Rhabdomyolysis: Evidence-Based Management in the Emergency Department -

Rhabdomyolysis: Evidence-Based Management in the Emergency Department
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Publication Date: December 2020 (Volume 22, Number 12)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 12/01/2023.


Gi Xiang Lee, MD
Highland Hospital, Oakland, CA
David K. Duong, MD, MS, FACEP
Associate Clinical Professor, University of California San Francisco School of Medicine, San Francisco, CA; Associate Residency Program Director, Highland Hospital, Oakland, CA

Peer Reviewers

Ryan Knight, MD
Assistant Professor of Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; Clinical Staff, University of Cincinnati, Cincinnati, OH
Ram A. Parekh, MD
Assistant Professor, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, NY


Rhabdomyolysis is a life-threatening pathological process that must be treated as early as possible to avoid potentially life-threatening sequelae. Much of the evidence that informs the management of rhabdomyolysis is retrospective research, often reported from mass disasters, and many practices that have been implemented as standard treatment are based on small studies published more than 30 years ago. This issue reviews the current literature on rhabdomyolysis and provides recommendations for each phase of care, from the prehospital setting through disposition. The evidence is examined regarding the variety of therapies that are used to manage rhabdomyolysis, the potential for recognizing a genetic predisposition for the condition, and therapeutic recommendations that improve patient outcomes.

Excerpt From This Issue

A 25-year-old man is brought to the ED in police custody. The police officer states that the man was found running in the street, screaming incoherently, and attacking passersby. The man is in 4-point hard restraints and is severely agitated, thrashing on the EMS gurney and yelling profanities. He is tachycardic but his other vital signs are normal. In order to safely transfer him to the hospital gurney, he is given 4 mg of midazolam IM and 20 mg of ziprasidone IM, after which he is sedated. You order laboratory studies, including a total CK level, and start 1 L of IV crystalloid fluids. A urine toxicology screen returns positive for methamphetamines. His CK level is 6000 U/L and the CMP is notable for a new AKI with a creatinine level of 2.0 mg/dL. You wonder how much fluid he should receive, and whether you should initiate any other medical interventions, such as alkalinization of the urine, loop diuretics, or mannitol . . .

A 40-year-old woman presents to the ED as a trauma activation following a rollover motor vehicle accident. She had been pinned under a vehicle and extrication took 40 minutes. She is tachycardic on arrival, but her vital signs are otherwise normal. She is alert, oriented, and protecting her airway, but has gross deformity of both of her thighs. Due to concern for possible crush syndrome, you order laboratory studies including CK levels, and administer 1 L of IV crystalloid fluids prior to sending her to the radiology department. Imaging reveals bilateral femur fractures. Her laboratory test results include a CK level of 40,000 U/L, a CMP notable for a new AKI with a creatinine level of 3.0 mg/dL, and a K+ level of 6.2 mEq/L. She is producing urine but it is dark. You consider reaching out to the on-call nephrologist about starting dialysis . . .

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