Guideline 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). 1 2 3 Calculator McMahon score for kidney failur Guidelines 1. Screening and diagnosis Clinical presentation: https://web.pathway.md/diseases/recPBZt7yxWy3mkCC 1/4 6/24/23, 2:57 PM Rhabdomyolysis Pathway 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 Diagnosis: As per AAST 2022 guidelines, suspect rhabdomyolysis in patients with a large burden of traumatic injury involving muscular tissue, especially patients with crush injuries involving the extremities or mangled extremities. E Show 2 more As per AOSSM 2014 guidelines, diagnose exertional rhabdomyolysis in the presence of a serum creatinine level at least 5 times the ULN. B 2. 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 As per AOSSM 2014 guidelines: Regard the following patients to be at high risk in the context of exertional rhabdomyolysis: delayed recovery (> 1 week) persistent elevation of CK despite rest for 2 weeks AKI of any degree personal or family history of exertion rhabdomyolysis personal or family history of recurrent muscle cramps personal or family history of malignant hyperthermia personal or family history of sickle cell trait. Regard the following patients to be at low risk in the context of exertional rhabdomyolysis: rapid clinical recovery and CK normalization after exercise restrictions sufficiently fit or well-trained athlete with a history of intense training/exercise no personal or family history of rhabdomyolysis existence of other group or team-related cases of exertion rhabdomyolysis during the same exercise sessions suspected or documented concomitant viral illness ingestion of a drug or dietary supplement likely contributed to the development of exertion rhabdomyolysis. https://web.pathway.md/diseases/recPBZt7yxWy3mkCC 2/4 6/24/23, 2:57 PM Rhabdomyolysis Pathway 3. 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 As per AOSSM 2014 guidelines, recognize that myoglobinuria itself is not a good indicator for exertional rhabdomyolysis. B 4. 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 As per UKKA 2019 guidelines, administer IV fluids promptly for volume expansion, if not already volume overloaded, in order to achieve a high urinary flow rate and protect against AKI in adult and pediatric patients with rhabdomyolysis. B Urine alkalinization: insufficient evidence to support the use of sodium bicarbonate for the prevention of rhabdomyolysis-induced AKI. I Diuretics: insufficient evidence to support the use of loop diuretics and mannitol for the prevention of rhabdomyolysis-induced AKI. I Management of electrolyte abnormalities: Recognize that hyperkalemia, hyperphosphatemia, and hypocalcemia are electrolyte abnormalities most commonly encountered in patients with rhabdomyolysis. E Correct biochemical equilibrium and electrolytes during rhabdomyolysis to avoid complications from treatment. Correct hyperkalemia timely to reduce risk of cardiac arrhythmia. E 5. Nonpharmacologic interventions Rest: advise rest from the provoking activity and hydration for the management of patients with exertional rhabdomyolysis. B https://web.pathway.md/diseases/recPBZt7yxWy3mkCC 3/4 6/24/23, 2:57 PM Rhabdomyolysis Pathway 6. Therapeutic procedures Renal replacement therapy: 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 7. Follow-up and surveillance Serial laboratory assessment: 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 Monitoring for complications: monitor for a variety of complications, ranging from an asymptomatic elevation of muscle protein to an accumulation of electrolyte imbalances, edema, and toxic cellular components. E Show 2 more Return to play: ensure gradual returning to play only after the clinical syndrome of exertion rhabdomyolysis has resolved. B References 1. David C. Tietze, MD and James Borchers, MD et al. Exertional rhabdomyolysis in the athlete: a clinical review. Sports Health. 2014 Jul; 6 4 336 339. Open 2. Lisa Kodadek, Samuel P Carmichael Ii, Anupamaa Seshadri et al. Rhabdomyolysis: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open. 2022 Jan 27;7 1):e000836. Open 3. Suren Kanagasundaram, Caroline Ashley, Sheetal Bhojani et al. Clinical Practice Guideline Acute Kidney Injury. UKKA. 2019 Aug. Open 4. Gearoid M McMahon, Xiaoxi Zeng, Sushrut S Waikar. A risk prediction score for kidney failure or mortality in rhabdomyolysis. JAMA Intern Med. 2013 Oct 28;173 19 1821 8. Open https://web.pathway.md/diseases/recPBZt7yxWy3mkCC 4/4