Rhabdomyolysis

Dipstick 'blood' positive with no RBCs on microscopy = myoglobinuria. Causes: long lie, crush, seizures, exertion, statins (esp. with interacting drugs), NMS, alcohol. Hyperkalaemia kills first. Aggressive early crystalloid targeting 200–300 ml/hr…

Rhabdomyolysis / Myoglobinuric AKI Pathway

The pathway

1 · Recognise

Dark 'tea/cola' urine
Dipstick blood +ve, no RBCs on microscopy
Tender swollen muscles
Send CK (>5,000 significant, >15,000 high risk)

2 · Hyperkalaemia FIRST

ECG immediately
Treat K⁺ >6.0 or any ECG change
Calcium gluconate, insulin-glucose, salbutamol
BM at 0, 30, 60, 90 and 120 minutes, then hourly to 6 hours after insulin
Repeat K⁺ frequently — it keeps rising

3 · Aggressive fluids

Isotonic crystalloid, often 1–2 L in first hour
Target urine output 200–300 ml/hr
Catheter + hourly UO + strict balance
Watch for overload in the elderly/cardiac

4 · Don't over-treat the calcium

Hypocalcaemia usually asymptomatic — do NOT routinely correct
Calcium only for symptoms or cardiac protection in hyperkalaemia
Rebound hypercalcaemia occurs in recovery

5 · Adjuncts are unproven

Bicarbonate and mannitol — no consistent benefit over volume
Mannitol dangerous in oliguria
Renal/ITU advice only

6 · Look for compartment syndrome

Pain out of proportion, pain on passive stretch
Pulses usually PRESENT — never excludes it
Fluids can worsen it → urgent orthopaedics, fasciotomy

7 · Find the cause

Long lie, crush, seizures, exertion
Statin + clarithromycin/fibrate/diltiazem
Alcohol, cocaine, NMS/serotonin syndrome, sepsis

Drugs

Drug	Dose	Route	Notes
Sodium chloride 0.9% / Hartmann's	1–2 L/hr initially	IV	The treatment. Titrate to urine output 200–300 ml/hr.
Calcium gluconate 10%	30ml over 10 min	IV	Cardiac protection in hyperkalaemia with ECG changes only. Calcium chloride 10% 10ml if arrest.
Insulin (actrapid) + 50% dextrose	10 units in 50ml	IV	Shifts potassium. BM at 0, 30, 60, 90 and 120 minutes, then hourly to 6 hours. If pre-treatment BM <7.0, follow with 10% glucose 50ml/hr for 5 hours (UKKA 2026).
AVOID: mannitol in oliguria	—	—	No proven benefit; harmful if not passing urine.

When to escalate

K⁺ >6.5 or ECG changes — resuscitation-level response,Oliguria despite aggressive fluids, or fluid overload — renal/ITU,CK rising despite treatment, or acidosis — renal review for filtration,Suspected compartment syndrome — orthopaedics immediately

Reference: UK Renal Association AKI guidance / Oxford Handbook — rhabdomyolysis

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