Suspected Rhabdomyolysis
Muscle injury with risk of myoglobin-induced AKI
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NephrologyManagement
Rhabdomyolysis Management (AAST Consensus)
Rhabdomyolysis Management (AAST Consensus): Suspected Rhabdomyolysis → Confirm Diagnosis → Severity Assessment → Mild Rhabdomyolysis → Recovery.
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Action Confirm Diagnosis
Clinical presentation and lab findings
- Classic triad: Muscle pain, weakness, dark urine
- Labs: CK >5× upper limit of normal (typically >1000 U/L)
- Myoglobinuria: Urine dipstick + for blood, no RBCs on microscopy
- Common causes: Trauma, crush, exertion, drugs, seizures, immobilization
03Decision Severity Assessment
CK level and AKI risk stratification
- Mild: CK 1,000-5,000 U/L - Low AKI risk
- Moderate: CK 5,000-15,000 U/L - Moderate AKI risk
- Severe: CK >15,000 U/L - High AKI risk (~50%)
- Very severe: CK >40,000 U/L - Very high AKI risk
04Action Mild Rhabdomyolysis
Outpatient management may be possible
- Encourage oral hydration (2-3 L/day)
- Avoid nephrotoxins and strenuous activity
- Daily CK until trending down
- Monitor creatinine
- Admit if unable to hydrate orally
05Outcome Recovery
CK normalizing, no AKI or AKI resolving
06Action Moderate-Severe: Aggressive Hydration
IV fluid resuscitation is cornerstone of treatment
- Initial bolus: 1-2 L NS over 1 hour
- Maintenance: 200-400 mL/hr (adjust to urine output)
- Target urine output: 200-300 mL/hr (or 3 mL/kg/hr)
- Crystalloid (NS or LR) preferred
- Monitor for volume overload
07Decision Role of Bicarbonate?
Alkalinization of urine is controversial
- Theoretical benefit: Prevents myoglobin precipitation in tubules
- No RCT evidence of benefit
- AAST: NOT routinely recommended
- Consider if metabolic acidosis (pH <7.3) present
08Action Continue NS/LR
Standard crystalloid resuscitation
09Action Monitor for Complications
Serial labs and clinical assessment
- Hyperkalemia: Can be severe and early - most dangerous
- Hypocalcemia: Early (calcium binds damaged muscle)
- Hypercalcemia: Late (during recovery phase)
- Metabolic acidosis
- DIC (severe cases)
- Compartment syndrome (if limb injury)
10Decision Compartment Syndrome?
Assess for limb compartment pressure elevation
- 5 Ps: Pain (out of proportion), Paresthesia, Pallor, Pulselessness, Paralysis
- Pain with passive stretch
- Measure compartment pressures if concern
- Pressure >30 mmHg or within 30 of diastolic = surgical emergency
11Warning URGENT Fasciotomy
Surgical emergency - immediate decompression
- Emergent surgical consultation
- Delay causes irreversible muscle/nerve damage
- Can be limb-saving and life-saving
12Decision AKI Developing?
Monitor creatinine for rise despite fluids
13Action Continue Supportive Care
Maintain high urine output until CK normalizing
- Path rejoins step 05Shared downstream outcome
14Decision Need for RRT?
Standard AKI indications apply
- Refractory hyperkalemia
- Severe acidosis (pH <7.1)
- Volume overload
- Uremic complications
- NOTE: RRT does NOT prevent AKI in rhabdo
15Action Initiate RRT
HD or CRRT based on hemodynamic status
- CRRT may be preferred in hemodynamically unstable
- High-flux dialyzers for myoglobin clearance
- Watch for rebound hyperkalemia
16Outcome Nephrology Follow-up
If AKI developed, monitor for CKD
- Path rejoins step 13Shared downstream outcome
- Path rejoins step 12Shared downstream outcome
17Action Add Bicarbonate
If acidosis present
- 150 mEq NaHCO3 in 1L D5W
- Target urine pH >6.5
- Monitor for hypocalcemia (bicarb can worsen)
- Avoid if hypocalcemia present
- Path rejoins step 09Shared downstream outcome
Guideline Source
Rhabdomyolysis: AAST Critical Care Committee Clinical Consensus Document
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- CK thresholds for AKI risk are not absolute
- Fluid resuscitation must be individualized
- Does not address underlying cause treatment in detail
- Fasciotomy decisions require surgical consultation
Applicable Regions
EUUSglobal
US: AAST consensus widely used in trauma centers
global: General principles apply internationally
Version 1Next review: 2027-01-01
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Frequently Asked Questions
What is the Rhabdomyolysis Management (AAST Consensus)?
The Rhabdomyolysis Management (AAST Consensus) is a management clinical algorithm for Nephrology. It provides a structured decision tree to guide clinical decision-making, based on Rhabdomyolysis: AAST Critical Care Committee Clinical Consensus Document.
What guideline is the Rhabdomyolysis Management (AAST Consensus) based on?
This algorithm is based on Rhabdomyolysis: AAST Critical Care Committee Clinical Consensus Document (DOI: 10.1097/TA.0000000000003463).
What are the limitations of the Rhabdomyolysis Management (AAST Consensus)?
Known limitations include: CK thresholds for AKI risk are not absolute; Fluid resuscitation must be individualized; Does not address underlying cause treatment in detail; Fasciotomy decisions require surgical consultation. Individual patient factors may require deviation from these recommendations.
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