperkalemia]] changes (peaked T waves, wide QRS)
	*Consider compartment pressures if clinical concern		*Consider compartment pressures if clinical concern

	==Management==		==Management==
	===Aggressive IV Fluid Resuscitation===		===Aggressive IV Fluid Resuscitation===
	*~~'''~~Cornerstone of treatment~~'''~~		*Cornerstone of treatment
	*~~'''~~Normal saline~~'''~~ at ~~'''~~200-300 mL/hr~~'''~~ (or 1-2 L/hr initially if severely hypovolemic)<ref name="scharman">Scharman EJ, et al. Prevention of kidney injury following rhabdomyolysis: a systematic review. ''Ann Pharmacother''. 2013;47(1):90-105. PMID 23324509.</ref>		*Normal saline at 200-300 mL/hr (or 1-2 L/hr initially if severely hypovolemic)<ref name="scharman">Scharman EJ, et al. Prevention of kidney injury following rhabdomyolysis: a systematic review. ''Ann Pharmacother''. 2013;47(1):90-105. PMID 23324509.</ref>
	*Target urine output ~~'''~~200-300 mL/hr~~'''~~ until CK trending down and urine clears		*Target urine output 200-300 mL/hr until CK trending down and urine clears
	*Monitor for fluid overload, especially in elderly and those with cardiac/renal disease		*Monitor for fluid overload, especially in elderly and those with cardiac/renal disease
	*Bicarbonate drip (150 mEq NaHCO3 in 1 L D5W) may be considered to alkalinize urine (target urine pH >6.5) — evidence is limited		*Bicarbonate drip (150 mEq NaHCO3 in 1 L D5W) may be considered to alkalinize urine (target urine pH >6.5) — evidence is limited
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	===Treat Hyperkalemia===		===Treat Hyperkalemia===
	*See [[Hyperkalemia]] for detailed management		*See [[Hyperkalemia]] for detailed management
	*~~'''~~Calcium gluconate~~'''~~ 10% 10 mL IV for cardiac membrane stabilization if ECG changes		*Calcium gluconate 10% 10 mL IV for cardiac membrane stabilization if ECG changes
	*~~'''~~Insulin~~'''~~ 10 units regular IV + ~~'''~~D50W~~'''~~ 50 mL IV		*Insulin 10 units regular IV + D50W 50 mL IV
	*[[Sodium bicarbonate]], [[Albuterol]] nebulizer, [[Kayexalate]] or patiromer		*[[Sodium bicarbonate]], [[Albuterol]] nebulizer, [[Kayexalate]] or patiromer
	*Emergent [[Hemodialysis\|dialysis]] if refractory		*Emergent [[Hemodialysis\|dialysis]] if refractory
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	==Disposition==		==Disposition==
	*~~'''~~Admit~~'''~~ patients with:		*Admit patients with:
	**CK >5,000 U/L		**CK >5,000 U/L
	**AKI (elevated creatinine)		**AKI (elevated creatinine)

Danbot: Major rewrite: IV fluid targets, hyperkalemia management, etiology, CK thresholds, peer-reviewed references

2026-03-21T18:33:54Z

Major rewrite: IV fluid targets, hyperkalemia management, etiology, CK thresholds, peer-reviewed references

Show changes

Danbot: Add MedicationDose SMW entry for sodium bicarbonate urinary alkalinization; dose verified against nephrology/EM guidelines

2026-03-20T18:04:33Z

Add MedicationDose SMW entry for sodium bicarbonate urinary alkalinization; dose verified against nephrology/EM guidelines

← Older revision		Revision as of 18:04, 20 March 2026
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	*Peripheral nerve injury		*Peripheral nerve injury
	**Usually resolves within few days-weeks		**Usually resolves within few days-weeks


			==Medication Dosing==
			*{{MedicationDose\|drug=Sodium bicarbonate\|dose=150 mL (3 amps) of 8.4% in 1L D5W at 200 mL/hr\|route=IV drip\|context=Urinary alkalinization (goal urine pH >6.5)\|indication=Rhabdomyolysis\|population=Adult\|notes=Controversial; consider if CK >5000 and urine pH <6.5}}

	==See Also==		==See Also==

Jmccarter: /* Etiology */

2022-08-03T23:16:35Z

Etiology

← Older revision		Revision as of 23:16, 3 August 2022
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	**[[Crush Syndrome]]		**[[Crush Syndrome]]
	**Immobilization		**Immobilization
	**[[Compartment Syndrome]]		**[[Compartment Syndrome]]
			**[[Electrical injuries]]
	*Nontraumatic Exertional		*Nontraumatic Exertional
	**Exercise + hot weather		**Exercise + hot weather

Elcatracho: /* Intubation/RSI */

2022-01-03T09:21:35Z

Intubation/RSI

← Older revision		Revision as of 09:21, 3 January 2022
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	===[[Intubation]]/RSI===		===[[Intubation]]/RSI===
	*Use [[~~Rocuronium~~]] due to the potential elevations in potassium that result from the rhabdomyolysis		*Use [[rocuronium]] due to the potential elevations in potassium that result from the rhabdomyolysis

	==Disposition==		==Disposition==

Ostermayer: /* Management */

2021-09-07T16:16:21Z

Management

← Older revision		Revision as of 16:16, 7 September 2021
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	*CK		*CK
	*Calcium, phosphorus		*Calcium, phosphorus
			*LFTs (elevation will resolve with resolving rhabdo)

	===[[IV Fluids]]===		===[[IV Fluids]]===

Ostermayer: /* Evaluation */

2021-09-07T16:15:45Z

Evaluation

← Older revision		Revision as of 16:15, 7 September 2021
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	**[[Hypocalcemia]]		**[[Hypocalcemia]]
	**Hyperuricemia		**Hyperuricemia
	*~~[[LFT]]~~ elevation		*LFTs elevation
	**Intramuscular release of AST/ALT <ref>Mayo Clin Proc 2017;92[1]:e1; J Med Toxicol 2010;6[3]:294</ref>		**Intramuscular release of AST/ALT <ref>Mayo Clin Proc 2017;92[1]:e1; J Med Toxicol 2010;6[3]:294</ref> with AST>ALT.

	==Management==		==Management==

Ostermayer: /* Evaluation */

2021-09-07T16:14:51Z

Evaluation

← Older revision		Revision as of 16:14, 7 September 2021
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	**[[Hypocalcemia]]		**[[Hypocalcemia]]
	**Hyperuricemia		**Hyperuricemia
	*[LFT] elevation		*[[LFT]] elevation
	**Intramuscular release of AST/ALT <ref>Mayo Clin Proc 2017;92[1]:e1; J Med Toxicol 2010;6[3]:294</ref>		**Intramuscular release of AST/ALT <ref>Mayo Clin Proc 2017;92[1]:e1; J Med Toxicol 2010;6[3]:294</ref>

Ostermayer: /* Evaluation */

2021-09-07T16:14:29Z

Evaluation

← Older revision		Revision as of 16:14, 7 September 2021
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	**[[Hypocalcemia]]		**[[Hypocalcemia]]
	**Hyperuricemia		**Hyperuricemia
			*[LFT] elevation
			**Intramuscular release of AST/ALT <ref>Mayo Clin Proc 2017;92[1]:e1; J Med Toxicol 2010;6[3]:294</ref>

	==Management==		==Management==

Kxl328: /* See Also */

2021-06-29T20:54:05Z

← Older revision		Revision as of 20:54, 29 June 2021
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	*[[Crush Syndrome]]		*[[Crush Syndrome]]
	*[[Sympathomimetic Toxicity]]		*[[Sympathomimetic Toxicity]]
			*IBCC chapter on rhabdomyolysis - https://emcrit.org/ibcc/rhabdo/

	==References==		==References==