Surgical Fires &Thermal Injury
Surgical fires are relatively rare, with
an incidence of about 1:87,000 cases, which is close to the inci-dence rate of
other events such as retained for-eign objects after surgery and wrong-site
surgery.
Almost all surgical fires can be
prevented. Unlike medical complications, fires are aproduct of simple physical
and chemical proper-ties. Occurrence is guaranteed given the proper combination
of factors but can be eliminated almost entirely by understanding the basic
principles of fire risk. Likely the most common risk factor for surgical fire
relates to the opendelivery of oxygen.
Situations classified as carrying a high
risk for a surgical fire are those that involve an ignition source used in
close proximity to an oxidizer. The simple chemical combination required for
any fire is com-monly referred to as the fire triad or fire triangle. The triad
is composed of fuel, oxidizer, and ignition source (heat). Table 2–2 lists potential
contributors to fires and explosions in the operating room. Surgical fires can
be managed and possibly avoided completely by incorporating education, fire
drills, preparation, prevention, and response into educational programs
provided to operating room personnel.
For anesthesia providers, fire
prevention edu-cation should place a heavy emphasis on the risk relating to the
open delivery of oxygen. The Anes-thesia Patient Safety Foundation has
developed an educational video and online teaching module that
provides fire safety education from the
perspective of the anesthesia provider.
Operating room fire drills increase
awareness of the fire hazards associated with surgical procedures. In contrast
to the typical institutional fire drill, these drills should be specific to the
operating room and should place a greater emphasis on the particular risks
associated with that setting. For example, con-sideration should be given to
both vertical and hori-zontal evacuation of surgical patients, movement of
patients requiring ventilatory assistance, and unique situations such as prone
or lateral positioning and movement of patients who may be fixed in
neuro-surgical pins.
Preparation for surgical fires can be
incorpo-rated into the time-out process of the universal protocol. Team members
should be introduced and specific roles agreed upon should a fire erupt. Items
needed to properly manage a fire can be assembled or identified beforehand (eg,
ensuring the proper endotracheal tube for patients undergoing laser surgery;
having water or saline ready on the surgi-cal field; identifying the location
of fire extinguish-ers, gas cutoff valves, and escape routes). A poster or
flowsheet to standardize the preparation may be of benefit.
Preventing catastrophic fires in the
operating room begins with a strong level of communication among all members of
the surgical team. Different aspects of the fire triad are typically under the
domain of particular surgical team members. Fuels such as alcohol-based
solutions, adhesive removers, and surgical drapes and towels are typically
con-trolled by the circulating nurse. Ignition sources such as electrocautery,
lasers, drills, burrs, and light sources for headlamps and laparoscopes are
usually controlled by the surgeon. The anesthesia provider maintains control of
the oxidizer concentration of oxygen and nitrous oxide. Communication between
personnel is evident when a surgeon enters the air-way and verifies the concentration
of oxygen before using cautery, or when an anesthesiologist asks the circulator
to configure drapes to prevent the accu-mulation of oxygen in a surgical case
that involves sedation and use of a nasal cannula.
Administration of oxygen in concentrations
of greater than 30% should be guided by clinical presentation of the patient
and not solely by proto-cols or habits. If oxygen is being delivered via nasal
cannula or face mask, and if increased oxygen lev-els are needed, then the
airway should be secured by either endotracheal tube or supraglottic device.
This is of prime importance when the surgical site is above the level of the
xiphoid.
When the surgical site is in or near the
airway and a flammable tube is present, the oxygen concen-tration should be
reduced for a sufficient period of time before use of an ignition device (eg,
laser or cautery) to allow reduction of oxygen concentration at the site. Laser
airway surgery should incorporate either jet ventilation without an
endotracheal tube or the appropriate protective tube specific for the
wavelength of the laser. Precautions for laser cases are outlined below.
Alcohol-based skin preparations are
extremely flammable and require an adequate drying time.
Pooling of solutions must be avoided.
Large pre-filled swabs of alcohol-based solution should be used with caution on
the head or neck to avoid both oversaturation of the product and excess
flammable waste. Product inserts are a good source of infor-mation about these
preparations. Surgical gauze and sponges should be moistened with sterile water
or saline if used in close proximity to an ignition source.
Should a fire occur in the operating
room it is important to determine whether the fire is located on the patient, in the airway, or elsewhere in the operating room. For
fires occurring in the airway,the delivery of fresh gases to the patient must
be stopped. Effective means of stopping fresh gases to the patient can be
accomplished by turning off flowmeters, disconnecting the circuit from the
machine, or disconnecting the circuit from the endotracheal tube. The
endotracheal tube should be removed and either sterile water or saline should
be poured into the airway to extinguish any burning embers. The sequence of
stopping gas flow and removal of the endotracheal tube whenfire occurs in the
airway is not as important as ensuring that both actions are performed quickly.
Often the two tasks can be accomplished at the same time and even by the same
individual. If car-ried out by different team members, the personnel should act
without waiting for a predetermined sequence of events. After these actions are
carried out, ventilation may be resumed, preferably using room air and avoiding
oxygen or nitrous oxide– enriched gases. The tube should be examined for missing
pieces. The airway should be reestablished and, if indicated, examined with a
bronchoscope. Treatment for smoke inhalation and possible trans-fer to a burn
center should also be considered.
For
fires on the patient, the flow of oxidizing gases should be stopped, the
surgical drapes removed, and the fire extinguished by water or smothering. The
patient should be assessed for injury. If the fire is not immediately
extinguished by first attempts, then a carbon dioxide (CO2) fire
extinguisher may be used. Further actions may include evacuation of the patient
and activation of the nearest pull station. As noted previously, prior to an
actual emergency, the location of fire extinguishers, emergency exits,and fresh
gas cutoff valves should be established by the anesthesia provider.
Fires
that result in injuries requiring
medi-cal treatment or death must be reported to the fire marshal, who retains
jurisdiction over the facility. Providers should gain basic familiarity with
local reporting standards, which can vary according to location.
Cases in which supplemental delivery of
oxy-gen is used and the surgical site is above the xiphoid constitute the most
commonly reported scenario for surgical fires. Frequently the face or airway is
involved, resulting in life-threatening injuries and the potential for severe
facial disfigurement. For the most part, these fires can be avoided by the
elimi-nation of the open delivery of oxygen, by use of an oxygen blender, or by
securing the airway.
Related Topics
Privacy Policy, Terms and Conditions, DMCA Policy and Compliant
Copyright © 2018-2024 BrainKart.com; All Rights Reserved. Developed by Therithal info, Chennai.