Coca Cola Urine

Vigilance in the face of apparently common or benign presentations is a common theme of the PedEM Morsels.  As we have said, Grandma can diagnose the gastroenteritis; we need to consider the other sinister ailments that masquerade as the benign.  Rhabdomyolysis is potentially one of those masqueraders.


  • Literally, lysis of skeletal muscle, with resultant muscle injury, electrolyte derangement, and potential kidney failure.
  • “Classic” triad = Muscle Injury, Myoglobinuria (Dark Urine), and Renal Dysfunction
    •  “Classic” does not equate to common.
    • One study found only ~1% of pediatric patients had all three.

Rhabdomyolysis Presentation

  • Myalgia, muscle tenderness, and weakness are commonly seen…
    • and nice and vague (I had these after my recent overnight shift).
  • May have edema.
  • May have fever and viral-type symptoms (malaise, nausea, vomiting).
    • Look for calf pain and tenderness, gait disturbance, and refusal to walk following viral illness.
  • May present with over shock.

So the child who has had an antecedent “viral” illness who now presents with a limp and you naturally consider joint pathology (ex, toxic synovitis) you should also entertain the potential for Rhabdomyolysis (viral symptoms and LE pain +/- refusing to walk).

Rhabdomyolysis Etiologies

  • Trauma

    • Any trauma that leads to muscle damage may produce rhabdomyolysis.
    • Child abuse, electric injuries, overuse injuries, and crush injuries.
    • Prolonged immobilization or surgical procedures also can lead to it.
  • Exercise

    • Vigorous exercise in normal individuals, as well as well-trained individuals, can cause it.
    • Higher risk with impaired heat loss (high humidity, restrictive clothing, etc).
    • Also consider performance-enhancing supplements.
  • Infection

    • Viral myositis is one of the leading causes of rhabdomyolysis in children!
    • Influenza is the most predominant agent, but many others can lead to rhabdomyolysis as well!
      • EBV, Enterovirus, varicella, HIV, Parainfluenza, rotavirus, RSV, etc.
    • Bacterial infections also can be associated with rhabdomyolysis.
      • Legionella, Strep. pneumoniae, Salmonella, Staph, enterococcus, Pseudomonas, etc.
      • Pt’s with sepsis are at risk of developing rhabdomyolysis.
  • Drugs

    • More than 150 drugs and toxin have been associated with rhabdomyolysis.
    • Illicit drugs (ex, cocaine, ecstasy) and ETOH
    • SSRIs
    • Statins
    • Ketamine (… say it ain’t so…)
    • Any envenomation that leads to muscle damage (ex, brown recluse spider bite) can lead to rhabdomyolysis.
  • Metabolic Disease

    • Familial Causes / Inborn Errors of Metabolism
      • ex, Fatty Acid Oxidation Defects, Glycogen Storage Diseases, malignant hyperthermia, muscular dystrophies
      • Must consider these in the patient who has had recurrent episodes of rhabdomyolysis.
    • Thyrotoxicosis
    • Diabetic Ketoacidosis

Rhabdomyolysis Diagnosis

  • Urine dip with +heme but no or few RBCs is concerning for it.
    • Myoglobinuria does not have to be present for the diagnosis however.
    • Myoglobin is eliminated more rapidly than Creatine Kinase (CK).
  • CK levels > 1,000 U/L is often considered diagnostic.
  • Lower levels of CK are termed myositis.

Rhabdomyolysis Management in the ED

  1. Place on monitor and obtain 12 lead ECG (make sure you are not waiting around to find out the potassium is high).
  2. Treat underlying cause of the condition (ex, Seizure – stop the shaking).
  3. Vigorous fluid resuscitation!
    1. 20ml/kg to start with.
    2. Then run IVF at 2-3 times Maintenance to maintain Urine Output of ~1-2ml/kg/hr.
  4. Correct electrolyte abnormalities!
    1. Calcium should be given only to those with severe hyperkalemia or symptomatic hypocalcemia.
    2. It can deposit in the tissues.
    3. Additionally, during fluid resuscitation, calcium may reenter the bloodstream and actually lead to hypercalcemia.
  5. Monitor electrolytes frequently.
  6. Alkalinization of the urine:
    1. Not proven to be effective, but it is safe and theoretically useful.
    2. Start AFTER the patient has started to produce urine.
  7. Hemofiltration may be necessary.


Luck RP, Verbin S. Rhabdomyolysis: A reveiw of clinical presentation, etiology, diagnosis, and management. Pediatr Emerg Care. April 2008; 24(4): 262-268.

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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