**7. Fire containment: strategies and procedures**

the operative field [12, 21]. Finally, surgical gauzes and sponges should be moistened when

Examples of "high-risk" procedures include tracheostomy creation (e.g., direct exposure of surgical field to highly concentrated oxygen) or maxillofacial/head and neck surgery (e.g., close proximity between the endotracheal airway and surgical energy source) [23–25]. For such "high-risk" procedures, where proximity exists between an oxidizer and an ignition source, special caution is required by the entire OR team, including close communication and coordination between the surgeon and the anesthesiologist, as well as the use of operating field suctioning to scavenge any excess oxygen [12]. This is demonstrated well in our Clinical Vignette #2, where both the surgeon and the anesthesiologist took immediate and appropriate course of action. In addition to avoiding/limiting the use of nitrous oxide, the concentration of oxygen being delivered to the patient should be minimized, preferably based on close monitoring of patient oxygenation (e.g., pulse oximetry, and if possible tracking of inspired/expired/delivered oxygen concentration) [12].

The use of surgical laser equipment in a high-risk area (e.g., head and neck, trachea) should be done in the presence of laser "resistant" tracheal tubes, intended specifically for a given procedure and type of laser [12, 26, 27]. For any operative work requiring surgical energy application within the airway, reduction in oxygen or nitrous oxide concentration is thought to be safe for anywhere between 1 and 5 min at a time [12]. The same applies to procedures involving immediate proximity of the oxidizer and surgical energy source in the setting of nasal cannula or face mask [12]. Surgical suction should be utilized to scavenge oxygen or

According to the Emergency Care Research Institute (ECRI), approximately 200–240 surgical fires occur each year in the United States [28]. Other sources provide a much wider range of occurrences, ranging between 100 and 2260 annually [2, 24, 29, 30]. Generally speaking, the incidence of ORF appears to be similar to that of wrong-site surgery or retained surgical items [28], some of the most prominent categories of surgical "never events" [31–33]. As outlined in previous sections, the simultaneous presence of key components required for the ignition of a fire is the single biggest risk determinant (**Table 1** & **Figure 1**). Therefore, it is not surprising that surgical fires involve electrosurgical equipment in approximately 67–90% of all cases, and that supplemental oxygen administration was nearly universally present [2, 34]. Of importance, the operative environment is defined as being "oxygen-enriched" when the oxygen concentration is greater than 21% [17]. Most commonly and not surprisingly, given the previously outlined risk factors, ORFs result in burns to the head, face, neck, and upper chest [22]. Thankfully not

nitrous oxide from the oropharynx during cases involving this anatomic area [26].

all ORFs involve patients, operating room staff, or result in significant injury [2].

As discussed earlier in the chapter, the initiation (and propagation) of ORF is dependent on the simultaneous presence of an ignition source (e.g., surgical energy device), fuel (e.g., paper drapes, alcohol-based skin prep), and an oxidizer (e.g., oxygen, nitrous oxide) [22]. **Figure 1** lists

**6. The fire triangle: focus on education and knowledge**

**5. Operating room fire: true magnitude of the problem**

used in proximity to any potential source of ignition [22].

166 Vignettes in Patient Safety - Volume 3

In an event of a fire, healthcare facilities commonly employ the "rescue-alarm-confine-extinguish" or RACE protocol [40, 41]. All team members, regardless of assigned function or seniority, should be aware of the location of pertinent emergency equipment, including the "fire alarm" trigger, fire extinguisher, and phone/extension to be used for notification [42]. Within the OR environment, additional considerations may need to be taken into account, depending on specific circumstances, such as whether the fire involves the patient. Scenarios involving the patient (both cutaneous and within the airway) and those without patient involvement will now be discussed.

If the fire directly involves the patient, the initial steps should involve extinguishing the flames and removing any burning material from the patient [2, 43]. Simultaneously, other team members should be tasked with initiating the established "fire response" protocol, including alarm notification, personnel evacuation, removal of flammable materials from the vicinity of the fire, as well as using fire extinguisher to contain and put out the fire [44, 45]. Alarm notification should clearly indicate the precise location of the fire and any critical information regarding the circumstances of the occurrence [42, 45]. Due to the risk of thermal injury, timing of actions and team coordination are critical. The administration of exogenous gases (oxygen and nitrous oxide) should be discontinued immediately. Once fire control is achieved, care for the patient should resume, with specific management based on the degree of danger from smoke in the area.

If the fire is not able to be immediately contained, then evacuation from the room, notification using established facility infrastructure (e.g., facility alarms, the emergency operator, and the OR operational leadership), and immediate notification of the fire department should take place. The surgeon typically recognizes the fire first and thus is involved in extinguishing and removing the fire, primarily by dousing the area with saline. Equipment immediately available in the event of an ORF includes ample supply of sterile saline or water; a "carbon dioxide" or a "water mist" fire extinguisher; replacement tracheal tubes, guides, and facemasks; rigid laryngoscope equipment; sponge and drape sets ready for rapid re-deployment; replacement ventilator circuits, tubes, and lines [2]. Because many drapes are waterproof, it is important for saline to cover all burning areas. If saline is not available, moist surgical towels draped across the operator's forearms may be used to smother the flames, with a sweeping motion away from the patient's airway. Of note, patting a fire may cause the flames to worsen [46].

During tracheostomy placement and other tracheal procedures, the fire may directly involve the patient's airway [47]. Although rare, this type of event can be fatal [48]. Due to its anatomic location, fire in the tracheobronchial tree is approached differently compared to other 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 in a large syringe suitable for direct and immediate intra-tracheal administration.

In addition to the primary location of the ORF, the alarms should also sound on the floor above and below the fire. Although this may seem obvious in larger hospitals, where fire alarm notifications are usually announced throughout the entire building, some smaller facilities may require specific modifications to ensure this important safety feature. In the case of hospital fire alarm activation, the on-site safety team must determine whether an evacuation is necessary [2, 56]. This is especially important when one considers the risks associated with moving patients who are critically ill or actively undergoing surgery. Thus, in the event of an actual fire, personnel would be notified of detailed plan(s) to have the fire contained and controlled to facilitate safe and orderly evacuation of the involved building or structure [57–60]. Operating room personnel should conduct an assessment of specific patient needs such as monitoring equipment, ventilator availability and appropriate transport platform to safely perform evacuation procedures. Central to the ability to quickly and safely evacuate large number of patients and personnel is the need for specialized infrastructure, including critical

Avoiding Fire in the Operating Suite: An Intersection of Prevention and Common Sense

http://dx.doi.org/10.5772/intechopen.76210

169

Gas shut-off valves are used to stop the flow of anesthetic gases into the ORs and are designed for easy access. The front of these gas supply consoles should be clear of medical equipment and clutter at all times [61]. The gas shut-off procedure should be managed using preexisting plans and/or protocols, again emphasizing staff education and periodic team drills. All pertinent equipment should be clearly labeled, including the relationship between valve position and its functional state [61, 62]. As with other emergencies that may involve limited visibility and/or lack of power, emergency lighting, battery-operated safety equipment, and any smoke

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

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

components such as "fire-safe" elevators [56].

management devices should be available and operational [63–65].

the airway, with the remainder occurring in other "cavitary" locations [17].

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

protein denaturation and coagulation [68, 71–73].

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 electrocautery grounding pads [53].

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 the patient becomes the fuel source, a CO<sup>2</sup> extinguisher (effective on electrical fires and flammable 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 using the PASS (pull pin, aim, squeeze, and sweep) acronym [54].

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.

In addition to the primary location of the ORF, the alarms should also sound on the floor above and below the fire. Although this may seem obvious in larger hospitals, where fire alarm notifications are usually announced throughout the entire building, some smaller facilities may require specific modifications to ensure this important safety feature. In the case of hospital fire alarm activation, the on-site safety team must determine whether an evacuation is necessary [2, 56]. This is especially important when one considers the risks associated with moving patients who are critically ill or actively undergoing surgery. Thus, in the event of an actual fire, personnel would be notified of detailed plan(s) to have the fire contained and controlled to facilitate safe and orderly evacuation of the involved building or structure [57–60]. Operating room personnel should conduct an assessment of specific patient needs such as monitoring equipment, ventilator availability and appropriate transport platform to safely perform evacuation procedures. Central to the ability to quickly and safely evacuate large number of patients and personnel is the need for specialized infrastructure, including critical components such as "fire-safe" elevators [56].

Gas shut-off valves are used to stop the flow of anesthetic gases into the ORs and are designed for easy access. The front of these gas supply consoles should be clear of medical equipment and clutter at all times [61]. The gas shut-off procedure should be managed using preexisting plans and/or protocols, again emphasizing staff education and periodic team drills. All pertinent equipment should be clearly labeled, including the relationship between valve position and its functional state [61, 62]. As with other emergencies that may involve limited visibility and/or lack of power, emergency lighting, battery-operated safety equipment, and any smoke management devices should be available and operational [63–65].
