Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

crush injury and/or creatine kinase >5 times normal or >1000 IU/L

1st line – hydration therapy

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ACUTE
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crush injury and/or creatine kinase >5 times normal or >1000 IU/L
1st line – 

hydration therapy

Patients presenting with extremity trauma are at risk of developing compartment syndrome and rhabdomyolysis. Anticipation of this, and the initiation of hydration, is preventive therapy.

Potential complications are related to overhydrating the anuric patient and include fluid retention and congestive heart failure.

Intravenous infusion of either lactated Ringer’s solution or saline (0.9% or 0.45%) is typically recommended. A starting rate of 400 mL/hour with a range of 200 mL/hour to 1000 mL/hour is considered reasonable as goal-directed therapy, with a urine output target of 300 mL/hour.[2][31][33]

Consult your local protocols for further guidance.

Plus – correction of electrolyte abnormalities

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ACUTE
|
crush injury and/or creatine kinase >5 times normal or >1000 IU/L
Plus – 

correction of electrolyte abnormalities

Treatment recommended for ALL patients in selected patient group

Hyperkalemia can occur in rhabdomyolysis-induced acute kidney injury early in the disease process, and should be monitored closely due to the risk of cardiac arrhythmias.[2] Potassium levels >6 mEq/L (>6 mmol/L) require cardiac monitoring. Electrocardiographic changes of hyperkalemia require treatment with calcium gluconate. Elevated potassium levels should be treated with insulin and glucose infusions, albuterol inhalation, cation exchange resins, or dialysis as indicated.[2] Other electrolyte abnormalities should be meticulously monitored and corrected as required.[2]

Consult your local protocols for further guidance.

Consider – urine alkalinization

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ACUTE
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crush injury and/or creatine kinase >5 times normal or >1000 IU/L
Consider – 

urine alkalinization

Treatment recommended for SOME patients in selected patient group

Myoglobin is toxic to renal tubules in acidic urine. Some evidence suggests that a urine pH >6.0 is protective.[34][35] This is difficult to achieve without the use of large amounts of bicarbonate and although some specialists may recommend urine alkalinization, benefits of its use lack robust evidence-based support.[30][32][35][36]

European protocols report limited clinical evidence to support bicarbonate therapy.[31] BAPEN: British consensus guidelines on intravenous fluid therapy for adult surgical patients Opens in new window

The American Association for the Surgery of Trauma does not recommend the use of bicarbonate due to a lack of high quality evidence.[2]

Should the clinical decision be made to attempt urine alkalinization, pharmacy consultation should be considered to determine appropriate continuous intravenous therapy mixtures.

Consult your local protocols for further guidance.

Consider – diuretic therapy

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ACUTE
|
crush injury and/or creatine kinase >5 times normal or >1000 IU/L
Consider – 

diuretic therapy

Treatment recommended for SOME patients in selected patient group

The use of diuretic therapy to promote diuresis is unclear. The benefits of diuretic therapies (e.g., mannitol, furosemide) and at what point to administer them have not been prospectively studied. Reports have been spurious and anecdotal, and guidelines do not generally support their use.[2][31][32][37][38][39]

Consult your local protocols for further guidance.

acute kidney injury refractory to initial therapy

1st line – renal replacement therapy

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ACUTE
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acute kidney injury refractory to initial therapy
1st line – 

renal replacement therapy

In patients with rhabdomyolysis who develop acute kidney injury (AKI) and need renal replacement therapy (RRT), either continuous RRT (CRRT) or intermittent RRT (e.g., hemodialysis) should be used based on the degree of renal impairment and the clinical status of the patient. There are no recommendations regarding RRT modalities (filtration vs. diffusion), filter type (low vs. high cut-off membranes), or high-flow versus low-flow dialysis.[2]

Dialysis corrects refractory metabolic acidosis, hypervolemia, and electrolyte abnormalities in patients with rhabdomyolysis and AKI.[40] However, there is no evidence to support a role for RRT in the prevention of AKI in patients with rhabdomyolysis.[2] Utilization should be based on standard indications for AKI refractory to medical management.[2]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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