Rhabdomyolysis in the ED: Title: Muscle Breakdown, Real Consequences

-Case-
A 28-year-old man walks into the ED complaining of generalized muscle soreness and dark-colored urine. He mentions he recently started a new high-intensity workout program and pushed himself hard over the past few days. He’s alert but uncomfortable. His urine dipstick is positive for blood, but there are no RBCs on microscopy.

-Evaluation-
Rhabdomyolysis is a syndrome caused by skeletal muscle breakdown, leading to the release of intracellular contents like myoglobin, potassium, phosphate, and CK into the bloodstream. These can trigger complications like acute kidney injury (AKI), electrolyte disturbances, and even cardiac dysrhythmias.

  • Common Causes:
    • Trauma/crush injury
    • Prolonged immobilization
    • Extreme exercise or heat stroke
    • Seizures
    • Statins or other medications
    • Infections or metabolic disorders
  • Clinical Clues:
    • Muscle pain, weakness, or swelling
    • Dark (tea- or cola-colored) urine
    • Fatigue, malaise, low-grade fever
  • Key Labs:
    • CK >5x upper limit of normal (usually >1000 U/L but often much higher)
    • Elevated creatinine along with hyperkalemia, hyperphosphatemia, hypocalcemia
    • Urine dipstick positive for blood, but no RBCs on microscopy (myoglobinuria)

-Management-

  1. Aggressive IV Fluids:
    • Mainstay of treatment to prevent/treat AKI
    • Normal saline at 1-2 L bolus, then maintenance 200-300 mL/hr
    • Target urine output >200 mL/hr
  2. Monitor Electrolytes:
    • Watch for hyperkalemia, especially early on
    • Replace calcium only if symptomatic or severely low
  3. Avoid Nephrotoxins:
    • Hold NSAIDs, contrast agents, etc.
  4. Consider Bicarbonate or Mannitol?
    • Limited evidence; not first-line, but may be used selectively
  5. Admission:
    • Indicated for CK >5,000-10,000, signs of renal impairment, electrolyte abnormalities, or in patients with baseline comorbidities

-Fast Facts-

  • Urine positive for blood but no RBCs = think rhabdo!
  • CK levels can help trend severity but don’t always correlate with AKI
  • Hydration is the cornerstone of therapy and electrolyte monitoring is essential to avoid deadly complications
  • Muscle pain after a workout isn’t always benign; know when to dig deeper!

Rhabdomyolysis is one of those diagnoses that hides in plain sight. Muscle aches? Check. Fatigue? Sure. But when dark urine and recent exertion are in play, keep rhabdo on your radar, hydrate early, and treat promptly – because the kidneys (and the heart) are on the line.

Want to learn more? Read our listen to our podcast episode on this topic!

Cheers,

Tamir Zitelny, MD

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-References-

  1. Chavez LO, Leon M, Einav S, Varon J. Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice. Crit Care. 2016;20:135. doi:10.1186/s13054-016-1314-5
  2. Huerta-Alardín AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis — an overview for clinicians. Crit Care. 2005;9(2):158-169. doi:10.1186/cc2978
  3. Torres PA, Helmstetter JA, Kaye AM, Kaye AD. Rhabdomyolysis: pathogenesis, diagnosis, and treatment. Ochsner J. 2015;15(1):58-69.
  4. Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med. 2009;361(1):62-72. doi:10.1056/NEJMra0801327
  5. Melli G, Chaudhry V, Cornblath DR. Rhabdomyolysis: an evaluation of 475 hospitalized patients. Medicine (Baltimore). 2005;84(6):377-385. doi:10.1097/01.md.0000188565.48918.41
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