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Rhabdomyolysis

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of rhabdomyolysis are prepared by our editorial team based on guidelines from the American Association for the Surgery of Trauma (AAST 2022), the United Kingdom Kidney Association (UKKA 2019), and the American Orthopaedic Society for Sports Medicine (AOSSM 2014). ...
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Screening and diagnosis

Clinical presentation
As per AAST 2022 guidelines:
Recognize that rhabdomyolysis presentation may vary from asymptomatic to commonly implicated clinical features, including acute muscle weakness, pain/tenderness, and swelling (dolor, tumor) of the affected extremity or body region.
E
Recognize that darkened (tea-colored) urine may be present in patients with rhabdomyolysis.
E
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  • Diagnosis

Classification and risk stratification

Risk stratification
As per AAST 2022 guidelines:
Consider estimating the risk of AKI, RRT, and/or in-hospital mortality in patients with rhabdomyolysis using admission demographic, clinical, and laboratory variables.
E
Recognize that risk prediction scores may not directly influence treatment; however, they may be useful in estimating prognosis and setting expectations.
E

Diagnostic investigations

Laboratory tests
As per AAST 2022 guidelines:
Recognize that the most commonly implicated variables include elevations of the following:
serum concentrations of CK (> 5 times the ULN or > 1,000 IU/L)
myoglobin (provides additional evidence)
LDH
potassium
creatinine
AST
E
Set a low threshold of suspicion in the proper clinical context to initiate appropriate therapy.
E

Medical management

Intravenous fluids: as per AAST 2022 guidelines, administer either lactated Ringer's solution or saline (0.9% or 0.45%) for resuscitation in patients withrhabdomyolysis. Consider starting at a rate of 400 mL/hour, with goal-directed therapy of urine output of 1-3 mL/kg/hour, and up to 300 mL/hour.
E

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  • Urine alkalinization

  • Diuretics

  • Management of electrolyte abnormalities

Nonpharmacologic interventions

Rest: as per AOSSM 2014 guidelines, advise rest from the provoking activity and hydration for the management of patients with exertional rhabdomyolysis.
B

Therapeutic procedures

RRT
As per AAST 2022 guidelines:
Do not offer RRT (either continuous or intermittent) to prevent AKI in patients with rhabdomyolysis.
D
Offer RRT in patients with rhabdomyolysis based on traditional indications for AKI and the degree of renal impairment.
E

Follow-up and surveillance

Serial laboratory assessment: as per AAST 2022 guidelines, obtain serial CK measurement for monitoring until a peak concentration is identified (typically at 24-72 hours), and discontinue once the CK is reliably downtrending.
E

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  • Monitoring for complications

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