**8. Consequences of fire in the OR: thermal injury**

circumstances. As soon as the airway fire is recognized, the administration of all gases by anesthesia must be stopped and the tracheal tube removed (to prevent plastic melting within the airway and the oropharynx) [2, 48]. Any items at risk of ignition should also be immediately removed, followed by the administration of saline or water into the airway [2]. After the fire is extinguished, the patient can be reintubated and ventilated, provided that no smoldering materials remain [2, 48]. Concentration of administered oxygen can be increased after the risk of re-ignition is no longer present. It is important for OR teams to remember that a tracheostomy procedural setup should include a readily available source of saline, preferably

One important, and thankfully exceedingly rare consideration is the secondary ignition of the operating room team's gowns, gloves, possibly resulting in thermal injuries among operating team members [49]. Electrical injury causing harm to hospital staff has also been described [50]. Although generally underreported, these and other similar scenarios may put at risk both the patient and his or her caretakers, especially when the fire is intense, when an explosion occurs, or when heavy smoke causes inhalation injury [49, 51, 52]. Also of importance is the need for the OR staff to be aware of the potential for patient thermal injuries from improperly placed

In fires that occur in the operating suite or its immediate proximity, not involving the patient, the source is usually related to faulty electrical equipment or wires [2, 53]. In case of such occurrence, the initial step is to turn off (if possible, of course) and then safely unplug the affected equipment and remove it physically to reduce any potential future threat of fire [53]. However, if this is not feasible, the device may need to be extinguished in its stationary location [2].

Fire extinguishers using carbon dioxide should be readily available, easily accessible, and regularly checked for operational readiness [25]. Consequently, extinguishers must be clearly identified by an appropriate sign, and each employee should be familiar with operational characteristics of these life-saving tools. It has also been recommended that extinguishers should be located near pull stations, stairwells, and fire exits [2]. All fire extinguishers used in the OR are of the *ABC* variety, meaning that they are effective across all major fire types (A, ordinary combustibles; B, flammable liquids; C, electricity) [41]. The dry chemical fire retardant used is ammonium phosphate and is mildly corrosive in moist environments. If

mable liquids) would be preferable because of its lack of ammonium phosphate and thus less potential for contamination and tissue damage. Proper extinguisher use can be described

Strategically located, centrally monitored fire, smoke, and heat sensors must be present and fully functional at each healthcare facility, including all procedure/operating rooms [55]. Additionally, fire alarm pull stations should be located near evacuation stairwells and other predesignated locations. When any fire is present, both visual (strobe lights) and audible alarms should activate [2]. The hospital fire response plan should immediately go into effect, notifying designated fire response team about where to respond. The response team includes but is not limited to security and facility management personnel. Determinations regarding resource mobilization and whether to initiate additional evacuation procedures should also be made.

extinguisher (effective on electrical fires and flam-

in a large syringe suitable for direct and immediate intra-tracheal administration.

electrocautery grounding pads [53].

168 Vignettes in Patient Safety - Volume 3

the patient becomes the fuel source, a CO<sup>2</sup>

using the PASS (pull pin, aim, squeeze, and sweep) acronym [54].

It has been noted that approximately two-thirds of surgical fires occur on the patient while approximately one-third occur in a cavitary location (e.g., airway) [17]. In terms of decreasing frequency of anatomic locations, approximately 40–45% ORFs involve the head, neck, and upper chest; about 25% involve other "external" body areas; and finally about 20% occur in the airway, with the remainder occurring in other "cavitary" locations [17].

In addition to traditional electrocautery equipment, various forms of devices utilizing different types of nonionizing radiant energy have been introduced into medical applications, including ultraviolet, visible light, microwaves, and radio-frequency waves [66, 67]. Starting with overall exposure and risk reduction, providers must be aware of the potential dangers as well as the full spectrum of possible injury—associated with these devices [66, 68]. Prompt recognition and timely management of injuries from both direct thermal exposure and other forms of "surgical energy" misapplication cannot be overstressed. This includes immediate attention to any injuries sustained by the patient and/or staff [29, 69, 70]. Thermal burns are associated with coagulation necrosis of the involved tissues, with the degree of severity depending on the temperature and the duration of the exposure. The initial tissue response primarily results from the direct transfer of energy in the localized area of injury, resulting in protein denaturation and coagulation [68, 71–73].

In case of cutaneous burn, skin is an effective thermal barrier, causing most of the immediate damage to be confined to epidermis and dermis. At the same time, various humoral mediators (cytokines, prostaglandins, oxygen free radicals, histamine, complement) are released that may result in vasoactive response, increased capillary permeability, and the appearance of local as well as distal tissue edema. Beyond the general pathophysiology of the burn wound, additional factors contributing to the overall physiologic response include resuscitation fluid administration, effects of various therapeutic agents, impaired host defense leading to elevated risk of infection, endocrine system changes, and the associated hypermetabolic state that affects metabolism across a broad range of tissues (e.g., muscle, liver, kidneys, gastrointestinal tract) [73].

OR safety checklist aimed at reducing the risk of ORF, either alone or in combination with other existing checklists, has been proposed as one potential solution to the problem [91–93]. Another area where iatrogenic fires can occur, yet the issue appears to be relatively neglected despite some

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One important focus of existing guidelines (with some exceptions) is that the traditional practice of using highly concentrated oxygen should be discontinued during head, face, neck, and upper chest surgery [28, 46]. The recommended practice is to use medical air whenever possible in such cases, and if the patient's condition warrants supplemental oxygen, additional precautions should be taken to protect the surgical field from oxygen "contamination" [2]. The exception to this rule would be a case in which a patient must remain responsive but requires supplemental oxygen while undergoing a procedure involving the head, face, neck, or upper chest. Under such circumstances, the lowest concentration of oxygen should be employed (e.g., 30%), and if concentrations exceed 30% prior to using any surgical energy source, one should stop oxygen and deliver medical air at 5–10 L/min for at least 1 min to dissipate any trapped oxygen [95, 96]. As previously outlined, tracheal incision should only be performed using "cold" devices such as scalpels or scissors. Finally, communication among the team members is essential, including

procedural similarities to the OR, is the clinical setting of the emergency department [94].

universal patient safety education and utilization of patient safety checklists [97].

surgical team during the "time out" or "pre-op briefing" [102].

identifiable pooling, before proceeding with the use of electrocautery [99].

Because ORF requires the simultaneous presence of an oxidizer, an ignition source, and a fuel, the key to prevention is intentionally minimizing (or eliminating, if applicable) one or more of these components so combustion is not possible [98]. Thus, the overall framework for ORF prevention must incorporate specific steps to identify risk level for each surgical case, ensure proper use of surgical energy devices, safe and appropriate use of supplemental oxygen, excellent communication and coordination, as well as meticulous attention to detail when using any potentially flammable materials to prep and/or drape the surgical field [99]. The assessment of fire risk potential should take place during the universal surgical time-out for every single patient and for each individual procedure [99, 100]. The fire risk is calculated/ estimated by considering all possible risk factors associated with a particular surgical procedure [101, 102]. The resulting "risk score" (with "1" representing "low risk," "2" representing "intermediate risk," and "3" representing "high risk") should then be communicated to the

In the OR, each healthcare worker takes the "ownership" of a part of the fire triangle. For example, alcohol-based skin preparations have become more common as a source of fuel since the Centers for Disease Control and Prevention identified them as the preferred skin disinfection method. Thus, the team member who applies the prep (e.g., circulating nurse) must work closely with the surgeon who controls the surgical energy device, and these stakeholders must ensure that the potentially flammable prep agent is completely dry, without any

One never knows who will be present when the fire occurs; thus, the role of each team member may change in any given scenario. A simplified guideline for all three broad types of ORF (e.g., involvement of airway, cutaneous/non-airway, and environment) is presented in **Figure 2**. High degree of flexibility on the part of all team members is required, and this can only be accomplished in the presence of meticulous preparation, optimized use of resources, readiness drills, simulation, and other forms of team practice [103, 104]. For

If airway or intracavitary fire is present, the abovementioned considerations may become amplified, potentially worsening the clinical prognosis [35, 74, 75]. Injuries involving the airway may become life threatening if not promptly and properly managed [48]. More specifically, what may appear to be a minor injury can result in severe tissue edema that severely restricts or obstructs an airway over the course of a few hours [74, 76, 77]. Long-term followup is required in cases of severe airway injury [78].
