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Rhabdomyolysis Nursing Diagnosis and Nursing Care Plan

Last updated on January 4th, 2023 at 09:38 am

Rhabdomyolysis Nursing Care Plans Diagnosis and Interventions

Rhabdomyolysis NCLEX Review and Nursing Care Plans

Rhabdomyolysis is a complex condition characterized by the rapid destruction of an already injured skeletal muscle. Injury can cause a disruption to the integrity of the skeletal muscles which may lead to the release of intracellular contents including potassium, creatinine kinase (CK), phosphate, myoglobin, and urate into the extracellular compartments.

In effect, the disruption in the levels of these chemicals in the blood stream and other extracellular spaces can cause serious and life-threatening complications.

About 26,000 cases of rhabdomyolysis are reported annually in the United States alone.

In adults, the most common causes are crush injuries, alcohol and drug abuse, and overexertion. 

Signs and Symptoms of Rhabdomyolysis

The signs and symptoms of rhabdomyolysis are non-specific.

The clinical manifestations are often reliant on the cause of the disease. Historically, rhabdomyolysis is known to have a triad of symptoms which include myalgia, weakness, and myoglobinuria.

However, this idea is not anymore relied on as only less than 10% of cases showcased the presence of all these symptoms.

The following are the common signs and symptoms associated with rhabdomyolysis:

• Muscle pain, tenderness, and/or swelling
• Tea-colored urine which may suggest myoglobinuria
• Nausea and vomiting
• Confusion, agitation

Causes of Rhabdomyolysis

The causes of rhabdomyolysis are often classified into traumatic and non-traumatic reasons.

Traumatic causes directly lead to muscle injury while the non-traumatic causes indirectly cause muscle injury.

• Traumatic Causes
• crush injuries including fall, vehicular accident, or building collapse.
• Prolonged muscle compression such as immobility due to medical conditions and frailty in old age group
• Electrical shock
• Severe burn
• Lightning strike
• A bite from a venomous snake
• Non-traumatic Causes
• Alcohol and drug use
• Muscle strain
• Use of antipsychotics and statins in high doses. The relationship between rhabdomyolysis and statins have long been discussed and studied. Data suggest that there is a real risk of developing rhabdomyolysis, although rare, in prolonged use of statins in high doses.
• Hyperthermia or heat stroke
• Diabetic Ketoacidosis
• Viral infections such as HIV and AIDS
• Bacterial infections

Complications of Rhabdomyolysis

  Early complications of rhabdomyolysis may include the following:

• Hyperkalemia – Potassium is a major intracellular electrolyte. Destruction of skeletal muscle cells hence increases potassium in the blood stream causing hyperkalemia.
• Hypocalcemia – Hypocalcemia occurs due to the release of phosphate from muscle breakdown. The high phosphate level triggers the body to deposit calcium on the injured skeletal muscle cells.
• Hepatic Inflammation – This complication occurs in 25% of cases of rhabdomyolysis. Liver involvement in rhabdomyolysis is believed to be precipitated by proteases.
• Cardiac arrhythmia – this complication is caused by hyperkalemia.
• Cardiac arrest – hyperkalemia can also lead to cardiac arrest.

Late complications are as follows:

• Precipitation of myoglobin
• Toxic effect of chelatable iron on renal tubules
• Hypovolemia
• Disseminated intravascular coagulation – DIC is also a possible complication of rhabdomyolysis. It is usually worse on the 3 rd to 5th day of presentation.

Early or Late complications:

• Compartment syndrome – may result from the direct or indirect injury to the muscles. Treatment to release pressure should be considered when the pressure reaches 30mmHg.

Diagnosis of Rhabdomyolysis

Rhabdomyolysis may be difficult to diagnose as signs and symptoms are often non-specific.

A high index of suspicion is necessary for the early identification of the disease.

• History and physical examination – Medical history and physical examination will need to focus on the presence of risk factors, muscle injuries and trauma. Neuromuscular exam focusing on the lower extremities to check for pulses, sensation, color, muscle power and size once completed is very informative for the diagnosis of this condition.
• Plasma CK levels – This laboratory test is a gold standard in diagnosing rhabdomyolysis. At the moment there is no general rule of what the cut off is in CK levels is used. However, most physicians follow the rule of CK levels becoming 5 times more than the normal levels. CK level is also predicative of possible acute renal failure.

Treatment of Rhabdomyolysis

Rhabdomyolysis can occur due to several reasons.

However, no matter what the etiology is, the primary focus of rhabdomyolysis treatment is prevention of acute renal failure.

• Fluid management. Hydration is very crucial in the treatment of rhabdomyolysis.  Fluid management through increased oral fluid intake and intravenous therapy promotes normal blood volume level in the body and also prevents acute renal failure from occurring. 
• Hypocalcemia treatment. This should not be given unless it causes any significant problems. This is to prevent further occurrence of hypercalcemia which is normal in the recovery phase of the disease. 
• Hemodialysis . This treatment may sometimes be necessary to promote normal chemicals and electrolytes level in the blood stream. It also allows the kidneys to recuperate from the extra work load it received at the height of the disease process.
• ICU care. Care in the intensive care unit is often required in elderly patients with rhabdomyolysis. Constant monitoring of vital signs and of fluid volume is important to assess the progress of the disease.  

Rhabdomyolysis Nursing Diagnosis

Rhabdomyolysis nursing care plan 1.

Nursing Diagnosis: Hyperthermia related to the inflammatory process of Rhabdomyolysis as evidenced by temperature of 39 degrees Celsius, rapid and shallow breathing, flushed skin, profuse sweating, and weak pulse.

  Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.

Rhabdomyolysis Nursing Care Plan 2

Nursing Diagnosis: Fluid Volume Deficit related to injury of skeletal muscles due as evidenced by temperature of 39.0 degrees Celsius, tea-colored urine output, nausea and vomiting, profuse sweating, and blood pressure of 89/58.

Desired Outcome: Within 24 hours of nursing interventions, the patient will be able to achieve a normal fluid balance with absence of fever.

Rhabdomyolysis Nursing Care Plan 3

Nursing Diagnosis: Acute Pain related to the inflammatory process of rhabdomyolysis as evidenced by pain score of 10 out of 10, verbalization of muscle pain, guarding sign on the painful areas, irritability, and restlessness

Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.

Rhabdomyolysis Nursing Care Plan 4

Nursing Diagnosis: Fatigue related to injury of skeletal muscles as evidenced by body malaise, overwhelming lack of energy, verbalization of tiredness and generalized weakness, lack of appetite, and shortness of breath upon exertion

Desired Outcome: The patient will demonstration active participation in necessary and desired activities and demonstrate increase in activity levels.

More Nursing Diagnosis for Rhabdomyolysis

• Risk for Injury
• Impaired Urinary Elimination
• Disturbed Thought Processes

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020).  Nursing diagnoses handbook: An evidence-based guide to planning care . St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2022).  Nursing care plans: Diagnoses, interventions, & outcomes . St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020).  Medical-surgical nursing: Concepts for interprofessional collaborative care . St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020).  Saunders comprehensive review for the NCLEX-RN examination . St. Louis, MO: Elsevier.  Buy on Amazon

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Rhabdomyolysis: a case-based critical reflection on its causes and diagnosis, clare o’carroll trainee advanced clinical practitioner, emergency department, heartlands hospital, university hospitals birmingham nhs foundation trust, birmingham, england, rob fenwick lead advanced clinical practitioner, emergency department, heartlands hospital, university hospitals birmingham nhs foundation trust, birmingham, england.

• To recognise the traumatic and non-traumatic causes of rhabdomyolysis

• To learn about the potential causes and the signs and symptoms of rhabdomyolysis

• To gain awareness of the laboratory and point-of-care tests required to diagnose rhabdomyolysis

Rhabdomyolysis is a rare and complex condition that involves injury of the skeletal muscle fibres, resulting in the release of substances such as creatine kinase and myoglobin. It is associated with acute kidney injury and mortality.

This article describes the case of a 40-year-old man who presented to the emergency department after an overdose of tramadol hydrochloride. It uses critical reflection to explore traumatic and non-traumatic causes of rhabdomyolysis and reviews the literature relating to the diagnosis of rhabdomyolysis through laboratory and point-of-care testing. To ensure the timely identification of patients at risk of deterioration, emergency nurses need to be aware of the potential causes and the clinical signs and symptoms of rhabdomyolysis.

Emergency Nurse . doi: 10.7748/en.2020.e2004

This article has been subject to external double-blind peer review and has been checked for plagiarism using automated software

@robfenwick

[email protected]

None declared

O’Carroll C, Fenwick R (2020) Rhabdomyolysis: a case-based critical reflection on its causes and diagnosis. Emergency Nurse. doi: 10.7748/en.2020.e2004

Published online: 24 March 2020

accident and emergency - blood - blood tests - clinical - diagnosis - diagnostic tests - emergency care - medicines - mental health - nursing care - overdose - professional - self-harm - substance misuse

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Nursing Care Plan (NCP) for Rhabdomyolysis

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Lesson Objectives for Rhabdomyolysis

• Define rhabdomyolysis as a medical condition characterized by the breakdown of skeletal muscle tissue, leading to the release of muscle cell contents into the bloodstream.
• Explore the common causes and risk factors associated with rhabdomyolysis, including traumatic injuries, muscle overexertion, crush injuries, certain medications, and underlying medical conditions.
• Identify the signs and symptoms of rhabdomyolysis, such as muscle pain, weakness, dark urine (myoglobinuria), and potential complications like kidney injury. Understand the importance of early recognition for prompt intervention.
• Learn about the diagnostic methods used to confirm rhabdomyolysis, including blood tests to assess creatine kinase levels, urine myoglobin tests, and imaging studies. Understand the significance of these assessments in determining the extent of muscle damage.
• Explore the principles of managing rhabdomyolysis, including fluid resuscitation, electrolyte monitoring, and addressing the underlying cause. Understand the role of nursing interventions in monitoring and supporting patients with rhabdomyolysis.

Pathophysiology of Rhabdomyolysis

• Rhabdomyolysis begins with muscle injury, often due to trauma, excessive exercise, crush injuries, or conditions leading to muscle breakdown. The integrity of muscle cell membranes is compromised.
• The damaged muscle cells release intracellular contents into the bloodstream, including myoglobin, creatine kinase (CK), potassium, and other cellular components.
• Myoglobin, a protein found in muscle cells, is released and filtered by the kidneys. In high concentrations, myoglobin can overwhelm the renal filtration capacity, leading to myoglobinuria (dark-colored urine).
• Myoglobinuria and the release of other cellular components can cause acute kidney injury (AKI). Myoglobin can precipitate in renal tubules, contributing to renal dysfunction and further complications.
• The release of potassium from damaged cells can lead to hyperkalemia, and the systemic inflammatory response may contribute to a cascade of events, including fluid shifts and electrolyte imbalances.

Etiology of Rhabdomyolysis

• Severe physical trauma, such as crush injuries, accidents, or prolonged immobilization, can result in muscle damage and the release of intracellular contents.
• Intense and prolonged physical activity, especially in individuals unaccustomed to such exertion, can lead to muscle breakdown and rhabdomyolysis.
• Certain medications, such as statins, antipsychotics, and illicit substances like cocaine or amphetamines, may contribute to muscle injury and rhabdomyolysis.
• Infections, especially viral myositis, and inflammatory conditions like autoimmune myopathies can trigger rhabdomyolysis.
• Metabolic disorders (e.g., metabolic myopathies) and genetic factors affecting muscle structure or function can predispose individuals to rhabdomyolysis.

Desired Outcome for Rhabdomyolysis

• Achieve a gradual decrease and eventual normalization of CK levels, indicating resolution of muscle breakdown and reduced risk of further complications.
• Prevent the development or progression of AKI by promoting adequate hydration, monitoring renal function, and promptly addressing any signs of renal impairment.
• Alleviate and manage muscle pain and discomfort through appropriate pain management strategies, contributing to improved patient comfort and mobility.
• Restore and maintain fluid and electrolyte balance, preventing complications such as electrolyte imbalances, hyperkalemia, and fluid shifts.
• Implement measures to prevent the recurrence of rhabdomyolysis by addressing underlying causes, educating the patient on risk factors, and promoting a balanced approach to physical activity.

Rhabdomyolysis Nursing Care Plan

Subjective data:.

• Muscle pain/cramps/aches
• Generalized weakness
• Tender muscles

Objective Data:

• Dark urine (tea, cola colored)
• Skin changes (may even look necrotic)
• Tense muscles

Nursing Assessment for Rhabdomyolysis

• Obtain a detailed medical history, including any recent trauma, exercise routines, medications (prescription and over-the-counter), substance use, and history of metabolic or genetic conditions.
• Assess the patient for symptoms of rhabdomyolysis, such as muscle pain, weakness, swelling, and dark urine. Pay attention to any signs of compartment syndrome in cases of trauma.
• Evaluate neurological status, including mental status and signs of compartment syndrome, as rhabdomyolysis can lead to neurological complications.
• Monitor fluid intake and output, assessing for signs of dehydration or fluid overload. Administer intravenous fluids as prescribed to maintain adequate hydration.
• Regularly assess renal function by monitoring urine output, serum creatinine, and blood urea nitrogen (BUN). Implement measures to prevent and manage AKI.
• Monitor vital signs, especially blood pressure and heart rate, to detect any cardiovascular instability related to fluid shifts or electrolyte imbalances.
• Evaluate the severity and location of muscle pain. Implement pain management strategies, such as analgesics and positioning, to alleviate discomfort.
• Monitor laboratory values, including CK levels, electrolytes (especially potassium), and urine myoglobin. Regular assessments help track the progress of rhabdomyolysis and guide interventions.

Implementation for Rhabdomyolysis

• Administer intravenous fluids, typically isotonic saline, to promote diuresis, maintain renal perfusion, and flush out myoglobin from the renal tubules.
• Monitor and manage electrolyte imbalances, especially hyperkalemia. Administer medications as prescribed (e.g., calcium gluconate, insulin and glucose, sodium bicarbonate) to address elevated potassium levels.
• Provide analgesics as ordered to alleviate muscle pain and discomfort. Consider non-pharmacological interventions, such as positioning and relaxation techniques, to enhance pain relief.
• Continuously monitor for signs of complications, such as acute kidney injury, compartment syndrome, and electrolyte imbalances. Implement preventive measures, such as turning and repositioning, to avoid complications associated with immobility.
• Collaborate with the healthcare team to identify and address the underlying causes of rhabdomyolysis. Adjust medications, modify exercise regimens, and address metabolic or genetic factors contributing to muscle breakdown.

Nursing Interventions and Rationales

Evaluation for rhabdomyolysis.

• Evaluate the trend of CK levels over time. A decreasing trend indicates resolution of muscle breakdown, and normalization suggests successful management.
• Assess renal function through monitoring of serum creatinine, blood urea nitrogen (BUN), and urine output. Stabilization or improvement in renal function indicates successful prevention or management of acute kidney injury.
• Evaluate the effectiveness of pain management interventions by assessing the patient’s reported pain levels. Adequate pain relief contributes to improved patient comfort and mobility.
• Monitor fluid balance and electrolyte levels. Normalization of electrolyte imbalances and maintenance of adequate hydration signify successful fluid resuscitation and management.
• Assess the patient’s understanding of preventive measures and lifestyle modifications to avoid recurrence. Education and adherence to recommendations contribute to long-term prevention.
• https://my.clevelandclinic.org/health/diseases/21184-rhabdomyolysis
• https://www.cdc.gov/niosh/topics/rhabdo/default.html

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Example Nursing Diagnosis for Rhabdomyolysis

• Acute Pain: Rhabdomyolysis often presents with severe muscle pain. This diagnosis focuses on pain management as a priority.
• Risk for Acute Kidney Injury: Rhabdomyolysis can lead to kidney damage due to myoglobin release. This diagnosis emphasizes the risk of kidney injury.
• Imbalanced Fluid Volume: Rhabdomyolysis can cause electrolyte imbalances and dehydration. This diagnosis addresses fluid and electrolyte needs.

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Nursing care plans.

How do I write a Nursing Care Plan? Why and how do we even use Nursing Care Plans ? This course is going to expand on that for you and show you the most effective way to write a Nursing Care Plan and how to use Nursing Care Plans in the clinical setting . PLUS, we are going to give you examples of Nursing Care Plans for all the major body systems and some of the most common disease processes. When you complete this course, you will be able to write and implement powerful and effective Nursing Care Plans.

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1 – understanding nursing care plans.

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The management and diagnosis of rhabdomyolysis-induced acute kidney injury: a case study

Affiliations.

• 1 Acute Kidney Injury Specialist Nurse, Royal Derby Hospital, University Hospitals of Derby and Burton Foundation Trust, Derby.
• 2 Associate Professor in Advanced Clinical Practice, University of Derby, Derby.
• PMID: 36094035
• DOI: 10.12968/bjon.2022.31.16.844

Rhabdomyolysis is characterised by a rapid dissolution of damaged or injured skeletal muscle that can be the result of a multitude of mechanisms. It can range in severity from mild to severe, leading to multi-organ failure and death. Rhabdomyolysis causes muscular cellular breakdown, which can cause fatal electrolyte imbalances and metabolic acidosis, as myoglobin, creatine phosphokinase, lactate dehydrogenase and other electrolytes move into the circulation; acute kidney injury can follow as a severe complication. This article reflects on the case of a person who was diagnosed with rhabdomyolysis and acute kidney injury after a fall at home. Understanding the underpinning mechanism of rhabdomyolysis and the associated severity of symptoms may improve early diagnosis and treatment initiation.

Keywords: Acute kidney injury; Management; Rhabdomyolysis; Treatment.

• Acute Kidney Injury* / diagnosis
• Acute Kidney Injury* / etiology
• Acute Kidney Injury* / therapy
• Creatine Kinase
• Muscle, Skeletal
• Rhabdomyolysis* / diagnosis
• Rhabdomyolysis* / etiology
• Rhabdomyolysis* / therapy

The most common causes of rhabdomyolysis are trauma, overexertion, toxic substances and medication. Overall, rhabdomyolysis caused by physical factors results in poorer outcomes than when caused by non-physical factors.

Take this topic on the go by tuning in to episode 251 of the Straight A Nursing podcast. Listen from any podcast platform, or straight from the website here .

Rhabdomyolysis pathophysiology

Rhabdomyolysis occurs when there is direct physical damage to the muscle tissue, depletion of ATP, and damage to the muscle tissue membrane (sarcolemma). 

In cases of physical damage, as the muscle reperfuses (such as when a patient who fell is lifted off the ground), leukocytes find their way to the damaged cells, which brings along a host of other components that further damage the fibers. 

Regardless of the cause, when a muscle cell membrane is injured, there’s an influx of sodium and calcium into the cell. Water follows and is drawn into the cell, leading to cellular edema and disruption of cell structures. The excessive intracellular calcium leads to further cell damage, disruption of ion channels, and depletion of ATP. Once ATP is depleted and calcium reaches a critical level, the cell is unable to compensate, resulting in cellular death. 

When the cell dies it breaks apart sending potassium, calcium, myoglobin, uric acid, creatine kinase, and other materials into circulation.

Let’s talk about each of these in more detail:

• Potassium – Hyperkalemia causes serious cardiac dysfunction ranging from palpitations to ventricular fibrillation. Additionally, hyperkalemia causes significant muscle weakness that can progress to total paralysis. 
• Calcium – Hypercalcemia causes a range of problems including bradycardia, hypertension, acute renal insufficiency, nephrolithiasis, muscle weakness, vomiting, and a short QT-interval (which can lead to arrhythmias and sudden cardiac death).
• Myoglobin – Excess myoglobin precipitates in the renal glomeruli causing damage. The heme in myoglobin is broken down into free iron, which also damages the renal tubules. Additionally, it reacts negatively with the lipid membrane, causing even more renal damage. The presence of myoglobin in the urine is what causes the characteristic dark, “tea-colored” urine of rhabdomyolysis.
• Uric acid – When muscle cells are damaged, uric acid is released and forms crystals which damage renal tubules.
• Creatine kinase – Found primarily in heart and skeletal muscle, levels will rise when muscle injury is present. 

What are the complications of rhabdomyolysis?

Acute kidney injury – Up to 58% of patients with rhabdomyolysis will suffer from acute kidney injury (AKI). Renal injury is associated with a higher incidence of mortality and increased usage of renal replacement therapy.

Electrolyte imbalances – At the time of injury, calcium first shifts into the muscle cell resulting in hypocalcemia. As the cells lyse, calcium and potassium are released, leading to hypercalcemia and hyperkalemia. The most important consideration with these electrolyte imbalances is their effect on cardiac electrophysiology.

Disseminated intravascular coagulation (DIC) – Thought to be caused by the release of thromboplastin, DIC is a late complication of rhabdomyolysis. You can learn more about DIC here .

Compartment syndrome – The release of intracellular components and fluid leads to edema which can be further compounded by aggressive fluid resuscitation. The edema can be significant, putting pressure on vasculature within the confined space and significantly impeding blood flow. Learn more about compartment syndrome here .

If left untreated, rhabdomyolysis can be fatal. In severe cases, mortality rates can be as high as 59%.

Now that you have some background understanding of rhabdomyolysis, let’s go through how to care for these patients using the Straight A Nursing LATTE method . 

L: How does the patient with rhabdomyolysis LOOK?

The classic triad of symptoms for rhabdomyolysis are muscle pain, weakness, and dark “tea colored” urine. However, it is important to note that only about 10% of patients actually present with all three symptoms. 

Other signs and symptoms include swelling, stiffness and/or cramping, presence of a pressure injury, reduced urine output, malaise, fever, nausea/vomiting, abdominal pain, palpitations and abnormal ECG.

A: How do you ASSESS the patient with rhabdomyolysis?

Due to the high risk for acute kidney injury, monitoring urine output and urine characteristics are vital nursing assessments. With that, you’ll also monitor the patient for signs of fluid volume overload, namely edema and pulmonary congestion. 

Other key assessments include: 

• Get a full set of vital signs. You are likely to see elevated HR, RR and BP due to pain and inflammatory response.
• Assess for the 5 Ps of limb ischemia. Compartment syndrome can be severe enough to cause limb ischemia. Assess for pulselessness, pallor, paresthesia, poikilothermia and paralysis.
• Neuromuscular assessment, looking for signs of muscle weakness and tenderness.
• Assess for localized and systemic edema, especially when giving fluid boluses.
• Assess cardiac function with continuous ECG monitoring. 
• Ask the patient/family about recent trauma, infections, periods of immobilization, intense seizure activity or exercise, and medications.
• Assess neurological status as drugs and toxins can induce rhabdomyolysis.
• Perform a thorough skin assessment. Illicit drug use, injuries, bites and stings can cause rhabdomyolysis.
• Ask the patient about their drug and alcohol use. Common culprit substances are alcohol, cocaine, marijuana, amphetamines, and ecstasy.
• Ask about recent illness or exposure to infection. Assess the patient for signs of infection such as swollen lymph nodes, cough, fever, and rash. Common viral causes are influenza, Epstein-Barr virus and cytomegalovirus. Common bacterial causes include group A strep and salmonella. Malaria is also a culprit, so inquire about recent travel to locations where malaria is prevalent. Viral infections are the leading cause of rhabdomyolysis in children.

T: What TESTS will be ordered for a patient with rhabdomyolysis?

• 12-lead ECG : Used to identify cardiac arrhythmias which may be present due to electrolyte imbalances.
• Creatine kinase : Highly sensitive to muscle injury and will begin to rise within 2 to 12 hours of the onset of injury and will reach its maximum in 24 to 72 hours. Serum CK levels are typically at least five times the normal value, with typical ranges between 1,500 and 100,000 units/L. This is the primary diagnostic lab test used to identify rhabdomyolysis.
• Myoglobin : May be used to confirm diagnosis, but because it has such a short half-life, it is not sensitive enough to be used on its own. Myoglobin will begin to rise before CK and return to baseline while CK is still continuing to increase. When plasma myoglobin levels exceed 1.5 mg/dL, you’ll see the tea-colored urine that is a hallmark sign of rhabdomyolysis. Myoglobin can also be detected in the urine with a dipstick test.
• BUN/Cr : These tests tell us about renal function and will be elevated in AKI.
• Uric acid : Will be elevated in rhabdomyolysis.
• WBC, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are likely to be elevated when the rhabdomyolysis is due to an infection or crush injury.
• CBC, urinalysis and cultures to monitor the infectious process.
• Toxicology for medication or drug-induced rhabdomyolysis.
• Electrolytes due to the high risk for severe imbalances.
• Albumin levels will be monitored as low levels are correlated with high risk for AKI and more severe disease.
• Coagulation studies to assess for DIC.
• CT and MRI may be helpful in identifying the underlying cause and identify the presence of compartment syndrome.

T: What TREATMENTS will be provided?

The key goals of treatment are to prevent the continued release of myoglobin into the bloodstream and to preserve renal function. 

Address the underlying cause – A vital component of rhabdomyolysis treatment is identifying and addressing the underlying cause to stop the release of myoglobin and other substances into circulation. 

Fluid resuscitation – Early fluid resuscitation restores renal perfusion, increases GFR and helps flush myoglobin and other substances from the kidneys. While there are no standard guidelines on the amount of fluid to administer, the consensus is that “normal saline” is preferred over Lactated ringers due to the lack of potassium in 0.9% NaCl. Patients may receive up to 10 liters of fluid per day to maintain a urine output of 200 -300 ml per hour until CK levels stabilize.

Bicarbonate administration – A sodium bicarbonate infusion may be utilized in patients with severe rhabdomyolysis (CK above 5,000 unit/L or evidence of a significant muscle injury). Sodium bicarbonate raises the pH of the urine and may help prevent AKI by diminishing the harmful effects of myoglobin on the kidneys. However, it is not used in all patients and is only used when arterial pH is less than 7.5, serum bicarbonate is less than 30 mEq/L and the patient does not have hypocalcemia.

Loop diuretics – Not given unless the patient has fluid volume overload and may actually cause hypocalcemia and promote cast formation in the kidneys.

Mannitol – Not routinely given but may be utilized if urine output is not adequate relative to the amount of fluid being administered.

Address hyperkalemia – Because hyperkalemia can cause significantly dangerous cardiac arrhythmias, it will be treated pharmacologically or with dialysis. The pharmacologic treatment for hyperkalemia is to give insulin plus dextrose. This combination causes a potassium shift into the intracellular environment. Patients with significant hyperkalemia may also receive calcium gluconate as it makes the heart less irritable and less likely to go into a dysrhythmia. 

Hemodialysis – In severe cases of rhabdomyolysis where the kidney injury is extensive and when patients have significant fluid volume overload, dialysis will be needed. 

Treat secondary complications – For example, a patient with compartment syndrome may require a fasciotomy and patients with DIC will receive platelets, cryoprecipitate, fresh frozen plasma and possibly PRBCs.

E: How do you EDUCATE the patient/family?

The important education components for your patient are to help them recognize the cause of rhabdomyolysis and any steps they can take to prevent future occurrences. This may include getting vaccinations to avoid infection, avoiding overexertion, abstaining from illicit drug use, or avoiding certain medications.

Other key teachings include: 

• Individuals can reduce their risk for exercise-induced rhabdomyolysis by starting new exercise routines gradually, staying hydrated and avoiding excessive heat exposure. 
• Know the signs of rhabdomyolysis – fatigue, weakness, muscle aches and tea-colored urine. 
• Individuals who have suffered AKI should avoid nephrotoxic medications, including NSAIDs until their MD states it is safe to do so.
• The individual will need to return to activity slowly. Swimming and other water exercises are good choices to prevent muscle strain and heat exposure.

Interested in more critical care Med-Surg topics? You’ll find more here .

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References : Burgess, S. (2021). Rhabdomyolysis: An evidence-based approach. Journal of the Intensive Care Society, 17511437211050782. https://doi.org/10.1177/17511437211050782

Cabral, B. M. I., Edding, S. N., Portocarrero, J. P., & Lerma, E. V. (2020). Rhabdomyolysis. Disease-a-Month, 66(8), 101015. https://doi.org/10.1016/j.disamonth.2020.101015

Candela, N., Silva, S., Georges, B., Cartery, C., Robert, T., Moussi-Frances, J., Rondeau, E., Rebibou, J.-M., Lavayssiere, L., Belliere, J., Krummel, T., Lebas, C., Cointault, O., Sallee, M., Faguer, S., & on behalf of the French Intensive Care Renal Network (F.I.R.N). (2020). Short- and long-term renal outcomes following severe rhabdomyolysis: a French multicenter retrospective study of 387 patients. Annals of Intensive Care, 10(1), 27. https://doi.org/10.1186/s13613-020-0645-1

Cleveland Clinic. (n.d.). Rhabdomyolysis: Symptoms, Treatments. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/21184-rhabdomyolysis

Fan, J., Ali̇, H., & Mi̇Dturi̇, J. (2020). Acute HIV Induced Rhabdomyolysis: Not on Antiretroviral Therapy. Journal of Microbiology and Infectious Diseases, 176–179. https://doi.org/10.5799/jmid.790295

Kodadek, L., Carmichael, S. P., Seshadri, A., Pathak, A., Hoth, J., Appelbaum, R., Michetti, C. P., & Gonzalez, R. P. (2022). Rhabdomyolysis: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surgery & Acute Care Open, 7(1), e000836. https://doi.org/10.1136/tsaco-2021-000836

Liu, Y., Pérez-Riera, A. R., Barbosa-Barros, R., Daminello-Raimundo, R., de Abreu, L. C., Nikus, K., & Baranchuk, A. (2018). Severe hypercalcemia from multiple myeloma as an acquired cause of short QT. Journal of Electrocardiology, 51(6), 939–940. https://doi.org/10.1016/j.jelectrocard.2018.07.020

Malkina, A. (n.d.). Rhabdomyolysis – Kidney and Urinary Tract Disorders. Merck Manuals Consumer Version. Retrieved September 13, 2022, from https://www.merckmanuals.com/home/kidney-and-urinary-tract-disorders/kidney-failure/rhabdomyolysis

Młynarska, E., Krzemińska, J., Wronka, M., Franczyk, B., & Rysz, J. (2022). Rhabdomyolysis-Induced AKI (RIAKI) Including the Role of COVID-19. International Journal of Molecular Sciences, 23(15), 8215. https://doi.org/10.3390/ijms23158215

Neal, E., & Burky, S. (2021). Imaging Findings in the Setting of Rhabdomyolysis. Applied Radiology, 50(2), 20–25. https://doi.org/10.37549/ar2721

Stanley, M., Chippa, V., Aeddula, N. R., Quintanilla Rodriguez, B. S., & Adigun, R. (2022). Rhabdomyolysis. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK448168/

Sauret, J. M., Marinides, G., & Wang, G. K. (2002). Rhabdomyolysis. American Family Physician, 65(5), 907–913. https://www.aafp.org/pubs/afp/issues/2002/0301/p907.html

Shefner, J. (2022). Clinical manifestations and diagnosis of rhabdomyolysis. UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-rhabdomyolysis/print

Stanley, M., Chippa, V., Aeddula, N. R., Rodriguez, B. S. Q., & Adigun, R. (2022). Rhabdomyolysis. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448168/

Szugye, H. S. (2020). Pediatric Rhabdomyolysis. Pediatrics In Review, 41(6), 265–275. https://doi.org/10.1542/pir.2018-0300

Ward, M. M. (1988). Factors predictive of acute renal failure in rhabdomyolysis. Archives of Internal Medicine, 148(7), 1553–1557.

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• v.4(3); 2017

Evaluation of rhabdomyolysis patients who opted for emergency services

Serdar ozdemir.

1 Department of Emergency Medicine, Umraniye Training and Research Hospital, Istanbul, Turkey

2 Department of Emergency Medicine, Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey

Gokhan Aksel

Rhabdomyolysis is a clinical and biochemical syndrome caused by skeletal muscle injury. Our aim was to contribute to the existing data on rhabdomyolysis in our country by evaluating the etiologic, demographic, and clinical features of rhabdomyolysis patients who applied to a tertiary hospital emergency department.

We retrospectively evaluated the data of patients who applied to the tertiary hospital emergency department from January 2015 to January 2016. The study population comprised patients admitted to the emergency department of our hospital with creatinine kinase levels above 5000 U/L at admission. The data of all cases that were included in the study were scanned by the researchers using the hospital’s computer-based data recording system. Age, sex, creatine kinase levels, complaints, etiology, whether or not acute renal failure developed, hospitalization and discharge status, and clinic of hospitalization were screened for all patients.

The creatine kinase levels of the patients at admission ranged from 5052 to 59140 U/L [median 7882 U/L (IQR: 7840)]. The most frequent (23.5%) cause of admission was extremity pain. The most common reason (19.6%) in the etiology was exercise. Twenty-one patients (41.1%) were admitted to clinics, and 1 patient (1.9%) died. Acute renal failure was observed in 4 patients (8.8%).

CONCLUSION:

Rhabdomyolysis is a clinical syndrome that can be life-threatening owing to muscle destruction. Although it is suspected after a traumatic injury, it should also be considered when other potential symptoms are observed. All clinicians should be aware of its common causes, diagnosis, and treatment options.

Rhabdomyolysis is a clinical and biochemical syndrome characterized by entry of cell content into circulation owing to skeletal muscle injury. The important indicators of muscle injury are myoglobin, creatine kinase, and lactate dehydrogenase. The severity of the disease may change from asymptomatic increase in muscle enzymes to life-threatening electrolyte disorders and renal failure [ 1 ].

Muscle injuries that cause rhabdomyolysis may occur secondary to muscle dystrophies, myositis, glycogen storage diseases, medications, and trauma. Muscle injury caused by various etiologic factors, myoglobin, and electrolytes released into circulation secondary to myocyte cell membrane injury are responsible for the development of complications. In particular, when hypovolemia and renal vasoconstriction accompany the accumulation of myoglobin in renal tubuli, acute renal failure may be observed [ 2 ].

Our aim was to investigate etiologic, demographic, and clinical characteristics of rhabdomyolysis patients who applied to the emergency department of a tertiary care hospital to contribute to the existing data pertaining to rhabdomyolysis in our country.

MATERIALS AND METHODS

In our study, data of patients who applied to the emergency department of a tertiary care hospital between January 1, 2015 and January 1, 2016 were retrospectively evaluated. Necessary permission for conducting the study was obtained at the meeting of Committee of Scientific Studies of our hospital on January 25, 2016 (approval no. #121).

Study population comprised patients with creatine kinase values above 5000 U/L at admission who applied to our emergency department that admits 250.000 patients annually. The patients who were referred to our hospital for hospitalization or consultation or those diagnosed at an external center before applying to our hospital were excluded from the study.

Data of all patients included in the study were scanned by the investigators using the computerized database recording system of the hospital. Age, sex, creatine kinase levels, complaints at admission, etiologies, development of acute renal failure (if any), hospitalization, and discharge status of the patients along with their clinics of hospitalization were screened. Diagnosis of acute renal failure was made based on a 0.5 mg/dL increase in serum creatinine values, increase in serum creatinine values with unknown baseline values, or decrease in urine output. Complaints of patients at admission were grouped as extremity pain; abdominal pain and nausea; diarrhea; lassitude and malaise; trauma and agitation; impaired general health status; dark-colored urine; symptoms of stroke; drowning; and seizures. Etiologies were grouped as exercise, pancreatitis, gastroenteritis, viral respiratory tract diseases, drug use, trauma, myopathy, sepsis, cannabinoid use, stroke, alcohol use, drowning, arterial occlusion, seizures, and pneumonia. The clinics where the patients were hospitalized were grouped as internal medicine and anesthesia; reanimation, general surgery, and neurology; and chest diseases. The discharge status of ambulatory patients (for patients treated and followed up at the emergency department) was grouped as no hospitalization, rejection of the treatment, and mortality.

Data obtained in the study were evaluated for statistical analyses using SPSS for Windows 16.0 and Microsoft Office Excel 2007 programs. For the statistical evaluation of data and fitness of parameters to the normal distribution pattern, descriptive analyses (mean, percentage, and median) and Shapiro–Wilk test, respectively, were employed.

A total of 51 (male, n=37, 72.55% and female, n=14, 27.45%) patients who applied to the emergency department of our hospital between January 2014 and January 2015 with creatine kinase levels above 5000 U/L at admission were included in the study. Patient ages ranged between 17 and 96 years. Creatine kinase levels of the patients at admission changed between 5052 and 59140 U/L (median, 7882 U/L; IQR: 7840 U/L). Complaints at admission of the patients who applied to the emergency department were as follows: extremity pain (n=12; 23.5%), abdominal pain and nausea (n=5; 9.8%), diarrhea (n=3; 5.8%), malaise and lassitude (n=6; 11.7%), agitation (n=7; 13.7%), impaired general health status (n=6; 11.7%), dark-colored urine (n=3; 5.8%), symptoms of stroke (n=1; 1.9%), drowning (n=1; 1.9%), and seizures (n=1; 1.9%) ( Figure 1 ). Most frequent (23.5%) complaint was extremity pain.

Complaints at admission of the patients.

When etiologic factors involved in rhabdomyolysis were evaluated, exercise (n=10; 19.6%), pancreatitis (n=2; 3.9%), gastroenteritis (n=4; 7.8%), viral respiratory tract infection (n=8; 15.6%), drug use (n=3; 5.8%), trauma (n=6; 11.7%), myopathy (n=1; 1.9%), sepsis (n=4; 7.8%), cannabinoid use (n=7; 13.7%), stroke (n=1; 1.9%), alcohol use (n=1; 1.9%), drowning (n=1; 1.9 %), arterial occlusion (n=1; 1.9%), pneumonia (n=1; 1.9), and seizures (n=1; 1.9%) were observed ( Figure 2 ). Most frequent etiologic factor was exercise (19.6%).

Etiologic factors involved in rhabdomyolysis.

When emergency service outcomes were evaluated, it was determined that 23 (45.1%) patients were followed up and treated in the emergency department before they were discharged. Six (11.7%) patients rejected the treatment and left the emergency room. However, 21 (41.1%) patients were hospitalized in relevant clinics, and one (1.9%) patient died.

The patients were hospitalized in the clinics of internal medicine (n=12; 57.1%), anesthesia and reanimation (n=5; 23.8%), general surgery (n=1; 4.7%), neurology (n=2; 9.5%), and chest diseases (n=1; 4.7%).

The patients were evaluated with respect to the development of renal failure, and the data of patients who rejected the treatment could not be obtained. In 8.8% (n=4) of the patients with available data, acute renal failure developed. Data of these patients are summarized in Table 1 .

Data of these patients

Rhabdomyolysis was first defined by Fleisher in the year 1881 when hemoglobinuria was observed in soldiers after a long and tedious march [ 3 ]. Explanation of its pathogenesis and its association with myoglobin entering into circulation following muscle injury and acute tubular necrosis were revealed by Bywaters and Beall in the year 1941 [ 1 ].

Ion channels and pumps in muscle cells maintain Ca 2+ and Na + ions at lower and K − ions at higher concentrations. Direct injury of the muscle cell or inability to produce intracellular energy induces rhabdomyolysis. When energy production cannot be realized, ATP-dependent ion pumps, namely, Na/K ATPase and Ca 2+ ATPase, cannot exert their functions [ 4 ]. Increased intracellular calcium levels enhance activation of calcium-dependent proteases and phospholipases and subsequently induce apoptosis. With onset of apoptosis, myofibrils, cytoskeletal proteins, and membrane proteins degrade. Intracellular proteins, namely, aldolase, myoglobin, creatine kinase, lactate dehydrogenase, aspartate transaminase, and intracellular metabolites such as potassium, phosphate, and urate enter into systemic circulation and induce rhabdomyolysis [ 5 ].

Rhabdomyolysis manifests itself with myalgia, weakness of the injured muscle, and is generally associated with myoglobinuria. In addition, atypically, nausea, vomiting, and fever are observed. Clinically, muscle pain as its characteristic feature, is associated with increased serum creatine kinase levels [ 6 ]. Its classical triad includes muscle pain, weakness, and tea-colored urine. This classical triad can be seen in only 10% of the patients. In more than 50% of the patients, muscle pain and weakness are not observed. The patients more often apply with causes related to primary pathology [ 2 ]. In our study, the most frequent symptom was muscle pain, and the classical triad was observed in 5.8% of the patients.

Many clinical conditions may cause rhabdomyolysis. These etiologic factors may be classified as hereditary, acquired or traumatic, and non-traumatic causes. Acquired causes are more frequently observed and constitute 75% of all cases [ 7 ]. Melli et al. indicated most frequently observed causes as substance use (34%), medications (11%), trauma (9%), and epileptic seizures (7%) [ 8 ]. Other rarely observed causes include metabolic disorders, infections, local, and muscle ischemia, widespread muscle ischemia, prolonged immobilization, exercise, and exposure to extreme heat [ 5 ]. However, in 60% of the patients, more than one etiologic factor was observed [ 5 , 8 , 9 ]. Also, in our study, acquired causes were more frequently observed (98.1%). Assessment of acquired causes revealed incidence rates comparable to those observed in the literature.

Creatine kinase is a muscle protein, and its levels increase 2–12 h after muscle injury and reach their peak 24–72 h later. Within 3–5 days, they return to normal. Brown et al. conducted a study with 2083 patients and demonstrated the correlation between acute renal failure and creatine kinase levels above 5000 U/L. [ 10 ] Veenstra et al. detected the risk of developing acute renal as 35% in patients with creatine kinase levels between 5000 and 15000 U/L and as 75% in those with creatine kinase levels above 15000 U/L [ 11 ]. In our study, the risk of developing acute renal failure in patients with creatine kinase levels between 5000 and above 15000 U/L was 7.3% and 10%, respectively. We believe that the difference between our estimates and the values reported in the literature stems from the fact that 45.1% of our patients were treated in the emergency department on an outpatient basis contrary to previous studies, which had been performed on inpatients.

In serum, myoglobin is bound to serum globulins while transporting. As a result of excessive degradation, greater amounts of myoglobin exceed the myoglobin binding capacity of globulin and circulate freely in the blood. Mechanical occlusion of renal tubuli caused by free myoglobin is an important factor in the development of acute renal failure. Renal toxic effects of accompanying vasospasm, hypovolemia, and myoglobin contribute to the development of acute renal failure [ 12 ].

The most important complication induced by free myoglobin, i.e., development of acute tubular necrosis and acute renal failure secondary to increased free myoglobin concentrations have been detected in various studies at a rate of 14–46% [ 13 , 14 ]. In a study by Günal et al. on inpatient trauma patients in our country, the authors found incidence of the development of acute renal failure to be 25% [ 15 ]. In our study, the incidence was 8.8%.

In the management of rhabdomyolysis, first, the underlying cause should be treated. Aggressive fluid resuscitation at an early phase to improve renal perfusion and increasing the urine output have been considered to be the main interventions for prevention and treatment of acute renal failure [ 16 ]. The decision to start renal replacement treatment should not be based on myoglobin or creatine kinase concentrations but on the development or prediction of the development of life-threatening hyperkalemia, hypercalcemia, hyperazotemia, anuria, or renal failure [ 17 ]. Scarce evidence is available concerning routine sodium carbonate, loop diuretic, or mannitol administration [18].

In conclusion, rhabdomyolysis is a potentially life-threatening clinical syndrome caused by muscle injury. Although it is suspected after a traumatic injury, other potential causes should also be contemplated. All clinicians should be aware of common causes and diagnostic and therapeutic alternatives.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

Authorship contributions: Concept – S.O.; Design – O.O.; Supervision – S.O.; Materials – O.O.; Data collection &/or processing – S.O.; Analysis and/or interpretation – G.A.; Literature search – S.O.; Writing – S.O.; Critical review – G.A.