Background: Rhabdomyolysis is defined as injury of the skeletal muscle, which results in the release of intracellular components into the circulation.1 The most common causes of rhabdomyolysis are reviewed in Tables 1 and 2. Rhabdomyolysis in critically ill patients can result in significant morbidity, including need for fasciotomy (52%), amputation (24%), renal insufficiency (29%), and dialysis (9.5%).2
CO – carbon monoxide; CN –
cyanide; DTs – delirium tremens; NMS – neuroleptic malignant syndrome; MH –
malignant hyperthermia; OTC – over the counter; DKA – diabetic ketoacidosis
Table 2. Drugs Associated
with Rhabdomyolysis
|
|
Drug Class
|
Examples
|
Lipid-lowering agents
|
Statins,
Fibrates
|
Psychiatric medications
|
Haloperidol,
atypical antipsychotics, SSRIs, lithium, valproic acid
|
Antimicrobial agents
|
Protease
inhibitors, trimethoprim-sulfamethoxazole, daptomycin, quinolones,
macrolides, amphotericin B
|
Anesthetics
|
Propofol
|
Paralytics
|
Succinylcholine
|
Antihistamines
|
Doxylamine,
diphenhydramine
|
Appetite suppressants
|
Phentermine,
ephedra
|
Chemotherapy
|
Sunitinib,
erlotinib
|
Antiarrhythmics
|
Amiodarone
|
Miscellaneous
|
Colchicine,
narcotics, aminocaproic acid, vasopressin
|
Illicit drugs
|
Cocaine,
amphetamines/methamphetamines, hallucinogens, heroin, bath salts
(methlenedioxypyrovalerone, mephedrone), phencyclidine
|
This list should not be considered comprehensive.
Consult with a pharmacist is recommended for all potential medication-induced
cases of rhabdomyolysis. SSRIs – selective serotonin reuptake inhibitors
Diagnosis: Obtain serum creatinine, base deficit, and creatine
kinase (CK) on admission. No utility in
obtaining urine myoglobin. 3
If CK > 1250, continue to trend (every 8 hrs) until peak usually
within 48hrs followed by decline. CK
< 20,000 is unlikely to be associated with a risk of renal impairment. No standard CK level otherwise exists.
Treatment: There
are no well-done randomized controlled trials of treatments for rhabdomyolysis.
Treatment is based around three core components: prevention of further skeletal
muscle damage, prevention of acute kidney injury (AKI), and rapid
identification of potentially life-threatening complications.
References:
(Adapted from reference 3)
References:
1)
Zimmerman JL, Shen MC. Rhabdomyolysis. CHEST. 2013; 144: 1058-65.
2)
Sharp LS, Rozychi GS, Feliciano DV. Rhabdomyloysis and secondary renal
failure in critically ill surgical patients. Am J Surg. 2004; 801-6.
3)
Bhavsar P, Rathod KJ, Rathod D, Chamania CS. Utility of Serum Creatinine, Creatinine
Kinase, and Urinary Myoglobin in Detecting Acute Renal Failure due to Rahabdomyolysis
in Trauma and Electrical Burns Patients.
Indian J Surg. (jan-feb 2013) 75
(1): 17-21.
4)
Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin. 2004; 20: 171-92.
Trauma Service: Severe Rhabdomyolysis Algorithm
This is a guideline only and not
to be substituted for individual clinical judgment. 
