Are your new recruits at risk for exertional rhabdomyolysis (ER)? Central Pierce Fire and Rescue had two recruits develop ER during recent fire training academies. These individuals were physically fit, one a distance runner and the other a cross-fit enthusiast. What is ER? Why did these indivuaduals develop it? What could we have done to prevent it?
Acute exertional rhabdomyolysis is a problem encountered by firefighters as a result of extreme or novel physical demands placed on the musculoskeletal system. When skeletal muscle fibers breakdown, their intracellular contents enter the bloodstream and can clog the kidneys. This can cause potentially serious side effects and even death.
Symptoms include muscle pain and swelling, stiffness, fatigue, dark cola-colored urine and excessive sweating. This condition can lead to electrolyte imbalance and possible renal (kidney) failure. Dehydration occurs because of inadequate replacement of sweat loss during and following exercise/training.
Predisposing factors include use of a statin drug to manage cholesterol, the presence of sickle-cell trait, on-going viral infection or susceptibility to hyperthermia. Some have questioned if the over-use of energy drinks may also be a factor.
Early recognition of exertional rhabdomyolysis is critical. Educating recruits of the symptoms of ER must take place as well as encouraging their reporting of these symptoms. Some ill-informed suggest it’s a “wimps disease”, thereby discouraging reporting these symptoms.
Treatment focuses around early fluid replacement. It is necessary to preserve kidney function and to prevent acute kidney failure. They should be seen in the emergency department to confirm the diagnosis through blood work and may receive IV fluids in excess of 10 liters over the first day.
There are several precautionary methods training officers must observe to help prevent exertional rhabdomyolysis. When personnel are exercising in extreme heat and humidity, the most important preventative measures include proper hydration and caloric intake and adequate peroids of rest and recovery.
Additional preventative measures that should be considered include training in the cooler early morning and evening hours and increasing training intensity gradually to give muscles time to adapt. Consider utilizing a sports drink rather than just plain water to replace electrolytes. In individuals with risk factors, monitor their body weight before and after training sessions for fluid loss.
The last step to ensure adequate preparation is by optimizing the individual’s diet plan, including the consumption of adequate amounts of carbohydrates, fats, proteins and water prior to training sessions. Research shows a firefighter burns up to 800 calories per hour with high physical activity. During times of heavy training, individuals will need to consume plenty of fluids to avoid dehydration. One quart of fluids, specifically water and electrolyte replacement drinks such as Gatorade® should be consumed every hour to offset fluids lost through sweating.
In most cases of exertional rhabdomyolysis, strenuous exercise is the primary factor. Low caloric intake and inadequate fluid volume for the energy expended is a huge factor. Prevention is the key. Ensure your recruits are ready to face their new challenge.
By: Judy Murphy, EMS Administrator, Central Pierce Fire & Rescue