In 2013 the ASA Task Force updated their practice advisory on operating room fires (referenced below).
There are an estimated 50-200 operating room fires annually in the United States including airway and non-airway fires. A fire requires three components known as the “fire triad” including: an oxidizer, ignition source, and fuel. Oxidizers in the OR include oxygen and nitrous oxide, which increase the likelihood and intensity of combustion. Ignition sources include electrosurgical devices, lasers, burrs and drills, and fiberoptic scopes. Fuels include tracheal tubes, sponges/gauzes, alcohol-containing solutions, drapes, masks, and nasal cannulae. A surgical fire is defined as a fire that occurs on or in a patient. An airway fire is a surgical fire that occurs in a patient’s airway and may or may not include a fire in the attached breathing circuit.
If possible, avoid using ignition sources near oxidizer-enriched environments. Configure the drapes to avoid oxidizer pooling or accumulation. Allow flammable skin prepping solutions to completely dry. Sponges and gauzes should be moistened if they are to be used near ignition sources. For laser procedures in the airway, it is recommended to use laser-resistant cuffed tubes, and to fill the cuff with saline tinted with methylene blue to identify a cuff puncture by the laser. Before an ignition source is used the surgeon should announce the intent to use the device upon which the oxygen concentration should be reduced to the minimum needed to avoid hypoxia, and nitrous oxide should be stopped. The surgeon should not begin until all of the above criteria are met.
In the case of an airway fire immediately, without hesitation, halt the procedure and remove the tracheal tube. Stop the flow of all airway gases. Remove sponges or any other flammable material from the airway, and pour saline into the airway. Once the fire is extinguished, re-establish ventilation either with the circuit or a self-inflating resuscitation bag. If possible, ventilate with room air. Examine the integrity of tracheal tube to make sure no fragments may have been left in the airway. Consider bronchoscopy (preferably rigid) to assess injury and, especially, to locate and remove tracheal tube fragments and other debris. Assess the patient and then devise a management plan.
For a fire in the airway or breathing circuit, as fast as possible:
- Remove the tracheal tube.
- Stop the flow of all airway gases.
- Remove all flammable and burning materials from the airway.
- Pour saline or water into the patient’s airway.
For a fire elsewhere on or in the patient, as fast as possible:
- Stop the flow of all airway gases.
- Remove all drapes, flammable, and burning materials from the patient.
- Extinguish all burning materials in, on and around the patient (e.g., with saline, water, or smothering).
If the airway or breathing circuit fire is extinguished:
- Reestablish ventilation by mask, avoiding supplemental oxygen and nitrous oxide, if possible.
- Extinguish and examine the tracheal tube to assess whether fragments were left in the airway. Consider bronchoscopy (preferably rigid) to look for tracheal tube fragments, assess injury, and remove residual debris.
- Assess the patient’s status and devise a plan for ongoing care.
If the fire elsewhere on or in the patient is extinguished:
- Assess the patient’s status and devise a plan for ongoing care of the patient.
- Assess for smoke inhalation injury if the patient was not intubated.
If the fire is not extinguished after the first attempt (e.g., after performing the preassigned tasks):
- Use a CO2 fire extinguisher in, on, or around the patient.
- If the fire persists after use of the CO2 fire extinguisher:
- Activate the fire alarm.
- Evacuate the patient if feasible, following institutional protocols.
- Close the door to the room to contain the fire, and do not reopen it or attempt to reenter the room.
- Turn off the medical gas supply to the room.
- Follow local regulatory reporting requirements (e.g., report fires to your local fire department and state department of health). Treat every fire as an adverse event, following your institutional protocol.