Monograph: Rhabdomyolysis-Article

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This 2025 AANEM monograph on rhabdomyolysis defines the condition as muscle injury causing elevated serum creatine kinase (CK) and release of muscle cell contents into blood and urine, including myoglobin, which can cause acute kidney injury (AKI). Rhabdomyolysis has diverse etiologies including trauma (crush injury, prolonged immobilization, burns), extreme exertion, medications (especially statins, neuroleptics), toxins (cocaine, snake venoms), infections, metabolic/myopathic disorders, and genetic causes like glycogen storage diseases and fatty acid oxidation defects.<br /><br />Clinically, patients may present with muscle pain, weakness, and dark “cola-colored” urine, but only a minority have the classic triad. Diagnosis is based on marked CK elevation (generally 3–5 times normal), with myoglobinuria detected by urine dipstick. CK rises within hours of injury, peaks by days 1–5, and declines if no ongoing muscle damage occurs. Laboratory abnormalities include hyperkalemia, hypocalcemia, metabolic acidosis, and AKI; EKG may show hyperkalemia-induced arrhythmias.<br /><br />The pathophysiology involves sarcolemmal membrane disruption or energy depletion leading to intracellular ionic imbalances, calcium overload, activation of proteases, myonecrosis, and inflammation. Myoglobin released from damaged muscle causes renal tubular injury principally due to oxidative damage and tubular obstruction, especially in volume-depleted, acidotic states.<br /><br />Treatment focuses on early aggressive intravenous fluid resuscitation to maintain urine output and correct metabolic derangements. The utility of urine alkalinization with bicarbonate or forced diuresis (e.g., mannitol) is unproven. Discontinuation of causative agents is essential. Renal replacement therapy may be needed if AKI progresses. Compartment syndrome may require surgical decompression.<br /><br />Special considerations include avoiding succinylcholine in patients with muscular dystrophies due to risk of malignant hyperthermia and rhabdomyolysis. Propofol infusion syndrome and rare ketamine-related rhabdomyolysis are also noted.<br /><br />In summary, rhabdomyolysis is a common syndrome with varied causes leading to muscle breakdown and potential multisystem complications. Prompt recognition, identification and removal of triggers, aggressive hydration, and management of complications like AKI are critical to improving outcomes.
Keywords
rhabdomyolysis
muscle injury
creatine kinase
myoglobinuria
acute kidney injury
trauma
statins
hyperkalemia
intravenous fluid resuscitation
compartment syndrome