List the causes and outline your management of a patient with severe rhabdomyolysis.

[Click here to toggle visibility of the answers]

College Answer

Rhabdomyolysis indicates muscle necrosis and release of intracellular constituents into the circulation. Causes of severe rhabdomyolysis (in this case implying Intensive Care management) include trauma (especially with compression injuries), extreme exertion (e.g. marathon or uncontrolled seizures), immobilisation for prolonged periods, Malignant Hyperpyrexia and Neurolept Malignant syndrome. Rare causes include metabolic myopathies and metabolic/endocrine abnormalities. Management includes confirmation of diagnosis (relevant history; marked elevation of  CK,  hyperkalaemia,  hyperphosphataemia,  hypocalcaemia,  hyperuricaemia,  and  acute  renal failure with metabolic acidosis [and/or lactic acidosis]), specific treatment for any underlying cause (e.g. fasciotomies for compartment syndromes, dantrolene and remove exposure to precipitant for MH, anti-seizure drugs and/or paralysis [as last resort] for status epilepticus), adequate fluid resuscitation (e.g. with isotonic saline), maintenance of an alkaline diuresis (e.g. use of mannitol), careful monitoring and treatment of metabolic disturbances, management of associated disorders (especially with multiple trauma or drug overdose) and consideration of renal replacement therapy.

Discussion

This question is virtually identical to Question 16 from the first paper of 2008, and vaguely resembles Question 26.3 from the second paper of 2013.