RHABDOMYOLYSIS IN WILDLAND FIRE FIGHTERS:

A PATIENT POPULATION AT RISK

Wildland fire fighting involves 

exposure to heat and prolonged, 

intense exertion. These factors 

increase the risk for rhabdomyolysis. 

Healthcare providers can prevent 

debilitating consequences. Be alert 

to wildland fire fighters reporting 

rhabdomyolysis signs and symptoms. 

Have a low threshold to check serial 

serum creatine phosphokinase 

(CK) in wildland fire fighters. 

Elements of wildland fire response and training associated with an increased risk for rhabdomyolysis are:

+ Carrying heavy loads, such as chainsaws and 

gear packs weighing up to 110 pounds 

+ High levels of exertion, such carrying heavy 

loads over rugged, steep terrain

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

+ Rigorous training and physical fitness tests 

Death and permanent disability of fire fighters have 

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

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.

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

+ Disseminated intravascular coagulation

Photo by BLM-California

Centers for Disease Control

and Prevention

National Institute for Occupational 

Safety and Health
Tips for Identifying Rhabdomyolysis and 

Possible Complications 

Suspect rhabdomyolysis in wildland fire fighters with 

heat-related illnesses and dehydration, muscle pain, and/

or exercise intolerance. Consider doing the following:

+ Ask about date of last fire response and last 

physical exertion. Fire fighters may not become 

symptomatic or seek care until several days after 

a fire response, training exercises, 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.

+ 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.

Bottom Line

Help keep fire fighters 

safe by having a high 

suspicion for rhabdomyolysis. For information 

on other heat-related 

disorders, see http://

www.cdc.gov/niosh/

topics/heatstress/.

References

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.

Fire fighter having blood drawn. 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 

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/NIOSHPUB2018132 | DHHS (NIOSH) Publication No. 2018-132 | May 2018