Recognise rhabdomyolysis, give early aggressive fluids, manage hyperkalaemia and compartment syndrome, and know when to start RRT.
At the bedside
- 1
Suspect
Crush injury, prolonged immobilisation (stroke, intoxication), seizures, heat stroke, extreme exertion, electrical injury, snakebite (sea snake, Russell's viper), drugs (statins, colchicine), hypokalaemia/hypophosphataemia, infections (leptospirosis, dengue, influenza).
- 2
Confirm and grade
CK (peaks 24-72 h), dark urine with dipstick positive for blood but no RBCs on microscopy, K, Ca (low), PO4 (high), urate, creatinine, ABG, ECG.
- 3
Fluids early
ASAPStart isotonic crystalloid early (ideally before extrication in crush): 1-2 L/h initially if not overloaded, then titrate to urine output 200-300 mL/h; continue until CK < 5,000 U/L and urine clears.
- 4
Treat hyperkalaemia
ECG; calcium gluconate for ECG changes, insulin-dextrose, salbutamol; avoid calcium for asymptomatic hypocalcaemia (Ca deposits in muscle, rebound hypercalcaemia later).
- 5
Watch compartments
Pain on passive stretch, tense limb, rising CK: measure compartment pressure (> 30 mmHg or delta pressure < 30 mmHg) → fasciotomy.
- 6
Bicarbonate and mannitol: not routine
No proven benefit; bicarbonate only for severe acidosis; mannitol not recommended.
- 7
RRT when indicated
Refractory hyperkalaemia, acidosis, overload or oliguric AKI. Conventional dialysis does not remove myoglobin significantly; RRT treats complications.
Prevent myoglobin AKI
Crystalloid (0.9% saline or balanced)
- Dose
- 1-2 L/h initially, then titrate to UO 200-300 mL/h
- Target
- Urine 200-300 mL/h (~3 mL/kg/h); CK falling
- Worked example
- 70 kg crush victim: 1 L/h for first 2 h, then adjust to keep 200-300 mL/h; reassess lungs 2-hourly
Reduce if oliguric despite fluids (established AKI) or overloaded.
References
Rhabdomyolysis
Step 1 of ~5
CK, K, Ca, PO4, creatinine, ABG, ECG, urine dipstick
Based on Bosch X, Poch E, Grau JM. Educational use; follow local protocol.
Pathophysiology
Myoglobin is filtered and, in acidic concentrated urine, precipitates with Tamm-Horsfall protein forming obstructive casts; its haem iron causes oxidative tubular injury, and it scavenges nitric oxide causing renal vasoconstriction. Volume sequestration in injured muscle adds hypovolaemia.
Evidence
- Bosch 2009 review: early aggressive volume expansion is the mainstay; bicarbonate and mannitol lack evidence [Bosch 2009].
Controversies
- Choice of fluid (saline vs balanced): no clear difference; balanced may cause less hyperchloraemic acidosis.
🇮🇳 India notes
- Common Indian causes: heat stroke in labourers, snakebite, leptospirosis, exertion (army training, marathons), crush in building collapses and earthquakes, OP poisoning-related seizures.
References
Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.