RHABDOMYOLYSIS IN STRUCTURAL FIRE FIGHTERS:

A PATIENT POPULATION AT RISK

Structural fire response and training 

involves exposure to heat and prolonged, 

intense exertion. These factors increase 

the risk for rhabdomyolysis. Healthcare 

providers can prevent debilitating 

consequences. Be alert to fire fighters 

reporting signs and symptoms of 

rhabdomyolysis. Have a low threshold to 

check serial serum creatine phosphokinase 

(CK) in structural fire fighters.

Elements of fire response and training associated 

with an increased risk for rhabdomyolysis are:

+ Carrying heavy loads such as turnout gear 

and air packs weighing up to 60 pounds, fire 

fighting tools weighing up to 80 pounds and 

incapacitated building occupants

+ High levels of exertion, such as victim rescue, 

climbing ladders and stairs with heavy 

gear, etc.

+ Prolonged exertion during overhaul (i.e. 

opening walls to check for smoldering 

embers, etc.)

+ Rigorous training and physical fitness tests

+ Exposure to heat from the fire, the environment, and physical effort

Death and permanent disability of fire fighters 

have been associated with heat stress and rhabdomyolysis in fire fighters [NIOSH 2009, 2012, 2014]. 

NIOSH investigators documented hyperthermia and 

rhabdomyolysis among structural fire fighters during 

cadet training which included a live fire exercise. One 

cadet had a peak core body temperature of 107.2°F; 

another was hospitalized for rhabdomyolysis 

[NIOSH 2015]. 

Fire fighter Trainee Suffers Fatal Exertional Heat 

Stroke During Physical Fitness Training—Texas

A case report of a NIOSH fire fighter 

fatality investigation highlighting the close 

relationship between fire fighting, heat 

and rhabdo

2009-17 Date Released: June 2010

The initial diagnoses were hyperthermia, severe 

dehydration, and heatstroke, with heatstroke 

complications including:

+ Rhabdomyolysis

+ Acute renal failure due to rhabdomyolysis

+ Disseminated intravascular coagulation

Photo by Hillsboro Fire Department

Centers for Disease Control

and Prevention

National Institute for Occupational 

Safety and Health
Rhabdomyolysis may be misdiagnosed as heat stress or 

dehydration as the presenting signs and symptoms can 

be similar [NWCG 2011]. Rhabdomyolysis can have debilitating or deadly consequences if not quickly diagnosed 

and treatment started.

Tips for Identifying Rhabdomyolysis 

and Possible Complications

Suspect rhabdomyolysis in structural fire fighters with 

heat-related illnesses and dehydration, muscle pain, or 

exercise intolerance. Consider doing the following:

+ Ask about date of last fire response, training 

exercise, and last physical exertion. Fire fighters 

may not become symptomatic or seek care until 

several days after a fire response, job-required 

physical fitness tests, or recreational exercise.

+ Check serial CK levels. This will let you know 

whether levels are rising or falling. Fire fighters with 

rising CK levels should be monitored for complications of rhabdomyolysis (arrhythmia, seizure, acute 

renal failure, compartment syndrome, etc.) and 

fluid treatment started. A single, CK level may be 

misleading. 

+ Do not rule out rhabdomyolysis solely on urine 

tests that check for myoglobin indirectly (urine 

dipstick positive for blood and a urinalysis with 

no red blood cells). Myoglobin is quickly cleared 

from the body so it may not be detected in 

the urine at the time of presentation while CK 

elevations in the blood may persist for days. 

Additionally, up to 81% of rhabdomyolysis 

patients may not exhibit myoglobinuria at all.

Bottom Line

Help keep fire fighters 

safe. Have a high suspicion 

for rhabdomyolysis. For 

information on other heatrelated disorders, see 

http://www.cdc.gov/niosh/

topics/heatstress/.

Fire fighter having blood drawn.

+ Check compartment pressures when severe muscle 

pain is localized to a specific compartment, diabetic 

neuropathy may make physical exam of that 

compartment unreliable, etc. Documentation of 

elevated compartment pressures may help facilitate rapid fasciotomy for compartment syndrome. 

Delayed diagnosis and treatment of compartment 

syndrome can result in permanent disability.

Photo by NIOSH

Right leg after fasciotomy for 

compartment syndrome. Note 

residual swelling in right leg, 

ankle, and foot.

Photo by Sarte at the English language Wikipedia 

References 

NIOSH [2015]. Evaluation of heat stress, heat strain, and rhabdomyolysis during structural fire fighter training. By Eisenberg J, Methner M, Dowell CH, Mueller C. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, HHE 

Report No. 2012-0039-3242.

NIOSH [2014]. Captain dies from hyperthermia and exertional heatstroke while performing advanced survival training—Texas. Cincinnati, OH: U.S. Department of Health 

and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FF Report No. F2012-27, http://www.cdc.gov/

niosh/fire/reports/face201227.html.

NIOSH [2012]. Report of a NIOSH Health hazard evaluation, HHE 2011–0035. By Eisenberg J and McFadden J. Cincinnati, OH: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. Unpublished. NIOSH [2009]. Fire fighter trainee suffers 

fatal exertional heat stroke during physical fitness training—Texas. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and 

Prevention, National Institute for Occupational Safety and Health, FF Report No. F2009-17, http://www.cdc.gov/niosh/fire/reports/face200917.html.

NWCG [2011]. Safety advisory: rhabdomyolysis epidemiological study results and recommendations. Risk Management Committee, National Wildfire Coordinating 

Group, http://www.wildlandfire.com/docs/2011/safe/rhabdo.pdf. 

Counselman FL, Lo BM. Rhabdomyolysis [2017]. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1658§ionid=109433424.

Additional Resources

NIOSH [2016]. NIOSH criteria for a recommended standard; occupational exposure to heat and hot environments. By Jacklitsch B, Williams WJ, Musolin K, Coca A, 

Kim J-H, Turner N. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication 2016-106.

To receive information about other occupational safety and health topics, contact NIOSH: 

Telephone: 1-800-CDC-INFO (1-800-232-4636) | TTY: 1-888-232-6348 | CDC-INFO: www.cdc.gov/info | NIOSH website: www.cdc.gov/niosh

For a monthly update on news at NIOSH, subscribe to NIOSH eNews at www.cdc.gov/niosh/eNews. 

DOI: https://doi.org/10.26616/NIOSHPUB2018134 | DHHS (NIOSH) Publication No. 2018-134 | May 2018