For some reason, the college loves rhabdomyolysis. Many questions either ask about it directly, or expect it as one of the differentials. Typically, the candidate is presented with a biochemistry panel strongly suspicious of rhabdomyolysis (eg. raised CK, LDH, potassium) as well as a history suggestive of some sort of crush injury or limb ischaemia. They are then asked to explain the mechanism, list the features, and describe their management.
Previous SAQs on this topic include the following:
Probably the best resource for something like this would be this UpToDate article. However, one must acknowledge the possibility that the CICM trainee will be unable to pay (or ideologically opposed to paying) a subscription fee to the Wolters Kluwer infohemoth, in which case some excellent freely available resources could be pointed out. One standout example is the 2002 article by Vanholder et al. Another is a 2016 systematic review by Chavez et al,
A nice NEJM article has within it a comprehensive table (Table 1). Additionally, infectious causes of rhabdomyolysis are reviewed by Singh & Scheld (1996)
It has been rearranged into a familiar framework:
Vascular causes |
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Infectious causes |
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Neoplastic causes |
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Drug-related causes |
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Idiopathic causes |
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Congenital causes |
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Autoimmune causes |
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Traumatic causes |
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Endocrine causes |
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In brief summary, these are the cardinal pathophysiological events in rhabdomyolysis:
This has been asked about in Question 30 from the second paper of 2014. The multiple mechanisms which lead to acute kidney injury in rhabdomyolysis are well described in this excellent article. It would probably be counterproductive to digress extensively on this minor topic in this summary.
This has been examined in Question 16 from the first paper of 2008, and to a lesser extent in Question 1 from the first paper of 2020
Chavez et al (2016), in theire review of management strategies for rhabdomyolysis, have presented the following conclusions:
The best shortcut for the time-poor exam candidate is this UpToDate article.
Vanholder, Raymond, et al. "Rhabdomyolysis." Journal of the American Society of Nephrology 11.8 (2000): 1553-1561.
Bosch, Xavier, Esteban Poch, and Josep M. Grau. "Rhabdomyolysis and acute kidney injury." New England Journal of Medicine 361.1 (2009): 62-72.
Shapiro, Mark L., Anthony Baldea, and Fred A. Luchette. "Rhabdomyolysis in the intensive care unit." Journal of intensive care medicine 27.6 (2012): 335-342.
Singh, Upinder, and W. Michael Scheld. "Infectious etiologies of rhabdomyolysis: three case reports and review." Clinical Infectious Diseases 22.4 (1996): 642-649.
Holt, S., and K. Moore. "Pathogenesis and treatment of renal dysfunction in rhabdomyolysis." Intensive care medicine 27.5 (2001): 803-811.
Vanholder, Raymond, et al. "Rhabdomyolysis." Journal of the American Society of Nephrology 11.8 (2000): 1553-1561.
Bosch, Xavier, Esteban Poch, and Josep M. Grau. "Rhabdomyolysis and acute kidney injury." New England Journal of Medicine 361.1 (2009): 62-72.
Allison, Ronald C., and D. Lawrence Bedsole. "The other medical causes of rhabdomyolysis." The American journal of the medical sciences 326.2 (2003): 79-88.
Brown, Carlos VR, et al. "Preventing renal failure in patients with rhabdomyolysis: do bicarbonate and mannitol make a difference?." Journal of Trauma-Injury, Infection, and Critical Care 56.6 (2004): 1191-1196.
Scharman, Elizabeth J., and William G. Troutman. "Prevention of kidney injury following rhabdomyolysis: a systematic review." Annals of Pharmacotherapy47.1 (2013): 90-105.
Sorrentino, Sajoscha A., et al. "High permeability dialysis membrane allows effective removal of myoglobin in acute kidney injury resulting from rhabdomyolysis." Critical care medicine 39.1 (2011): 184-186.
Tang, Wanxin, et al. "Renal protective effects of early continuous venovenous hemofiltration in rhabdomyolysis: improved renal mitochondrial dysfunction and inhibited apoptosis." Artificial organs 37.4 (2013): 390-400.
Ioannidis, Konstantinos, et al. "Safety and effectiveness of the combination acetazolamide and bicarbonates to induce alkaline diuresis in patients with rhabdomyolysis." European Journal of Hospital Pharmacy 22.6 (2015): 328-332.
Hohenegger, Martin. "Drug induced rhabdomyolysis." Current opinion in pharmacology 12.3 (2012): 335-339.
Chavez, Luis O., et al. "Beyond muscle destruction: a systematic review of rhabdomyolysis for clinical practice." Critical care 20.1 (2016): 135.
Chatzizisis, Yiannis S., et al. "The syndrome of rhabdomyolysis: complications and treatment." European journal of internal medicine 19.8 (2008): 568-574.