Suspected rhabdomyolysis (adult)
Muscle breakdown with risk of hyperkalaemia and AKI. Adult pathway: for children, get paediatric advice.
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NephrologyManagement
Rhabdomyolysis Management (AAST Consensus)
Rhabdomyolysis Management (AAST Consensus): Suspected rhabdomyolysis (adult) → Confirm the diagnosis and find the cause → Red flag: hyperthermia, rigidi...
Pathway Overview
18 steps
Algorithm Steps
18 total
01Start 02Action Confirm the diagnosis and find the cause
CK more than 5 times the upper limit of normal (or more than 1,000 U/L) with a matching history. Crush injury, long lie or dark urine: start IV crystalloid now; do not wait for the CK result.
- Bloods: CK, UEC, K+, calcium, phosphate, magnesium, VBG, LFTs; coagulation if severe
- ECG now if K+ is high or not yet known
- Stop the causing drug (for example a statin), nephrotoxins (NSAIDs) and drugs that raise K+ (ACE inhibitor, ARB, spironolactone, K+ supplements); avoid IV contrast if possible
- Symptoms: muscle pain, weakness, swelling, dark urine; can be absent
- Urine dipstick positive for blood with few or no red cells suggests myoglobin
- Causes: crush or limb ischaemia, long lie after a fall, exertion, seizures, alcohol, drugs (statins, cocaine, stimulants), infection, hyperthermia
- Repeat CK until it peaks (usually 24-72 h) and then falls
03Warning Red flag: hyperthermia, rigidity or clonus
Treat the cause now; IV fluids alone are not enough. Think of neuroleptic malignant syndrome, malignant hyperthermia, serotonin toxicity, heat stroke and stimulant toxicity.
- Cool actively now, stop the trigger drug and call ICU
- NMS: stop the antipsychotic; benzodiazepines. Serotonin or stimulant toxicity: benzodiazepines. Malignant hyperthermia: dantrolene, with the anaesthetist (MH protocol)
- Doses: toxicology advice, Poisons Information Centre 13 11 26
04Decision K+ 6.0 mmol/L or more, or ECG changes of hyperkalaemia?
Hyperkalaemia is the most dangerous early complication. Check K+ and the ECG first.
- If Yes
05Action Hyperkalaemia: treat now (adult doses)
K+ 6.0 mmol/L or more, or ECG changes. Cardiac monitor. Give calcium for ECG changes, even though calcium can deposit in injured muscle. Children: use paediatric doses.
- ECG changes: calcium gluconate 10% 30 mL IV over 10 min (peri-arrest: calcium chloride 10% 10 mL IV over 5 min)
- Insulin 10 units soluble insulin IV with glucose 25 g (50 mL of 50% glucose)
- Glucose before treatment below 7.0 mmol/L: then glucose 10% at 50 mL/h for 5 h; check glucose often
- Adjunct: nebulised salbutamol 10-20 mg (10 mg only in ischaemic heart disease; caution in tachyarrhythmia)
- Recheck K+ at 1, 2, 4, 6 and 24 h; glucose at 0, 30, 60, 90 and 120 min, then hourly to 6 h
- Taking digoxin: still give calcium for life-threatening ECG changes; get toxicology advice
- If intubation is needed: avoid suxamethonium (it raises K+)
- Refractory hyperkalaemia: urgent dialysis (nephrology or ICU)
06Decision Compartment syndrome suspected?
Check every injured or swollen limb now and repeat. Early signs: pain out of proportion and pain on passive stretch. Pallor and loss of pulses are late.
- If Yes
07Warning Compartment syndrome: urgent fasciotomy
Surgical emergency: call the surgical team now. A delay of more than 6 hours can cause irreversible muscle damage or death.
- Remove tight casts and dressings; keep the limb at heart level
- Do not wait for pressure measurement if the signs are clear
- Delta pressure (diastolic BP minus compartment pressure) below 30 mmHg supports the diagnosis
08Decision Any high-risk feature?
High risk: admit for IV fluids. CK alone predicts AKI poorly. High risk: creatinine above normal or AKI; abnormal K+, calcium or phosphate, or acidosis; McMahon score 6 or more; trauma, crush, compartment syndrome, hyperthermia, sepsis or drug toxicity; dark urine; CK above 20,000 U/L; heart failure, CKD, older age or frailty, sickle cell trait; cannot drink, ongoing muscle injury or no review in 24-72 h.
- If Yes
- High risk
09Action High risk: admit for IV fluids (adult rates)
Heart failure, dialysis dependence, oliguric or anuric AKI, or frailty: smaller volumes and an individual plan with ICU or nephrology. Children: paediatric advice.
- Hypovolaemic: resuscitate first with crystalloid boluses
- Start 0.9% sodium chloride or Hartmann's at about 400 mL/h (range 200-1,000 mL/h)
- No added potassium in IV fluids while K+ is high or rising
- Titrate to urine output 1-3 mL/kg/h, up to 300 mL/h; urinary catheter to measure
- No urine response despite fluids: stop high-volume fluids and assess for dialysis
- Reassess volume status often: lungs, oxygen, fluid balance
- Continue until CK is falling (many units use CK below 5,000 U/L), then reduce
10Action Bicarbonate, mannitol and diuretics: not routine
AAST does not recommend sodium bicarbonate, mannitol or loop diuretics to prevent AKI in rhabdomyolysis.
- Severe metabolic acidosis from AKI: isotonic bicarbonate may be used as the IV fluid, with ICU or nephrology advice
- If bicarbonate is given: monitor K+ and ionised calcium (both can fall)
11Action Monitor for complications
Serial K+, creatinine, calcium, phosphate, CK and fluid balance. Do not give calcium for low calcium without symptoms.
- Hyperkalaemia: early and most dangerous; cardiac monitor if K+ is above 6 mmol/L; treat as in the hyperkalaemia step
- Low calcium early: treat only if symptomatic or with hyperkalaemia and ECG changes; calcium can rise later in recovery
- High phosphate: usually falls with urine output; treat with caution
- Compartment syndrome can develop late: re-examine limbs
- Liver dysfunction, DIC and arrhythmia
12Decision AKI developing?
Creatinine rising or urine output falling despite fluids.
- If Yes
- AKI developing
13Decision AKI: indication for dialysis?
Use standard AKI indications. Dialysis does not prevent AKI in rhabdomyolysis. Indications: hyperkalaemia, acidosis or fluid overload that does not respond to medical treatment; anuria despite fluids; uraemic complications.
- If Yes
14Action Dialysis indicated: start RRT
Intermittent haemodialysis or CRRT, chosen by haemodynamic status and degree of renal impairment, with nephrology or ICU.
- CRRT if haemodynamically unstable
- No evidence for a specific filter or modality to remove myoglobin
- Recheck K+ after each session: ongoing muscle release can raise it again
15Outcome Dialysis-requiring AKI: nephrology follow-up
Risk of CKD and ongoing dialysis; follow up renal function after discharge.
If No16Action No AKI or no dialysis indication: continue supportive care
Continue IV fluids to the urine output target and serial bloods until CK is falling and electrolytes settle.
17Outcome Recovery
CK falling, electrolytes normal, creatinine at baseline. If AKI occurred: check creatinine after discharge and arrange follow-up. Recurrent episodes, a family history, or muscle symptoms with exercise: refer to a medical genetics specialist.
If No- No AKI
- Path rejoins step 16Shared downstream outcome
If No- Low risk
18Action No high-risk feature: outpatient care may be safe
Only if otherwise well, creatinine and K+ normal, the cause is removed, the patient can drink, and review is booked in 24-72 h.
- Oral fluids; no strenuous exercise until review
- Avoid NSAIDs and other nephrotoxins
- Repeat CK and creatinine in 24-72 h until CK falls
- Return now for dark urine, less urine, more pain or swelling, or vomiting
- Admit if creatinine or K+ rises, or CK keeps rising
- Path rejoins step 17Shared downstream outcome
If No- Path rejoins step 08Shared downstream outcome
If No- Path rejoins step 06Shared downstream outcome
Guideline Source
Rhabdomyolysis: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document (Kodadek et al, 2022)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adult pathway based on consensus and observational evidence; fluid rates must be individualised, with smaller volumes in heart failure, dialysis dependence or frailty
- CK alone predicts AKI poorly; outpatient care is for well patients with normal creatinine and K+ and review in 24-72 h
- Cause-specific treatment (toxicology, hyperthermic syndromes, statin myopathy) is outlined only
- Fasciotomy decisions need urgent surgical review
Contraindicated Populations
Children (use a paediatric guideline)Dialysis-dependent patients (individual fluid plan with nephrology)
Applicable Regions
AUEUUSglobal
AU: Poisons Information Centre 13 11 26. Hartmann's solution is compound sodium lactate (lactated Ringer's). Doses of calcium, insulin and glucose follow UKKA 2023; check the local hyperkalaemia protocol. McMahon score in Australian units: creatinine 124-194 umol/L scores 1.5, above 194 umol/L scores 3; calcium below 1.87 mmol/L scores 2; phosphate 1.29-1.74 mmol/L scores 1.5, above 1.74 mmol/L scores 3; bicarbonate below 19 mmol/L scores 2.
US: AAST consensus written for surgical and trauma critical care.
global: General principles apply internationally.
Version 2Next review: 2027-09-30
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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: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document (Kodadek et al, 2022).
What guideline is the Rhabdomyolysis Management (AAST Consensus) based on?
This algorithm is based on Rhabdomyolysis: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document (Kodadek et al, 2022) (DOI: 10.1136/tsaco-2021-000836).
What are the limitations of the Rhabdomyolysis Management (AAST Consensus)?
Known limitations include: Adult pathway based on consensus and observational evidence; fluid rates must be individualised, with smaller volumes in heart failure, dialysis dependence or frailty; CK alone predicts AKI poorly; outpatient care is for well patients with normal creatinine and K+ and review in 24-72 h; Cause-specific treatment (toxicology, hyperthermic syndromes, statin myopathy) is outlined only; Fasciotomy decisions need urgent surgical review. Individual patient factors may require deviation from these recommendations.
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