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 M. Fox
Sean M. 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 renowned 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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  1. I came across this page in my search for an answer to my sons condition. My son suffers from swelling in his legs and last year had emergency surgery due to compartment syndrome on his left calf. After this surgery we have been in and out of ERs due to swelling after trauma (he’s a very active 4yr old). He complains of pain on his legs when he wakes up in the morning or sits for too long. He also goes off into these staring spells which neurology is now looking out. I am reading some of the articles on Rhabdomyolysis and I am beginning to find common symptoms my son shows before presenting pain or swelling. Every time we’ve been to the ER for an issue with swelling or limping, he’s had a runny nose and a bad cough. Hematology has done every type of bloodwork possible and claims to find nothing however they’ve never done a urine test. I am desperately trying to find an answer to what’s babe has so I can help him. I’m from NY so if anyone knows of a Doctor with experience on this illness please share. We now have an appointment with genetics this month. I’m praying for answers.

  2. Hello!
    My 8 year old boy was admitted to the hospital with Rabdomyolisis and had an IV for 2 days, we were let go the 4th day.
    I had a follow up with our family doctor the next day after released from the hospital and he ordered a complete blood test. Then again another blood test 5 days after.
    The levels of CK and myoglobin have gone down, but not normal yet.
    Our boy is walking well and is happy and has returned to school. No excersise yet.
    I feel like our doctor wants to keep monitoring my son’s blood until is “normal” CK and myoglobin. Is this really necessary?

  3. My 8 year old gets Rhabdomyolysis after influenza almost every year. He’s had it 4 times already.

  4. Why does my child 5yr old male have reoeated rhabdomyolysis, cpk over 5,000. Genetic dr running test for fatty oxidation problem. But if this comes back as positive for genetic problem Why is he having reaccuring episodes? Why didn’t this hapoen when he was a baby? Was 2 months premie with asthma.

  5. What can be done to find out why my 5 yr old has rhabdomyolysis repeatedly now? His cpk goes up over 5,000. How do I stop him from getting this again?
    Having genetic dr do test for fatty oxidation etc

    • Mary,
      Obviously, I cannot give out specific medical advice over the internet… but it does sound like your doctors are appropriately evaluating the issue. I recommend that you continue to have open conversations with them to help all of you take the best care of your child!

      All of the best,

  6. Im a parent of a 2 year old child recently diagnosed with Rhabdomylosis. He got sick on a Sunday quite suddenly and had a febrile seizure. By tuesday his fever had broken. The next day didnt complain of pain, however was having trouble walking. Blood work came back with ck 3400. Doctor said it was acute mytosis and he would get better in a few days. The next day he could barely stand. Back to the doctor rechecked ck levels (14600). It took 3 days of iv fluids for his levels to drop below 5000 & they released him from the hospital. Two weeks later my son has started to have trouble walking again. I took him to the doctor and he tested positive for strep throat. They said infections like this can flare up his symptoms but that he will be fine because he doesn’t have the flu. I’m reading case studies that mytosis can be caused by more than just the flu. As an advocate for my child Im looking for a second opinion.

    • He has rhabdomyolitis. Anything above 1500 in adults is classified and rhabdo. It would be interesting to see if he is having myoglobin in the urine as well. Have that discussed what his creatinine is? After treatment is CK should be back in the normal range not just “less than 5000”. He should definitely be admitted for IV fluids again. He is breaking down muscle which is causing his CK to be elevated. Anything greater than 200 is abnormal, anything above 1500 is still really high and definitely abnormal. I would recommend seeing a pediatric specialist. There is something wrong. I work as a PA in Emergency Medicine, not a specialist by any means but this patient would have been transferred to a Children’s hospital for further evaluation and treatment as soon as his CK was 3400.

      • He was rechecked two days after this post and his levels went back to normal. However he has had two episodes since where he is falling down and I take him in for an appointment but they keep writing it off and say to just monitor him. Every morning when he wakes up he has trouble remaining steady and walking for the first hour of the day and slowly stabilizes from there until he wakes up from his nap where again he becomes shaky and has trouble walking. Should I take him somewhere else? The last appointment I was almost in tears because they acted like it was just growing pains.

    • My son had test positive for influenza ck levels reach 9900 after iv fluids it drop withing 2 days to 723. Still abnormal. He has been okay so far but hasn’t fully recovered. He still has muscle twitch at night. Just wonder how long will this last.

  7. […] potentially severe conditions present similarly to benign illnesses.  Kawasaki Disease, Rhabdomyolysis, Crohn’s Disease, and Compartment Syndrome are conditions that come to mind; however, one […]

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