Crush Injury Management with Suspected Rhabdomyolysis

Initial Management

The Kidney International guidelines recommend infusing 0.9% saline at 1 L/hour initially for crush victims, with 3-6 L total in the first 24 hours depending on clinical response, to prevent progression to acute renal failure 1, 2
Early and aggressive crystalloid infusion is the cornerstone of preventing progression to acute renal failure and is most effective when initiated within 6 hours of injury, with a therapeutic goal of maintaining renal perfusion and diluting nephrotoxic myoglobin 1, 2

Creatine kinase measurement is essential for confirming rhabdomyolysis and assessing severity, with levels >5,000 IU/L confirming rhabdomyolysis and levels >75,000 IU/L indicating >80% risk of acute kidney injury requiring intensive monitoring 3

Continue 0.9% normal saline at 1 L/hour initially, then taper by at least 50% after 2 hours based on clinical response, avoiding lactated Ringer's or other potassium-containing fluids due to potential hyperkalemia 4
Avoid starch-based colloids due to increased risk of AKI and bleeding 1, 4

Target urine output of 200-300 mL/hour until myoglobinuria clears, with immediate monitoring of creatine kinase, complete metabolic panel, and urine output after fluid bolus initiation 1, 3
The Kidney International guidelines warn against the use of mannitol before volume resuscitation, as it can worsen renal injury in hypovolemic patients 1