Rhabdomyolysis

Answer

Textbook Core – 6 Points

Latest Update – 1 Point

Examiner’s Tip — Verbatim Mark-Earning Lines

“Urine positive for blood on dipstick with no red cells on microscopy is myoglobinuria until proved otherwise.” “Fluids, fluids and more fluids — and neither bicarbonate nor mannitol.”

“Early hypocalcaemia, late hypercalcaemia — do not correct the calcium unless the patient is symptomatic.” “In geriatrics, rhabdomyolysis is the metabolic consequence of the long lie — check the CK in every patient found on the floor.”

Appendix — Rapid Revision Grid

Consolidated from both source volumes. Where a fact appears in more than one answer it is listed once here.

A. Examinable Numbers

Topic Number to reproduce

Epilepsy in the elderly Incidence >100/1,00,000/yr after 65; cerebrovascular cause 30–50%; EEG sensitivity 26–38%; ~80% seizure-free on low-dose monotherapy Complex partial seizure Duration 30 s–3 min; post-ictal confusion 5–30 min; temporal lobectomy seizure-free in ~2/3 of selected cases Status epilepticus Lorazepam 0.1 mg/kg; levetiracetam 60 mg/kg; fosphenytoin 20 PE/kg; valproate 40 mg/kg TIA ABCD² ≥4 = high risk; stroke risk ~5% at 7 days, 10% at 90 days; DAPT 21 days; DWI lesion in up to 1/3 Lacunar stroke Infarct <15–20 mm; ~25% of ischaemic strokes; SPS3 systolic target <130 mmHg Subarachnoid haemorrhage 85% aneurysmal; CT sensitivity >95% within 6 h; LP after 12 h; nimodipine 60 mg 4-hourly × 21 days; vasospasm days 4–14; mortality 30–40% Carotid disease Symptomatic 70–99% → CEA, ARR ~16%, NNT ~6, within 2 weeks; risk thresholds <6% symptomatic, <3% asymptomatic Hypoxic-ischaemic encephalopathy Prognosticate at ≥72 h off sedation, normothermic; temperature target ≤37.5 °C for 36–72 h; MRI at 2–7 days Traumatic brain injury Seizure prophylaxis 7 days only; depression up to 50%; screen pituitary at 3–6 and 12 months Wernicke encephalopathy Complete triad in only 10–16%; Caine criteria = any 2 of 4; thiamine 500 mg IV tds × 2–3 days; ~80% progress to Korsakoff Cluster headache Attacks 15–180 min, up to 8/day; O2 12–15 L/min effective in ~70%; sumatriptan 6 mg SC; verapamil 240–960 mg/day; galcanezumab 300 mg Tension headache Chronic = ≥15 days/month for >3 months; limit analgesics to <15 days/month; amitriptyline from 10 mg nocte Peripheral neuropathy Prevalence 8–15% over age 55 CSF Normal: 0–5 cells, protein 15–45 mg/dL, glucose ≥60% of blood; pyogenic 1000–5000 neutrophils; TB 100–500 lymphocytes; CSF lactate >3.5 mmol/L in bacterial Serotonin syndrome Onset <24 h; Hunter criteria sensitivity 84%, specificity 97%; cyproheptadine 12 mg then 2 mg 2-hourly Neuroleptic malignant syndrome Onset 1–3 days; mortality 5–10%; CK often >1000 IU/L; bromocriptine 2.5–5 mg tds; dantrolene 1–2.5 mg/kg; wait ≥2 weeks before rechallenge Rhabdomyolysis CK >5× ULN (>1000 IU/L); AKI risk above 5000 IU/L; AKI in 10–50%; fluids 1–1.5 L/h, urine output 200–300 mL/h NPH Evans index >0.3; shunt success ~80%; gait 81–86%, bladder 70%, cognition 40–44%; serious adverse events 11% PSP / CBD Falls within first year; median survival 6–8 years; midbrain “hummingbird sign” MND Riluzole prolongs survival ~3 months; 1-year survival 58% vs 49%; FTD in 10–15%; SOD1 ~2% of ALS Myasthenia gravis AChR antibody in ~85%; thymoma 10–15%; RNS decrement >10%; >90% remission or major improvement SCD of cord B12 1000 µg IM alternate days × 1–2 weeks → weekly → monthly lifelong; recovery poor if delayed >6–12 months RLS Ferritin target >100 ng/mL, transferrin saturation >20%; augmentation in 50–70% of long-term dopamine agonist users; PLMS in ~80% BPPV Posterior canal 85–90%; nystagmus latency 1–5 s, duration <60 s; Epley success 80–90%; recurrence 15–50%; vitamin D threshold <20 ng/mL Subdural haematoma Acute <3 days / subacute 3 days–3 weeks / chronic >3 weeks; recurrence 10–30%; anticoagulation restart ~4 weeks Stroke reperfusion Alteplase 0.9 mg/kg (max 90 mg); tenecteplase 0.25 mg/kg (max 25 mg); sICH 2–6%; thrombectomy NNT ~2.6; BP limits 185/110 pre-lysis, 180/105 post-lysis Post-stroke depression Affects ~one-third of survivors; peaks 3–6 months; continue antidepressant ≥6 months after remission Giant cell arteritis ESR often >50 (classically >75) mm/h; prednisolone 40–60 mg/day; IV methylprednisolone 500–1000 mg × 3 days; second eye involved in 25–50% within 1–2 weeks; taper 12–24 months Trigeminal neuralgia Pain <2 minutes; classical type 80–90%; carbamazepine 600–1200 mg/day, 70–80% initial response; MVD ~70–80% pain-free at 10 years B. Named Trials, Guidelines and Regulatory Decisions (2023–2026)

Trial / Guideline One-line message

ILAE Elderly Task Force (Epilepsia Lamotrigine, levetiracetam and lacosamide first line in older adults; gabapentin last resort.

2023)

ELUCID (2025) Late-onset unexplained epilepsy is a marker of future dementia and stroke, not just of seizures. SANAD II Levetiracetam was neither superior nor cost-effective versus lamotrigine in focal epilepsy. Cenobamate High seizure-freedom rates in drug-resistant focal epilepsy; slow 12-week titration to avoid DRESS.

ANNEXA-I (NEJM 2024) Andexanet improved haemostasis (67.0% vs 53.1%) but doubled thrombotic events (10.3% vs 5.6%); no mortality benefit.

INSPIRES (NEJM 2023) Clopidogrel + aspirin up to 72 h reduces 90-day stroke after minor stroke or high-risk TIA. CHANCE / POINT DAPT for 21 days within 24 h after high-risk TIA or minor stroke. SPS3 After lacunar stroke: systolic <130 mmHg helps; long-term DAPT causes harm. AHA/ASA 2023 aSAH Guideline Secure the aneurysm within 24 h; early enteral nimodipine; prophylactic hypervolaemia is harmful; no routine statin or magnesium.

CREST Stenting carries higher periprocedural stroke than endarterectomy, especially over age 70. CREST-2 (NEJM 2025) Asymptomatic ≥70% stenosis: stenting 2.8% vs 6.0% (p=0.02); endarterectomy no better than intensive medical therapy (3.7% vs 5.3%).

AHA/ASA 2026 AIS Guideline Tenecteplase Class 1; thrombolyse disabling deficits regardless of NIHSS; thrombectomy ASPECTS 3–10 and up to 24 h; thrombectomy for basilar occlusion.

ERC/ESICM 2025 Post- Fever prevention at ≤37.5 °C for 36–72 h replaces hypothermia at 33 °C; no prehospital cold Resuscitation fluids.

AHA Post-Cardiac Arrest 2025 NfL added alongside NSE for neuroprognostication; temperature control ≥36 h; predictors of (Circulation) favourable outcome now included.

Galcanezumab (consensus 2024) Only approved preventive for episodic cluster headache; failed in chronic cluster headache. AAN Painful Diabetic Neuropathy TCAs, SNRIs, gabapentinoids and sodium-channel blockers are equally effective; do not offer Guideline opioids or tramadol.

AMBITION-cm / WHO Single high-dose liposomal amphotericin B 10 mg/kg + flucytosine + fluconazole for cryptococcal meningitis; CrAg is the preferred rapid test.

WHO / NTEP Xpert MTB/RIF Ultra is the initial CSF test for suspected tuberculous meningitis. AGS Beers Criteria 2023 Avoid SSRI + tramadol; avoid antipsychotics for BPSD; amitriptyline is potentially inappropriate in older adults.

PENS (NEJM 2025) First placebo-controlled trial of shunting in iNPH — improves gait and balance, not cognition or continence.

NIO752 / LM11A-31; PSP Platform Tau-directed therapies in phase 3 for PSP; none yet approved.

Trial

VALOR + OLE (JAMA Neurol 2026); Tofersen slows decline and prolongs survival in SOD1-ALS; genetic testing now recommended for EAN 2024 all ALS.

Nipocalimab (FDA Apr 2025, EC Dec FcRn blocker for AChR/MuSK-positive generalised MG; joins efgartigimod, rozanolixizumab and 2025) the C5 inhibitors.

NICE NG239 (Mar 2024) MMA or homocysteine as confirmatory test for B12 deficiency; never delay replacement when SCD is suspected.

AASM RLS Guideline (JCSM 2025) Alpha-2-delta ligands and iron are first line; dopamine agonists demoted because of augmentation.

Vitamin D RCTs (2024–2025) Vitamin D supplementation reduces BPPV recurrence when 25(OH)D <20 ng/mL. EMBOLISE, STEM, MAGIC-MT Middle meningeal artery embolisation reduces recurrence of chronic subdural haematoma. (NEJM, 20 Nov 2024)

AHA/ASA 2026 AIS Guideline Tenecteplase Class 1; thrombolysis 4.5–9 h with mismatch; thrombectomy ASPECTS 3–10 and up to 24 h.

VA/DoD Stroke Rehab 2024; Do not use antidepressants to prevent post-stroke depression; fluoxetine increases falls, fractures FOCUS/AFFINITY/EFFECTS IPD meta- and seizures.

analysis (Int J Stroke 2024)

SELECT-GCA (upadacitinib, 2025) Sustained remission 46.4% vs 29.0%; first oral JAK inhibitor approved for giant cell arteritis. BTX-A meta-analysis (Clin J Pain Botulinum toxin A reduces pain and attack frequency in refractory trigeminal neuralgia.

2024)

C. Drug or Intervention of Choice — One Line Each

Condition Drug / intervention of choice

New-onset focal epilepsy in the elderly Levetiracetam or lamotrigine (avoid enzyme inducers) Status epilepticus IV lorazepam, then IV levetiracetam / fosphenytoin / valproate Seizure in a patient on an anticoagulant and a statin Levetiracetam (no CYP450 interaction; IV form available) Drug-resistant focal epilepsy Cenobamate, or referral for pre-surgical evaluation High-risk TIA / minor stroke (non-cardioembolic) Aspirin + clopidogrel for 21 days, then single agent TIA with atrial fibrillation DOAC anticoagulation — not antiplatelet therapy Lacunar stroke Single antiplatelet + high-intensity statin + systolic BP <130 mmHg Aneurysmal subarachnoid haemorrhage Endovascular coiling within 24 h + oral nimodipine 21 days Symptomatic carotid stenosis 70–99% Carotid endarterectomy within 2 weeks Asymptomatic carotid stenosis Intensive medical therapy (CREST-2)

Wallenberg syndrome Stroke unit care + nil by mouth and formal swallow assessment Comatose survivor of cardiac arrest Temperature control ≤37.5 °C for 36–72 h + delayed multimodal prognostication Suspected Wernicke encephalopathy IV thiamine 500 mg tds, given before any glucose Acute cluster headache attack High-flow oxygen 12–15 L/min (or subcutaneous sumatriptan 6 mg) Cluster headache prevention Verapamil (galcanezumab for episodic cluster if verapamil fails) Chronic tension-type headache CBT and exercise first; amitriptyline (or nortriptyline) as preventive Painful diabetic neuropathy in the elderly Duloxetine or a reduced-dose gabapentinoid — never an opioid Tuberculous meningitis Xpert MTB/RIF Ultra on CSF + ATT with adjunctive corticosteroids Cryptococcal meningitis Single-dose liposomal amphotericin B 10 mg/kg + flucytosine + fluconazole Serotonin syndrome Stop the drug + benzodiazepines (cyproheptadine if severe)

Neuroleptic malignant syndrome Stop the drug + fluids + bromocriptine ± dantrolene Rhabdomyolysis Aggressive isotonic saline — no bicarbonate, no mannitol Normal pressure hydrocephalus Ventriculoperitoneal shunt after a positive tap test or lumbar drainage PSP / CBD No disease-modifying drug — trial of levodopa, botulinum toxin for dystonia, falls prevention Motor neuron disease Riluzole + non-invasive ventilation (tofersen if SOD1 mutation) Myasthenia gravis Pyridostigmine + prednisolone (azathioprine as steroid-sparing); IVIG or plasma exchange in crisis Subacute combined degeneration Parenteral vitamin B12 — never folate first Restless legs syndrome Iron replacement + alpha-2-delta ligand (gabapentin or pregabalin) BPPV Epley canalith repositioning manoeuvre — not vestibular sedatives Chronic subdural haematoma Burr-hole drainage with drain ± middle meningeal artery embolisation Acute ischaemic stroke <4.5 h Tenecteplase or alteplase; thrombectomy for large-vessel occlusion Post-stroke depression SSRI (escitalopram or sertraline) — avoid tricyclics Central post-stroke pain Amitriptyline or pregabalin — not simple analgesics Giant cell arteritis Immediate high-dose corticosteroid (IV methylprednisolone if visual loss) + aspirin + bone protection Trigeminal neuralgia Carbamazepine (oxcarbazepine if poorly tolerated)

Format Reminder for the Examination Hall

20 marks = 17 points (14 + 3) • 15 marks = 12 points (10 + 2) • 7 marks = 7 points (6 + 1) • 6 marks = 6 points (5 + 1). Do not pad beyond the count.

Bold or box the keywords the examiner scans for: definition, diagnostic criterion, cut-off value, first-line drug, drug of choice, dangerous complication.

One named trial with a year and a number, correctly quoted, outscores three vague sentences. Where textbook and current practice differ — dopamine agonists in RLS, triple-H therapy in SAH, surgery for asymptomatic carotid stenosis, targeted temperature management, prophylactic antidepressants after stroke, enzyme-inducing antiseizure drugs — say so explicitly in one line. Examiners reward it.