inpatient / nephrology


Last Updated: 1/21/2023

# Rhabdomyolysis

-- ABCs: 
is there renal failure or hyperkalemia requiring urgent/emergent dialysis and ICU supervision?
-- Chart Check: *** h/o EtOH or other substance use, seizures, syncope; h/o statin or immunotherapy use
-- Can't Miss: *** hyperkalemia and compartment syndrome
-- Admission Orders: *** telemetry if e/o hyperK; EKG; CBC, BMP, LFTs, coags, CK, UA
-- Initial Treatment to Consider: *** aggresive IVF to protect the kindeys against myoglobin; address hyperkalemia as needed

-- History: *** preceding events, substance use, LOC (seizure, syncope), medication use,, h/o CKD
-- Clinical/Exam: *** myalgias, weakness, dark urine, fevers, evidence of compartment syndrome
-- Data: *** CK, K, Cr, Ca, UA, lactic acid, EKG
-- Etiology/DDx: *** crush injury, intoxication, found down, seizure, over-exertion, muscle ischemia, statin use, immunotherapy AE

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

-- IVF: *** aggressive fluids (within reason) as able until CK is down trending and <1000
-- Trend UOP with strict I/O’s
-- Trend BMP and CK *** q12, daily

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If You Remember Nothing Else

The sequelae of rhabdomyolysis are 2/2 the damage of muscles and the release of elctrolytes and myoglobin into the circulation. There are many etiologies; though there is often a specific insult (seizure, crush injury, over-exertion, etc), you should be on the lookout for ongoing ischemia or damage from certain medications. The major complications include hyperkalemia and renal failure 2/2 direct damage from myoglobin. As such, treatment involves fluids to prevent further ATN, and addressing hyperkalemia. You can generally stop trending CK when it is the downswing and is less than 1000.

Clinical Pearls

  • CK >1000 is generally the threshold to diagnose rhabdomyolysis
  • CK peaks within 24-72 hours and then declines over 3-5 days
  • Classcially will show UA positive for blood, but without RBCs on microscopy - myoglobinuria read as “blood” since a urine dip does not distinguish
  • AKI is caused by both hypovolemia/ischemia and direct toxicity of myoglobin to the renal tubules

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