Ethyl chloride ignites
From the August 26, 2004 issue
Sadly, we must report another surgical fire associated
with ethyl chloride spray. We last wrote about this in the
March issue of the newsletter (WorthRepeating... Extreme caution
needed with flammable products, ISMP Medication Safety Alert! March 11, 2004).
In this latest case, a physician applied ethyl chloride spray
to an area on a girls forehead and waited for it to
dry. He then turned on the cautery device as he proceeded
to drain an abscess. Due to hair loss, the teenager was wearing
a flammable synthetic wig, which soon ignited after the heat
source was applied to her forehead. The flames were quickly
but the patient sustained first degree burns to her ear.
we stated in our March publication, ethyl chloride containers
may have poorly visible warnings about flammability. The reporter
pointed out that one could
clearly read topical anesthetic skin refrigerant - relieves
pain but easily miss statements about it being flammable
because they are set in a small type size. There is an icon
on the bottle to indicate that
it is flammable, but it looks more like a flower than a flame.
Please dont let this happen again. Take time now to
ensure that someone at your location notifies physicians,
nurse practitioners, and all other
healthcare workers about the dangers of ethyl chloride spray
and the potential for burns when these products are used in
conjunction with a heat source. Even static discharge may
ignite it! Reevaluate the need for flammable products in your
facility, as there are often safer alternatives, especially
for topical anesthetics. At the least, add an auxiliary label
to warn about flammability before these products are
dispensed to units.