From the March 11, 2004 issue
In a physicians office, a nurse practitioner
was preparing to treat a 6-year-old childs 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 childs
foot ignited. The childs 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 patients 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 wasnt harmed.
This isnt the first time weve
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
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. Heres 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
containers 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.