Entry criteria for EGDT for rhabdomyolysis:
Absolute CK value of >15,000
or
CK >5000 AND ANY of:

Associated crush injury
Acute renal failure or injury
Myoglobinuria
Associated acidosis, hypocalcemia, or hyperkalemia
Massive muscle injury
Prolonged extraction or delayed arrival >4 hr

Large bore, IV access, baseline labs
Cardiac monitors, ECG
Urinary (Foley) catheter
Initial resuscitation 1-2 L of 0.9% NS

Check urine pH

End

D₅NL bicarb 1-L boluses @ 15-30 min

Continue NS boluses
Consider mannitol

Continue D₅NL bicarb, consider acetazolamide

Continue D₅NL bicarb bolus and reassess

Continue as above and consider nephrology consult for RRT

 IVF to maintain
UOP 200-300 ml/hr

Correct metabolic derangements

Admit, disposition

Continue NS
Start mannitol

Continue NS
Consider acetazolamide

GOALS

Rapid diagnosis and prognostic evaluation

Initial resuscitation and "safety net"

Establish urine output and prevent anuria

Determine urine pH

Alkalinize urine and avoid serum alkalinization

Achieve high-volume diuresis

Correct metabolic derangements

Admit, disposition

CK, Creatine kinase; CVP, central venous pressure; D5NL bicarb, 5% dextrose in normal sodium bicarbonate solution; EGDT, early goal-directed therapy; IV, intravenous; IVF, intravenous fluid; NS, normal saline; RRT, renal replacement therapy; UOP, urinary output.

Is there urine output (at least 30 ml/hr)?

YES

NO

Measure CVP

CVP <6 cm H₂O

1-2 L @15-30 min until either:

UOP or
Pulmonary edema

UOP or
Pulmonary edema

CVP >6 cm H₂O

Consider furosemide
Early nephrology consult for RRT
Continue 1-2 L @ hour until:

UOP or
Pulmonary edema

UOP or
Pulmonary edema

What is urine pH?

<6.5

6.5

Recheck urine pH
Check serum pH

Urine pH 6.5
Serum pH <7.5

Urine pH 6.5
Serum pH >7.5

Urine pH 6.5

Achieve urine output of 200-300 ml/hr?

YES

NO

Check serum pH

Serum pH <7.55

Serum pH 7.55