From the March 11, 2004 issue

In a physician’s office, a nurse practitioner was preparing to treat a 6-year-old child’s infected toe. She sprayed his foot with ethyl chloride to numb the area, and then proceeded to lance the area with surgical cautery. As soon as she triggered the cautery device, the entire surgical field went up in flames and the pad underneath the child’s foot ignited. The child’s mother, who happened to be holding her son, immediately pulled the child away from the fire. Miraculously, he did not suffer any burns even though his foot was in the middle of this fire. Later, the nurse practitioner admitted that she was unaware that ethyl chloride was a very dangerous fire hazard and should never be used in the presence of electrical cautery equipment. She also mentioned that she had observed a physician doing the same procedure previously on another child, without any problems.

Another recently reported fire happened in an ambulatory surgery unit. An assistant surgeon had prepared an operative incision for bandaging by spraying it with tincture of benzoin (which protects the skin and acts as an antiseptic). The primary surgeon had nearly completed suturing the patient’s incision, but he noticed a small bleeding area along the incision line and decided to cauterize it. The flammable benzoin ignited briefly, but fortunately, the patient wasn’t harmed.

This isn’t the first time we’ve written about surgical fires. In our May 30, 2001, issue we wrote about a fire that occurred when LACRI-LUBE S.O.P. (56.8% white petrolatum, 42.5% mineral oil) was ignited during laser surgery. A child who was having warts removed near his eyes suffered burns to the eyelids and periorbital area. According to ECRI (a patient safety partner), there are approximately 100 surgical fires each year, resulting in up to 20 serious injuries and 1-2 patient deaths. A number of these fires have involved flammable medications in the form of prepping agents (alcohol and alcohol-containing iodophors), eye lubricants, ointments, and wound dressings (tincture of benzoin and collodion).

Our past recommendations to prevent surgical fires are Worth Repeating. Ensure that physicians, nurse practitioners, and all other healthcare workers know about the dangers of flammable products, as well as the potential for burns when these products are used in conjunction with a heat source. Here’s just one example of how flammable some products can be. According to the material safety data sheet for ethyl chloride, it is heavier than air and the vapors may hug the ground, making distant ignition and flashback possible. Even static discharge may ignite it! Given this danger, you would think that warnings on the product container’s front label panel would grab your attention. However, the label on one brand of ethyl chloride (Gebauer) has the word “flammable” enclosed inside a border along with an icon that looks more like a flower than a flame (see photo). Likewise, the warning about flammability on tincture of benzoin labels may not be prominent or distinctive. Reevaluate the need for flammable products in your facility, as there are often safer alternatives, especially for topical anesthetics. For more information on preventing surgical fires, see the JC Sentinel Event Alert. Hazard warnings are poorly visible on ethyl chloride spray. The “flame” icon looks more like a flower.