Guidance Notice No.

GI 02/07: page 1 of 6

SURGICAL FIRE PREVENTION AND

MANAGEMENT
Guidance Notices provide information in support of general safety issues.

The Elements of Surgical Fires

The three basic elements of surgical fires constitute the traditional fire triangle. In the
operating theatre, these elements are present in the following forms:

• Ignition sources include electrosurgical equipment, surgical lasers, electrocautery

equipment, fiberoptic light sources, and defibrillators.
• Oxidizers include oxygen-enriched atmospheres, nitrous oxide, medical air, and
ambient air.
• Fuels include common theatre material such as mattresses, sheets, gowns, towels,
drapes, dressings, and sponges. Other fuels include volatile organic chemicals, body
hair, intestinal gases, tracheal tubes, and body tissue.

Each member of the surgical team is associated with—and should be concerned with—
one or more sides of the fire triangle. Surgeons are involved mainly with ignition sources,
anesthesia providers mainly with oxidizers, and nurses mainly with fuels, although these
areas frequently overlap. Each member of the surgical team should understand the
various fire hazards presented by each side of the fire triangle and should make a point of
communicating information on the risks to the other team members.

Recommendations for Preventing Surgical Fires

• Purchasing skin prep solutions that provide clear and explicit instructions and
warnings and that are packaged to ensure controlled delivery to the patient.
• Following prep solutions suppliers’ recommended instructions for use.
• Ensuring that the prep solution does not soak into hair or linens. Sterile towels
can be placed to absorb drips and runs during application, and can then be
removed prior to draping the patient.
• Prior to draping, ensuring that the prep solution is completely dry. This may take
a few minutes or more depending on the amount and location of the solution.
• Inspecting the prepped area before draping. Some solutions change appearance
when dry (e.g., change from shiny to matte).
• During surgery, being aware of any sudden flash of heat. Such a flash is
indicative of an alcohol fire. If a fire is suspected, immediately search for any
flaming or smouldering materials, and remove and extinguish them.
• In-service about the proper use and risks of using alcohol and alcohol-based prep
solutions should be provided to all surgical staff including nurses, surgeons, and
anaesthetist’s.
 Guidance Notice No. GI 02/07: page 2 of 6

The following items are examples of ways in which the risk of a surgical fire can be
minimized

Minimizing Ignition Risks

During Electrosurgery

• Place the electrosurgical pencil in a holster when it is not in active use-that is, when it
won't be needed within the next few moments.
• Activate the active electrode only when the tip is under the surgeon's direct vision.
• Allow the pencil to be activated only by the person wielding it.
• Deactivate the pencil before removing it from the surgical site.
• If open O2 sources are employed, use bipolar electrosurgery whenever possible and
clinically appropriate (such as for cauterization during head and neck surgery). Bipolar
electrosurgery creates little or no sparking or arcing.
• Never use insulating sleeves cut from catheters over electrosurgical active electrode
tips.
• Never use electrosurgery to enter the trachea during tracheostomy.

During Laser Surgery

• Place the laser in standby mode whenever it is not in active use.

• Activate the laser only when the tip is under the surgeon's direct vision.
• Allow only the person using the laser to activate it.
• Deactivate the laser and place it in standby mode before removing it from the surgical
site.
• When performing laser surgery through an endoscope, pass the laser fiber through the
endoscope before introducing the scope into the patient. This will minimize the risk of
damaging the fiber. Before inserting the scope in the patient, verify the fiber's
functionality.
• During lower-airway surgery, keep the laser fiber tip in view and make sure it is clear of
the end of the bronchoscope or tracheal tube before laser emission.
• Use appropriate laser-resistant tracheal tubes during upper-airway surgery. Follow the
directions in the product literature and on the labels, which typically include information
regarding the tube's laser resistance, use of dyes in the cuff to indicate a puncture, use
of a saline fill to prevent cuff ignition, and immediate replacement of the tube if the cuff
becomes punctured.

In General

• Remove unneeded footswitches so they are not accidentally activated. (Do this only
after the attached device has been placed in standby mode.)
• Dispose of electrocautery pencils properly - e.g., break off the cauterizing wire and cap
the pencil.
• Be aware that fiberoptic light sources can start fires.
• Use a pulse oximeter to monitor the patient’s blood oxygen saturation and titrate the
delivery of oxygen to the patient’s needs.
• Never place active fiberoptic cables on flammable materials.
• Place the fiberoptic light source in standby mode when disconnecting cables.
 Guidance Notice No. GI 02/07: page 3 of 6
Minimizing Oxidizer Risks

During Oropharyngeal Surgery

• Use suction as near as possible to any potential breathing gas leak to scavenge the
gases from the oropharynx of an intubated patient.
• Wet any gauze or sponges used with uncuffed tracheal tubes to minimize leakage of
gases into the oropharynx, and keep them wet.
• Keep all moistened sponges, gauze, pledgets, and their strings moist throughout the
procedure to render them ignition resistant.

In General

• Be aware of possible O2 and O2/N2O-enriched atmospheres near the surgical site

under the drapes, especially during head and neck surgery.
• Question the need for 100% O2 for open delivery to the face (for example, when using
a nasal cannula); if possible, use air or +30% O2 for open delivery, consistent with
patient needs.
• If possible, stop supplemental O2 (if concentration is more than 30%) at least one
minute before beginning the use of electrosurgery, electrocautery, or laser surgery on
the head or neck.
• Minimize the buildup of O2 and N2O (such as from an uncuffed tracheal tube or a
laryngeal mask airway) beneath the drapes.
• Use a properly applied incise drape, if possible, to help isolate head and neck incisions
from O2 enriched atmospheres and from flammable vapors beneath the drapes. Proper
application of an incise drape ensures that there are no gas communication channels
from the under-drape space to the surgical site.
• Consider active gas scavenging of the space beneath drapes during open O2 delivery,
or of the oropharynx of an intubated patient. When scavenging beneath drapes,
exercise caution so that the space beneath the drapes does not collapse.

Minimizing Fuel Risks

During Preparation

• Avoid pooling or wicking of flammable liquid preps.

• Allow flammable liquid preps to dry fully before draping; pooled or wicked liquid will
take longer to dry than will prep on the skin alone.
• Use a properly applied incise drape, if possible, to help isolate head and neck incisions
from O2 enriched atmospheres and from flammable vapors beneath the drapes. Proper
application of an incise drape ensures that there are no gas communication channels
from the under-drape space to the surgical site.

In General

• Coat facial hair (including eyebrows, beard, and mustache) near the surgical site with
water-soluble surgical lubricating jelly to make the hair nonflammable.
• Be aware of the flammability of tinctures, solutions, and dressings (such as benzoin,
phenol, and collodion) used during surgery, and take steps to avoid igniting their
vapors.
• Be aware that surgical gowns, dressings, sheets, etc. after sterilization may be very
dry and have increased flammability.
 Guidance Notice No. GI 02/07: page 4 of 6
Recommendations for Responding to Surgical Fires

When a Fire Starts

First Response

Small fires on the patient (such as those caused when a hot electrosurgical pencil ignites
drapes on a patient, or when an electrocautery pencil ignites a blotting sponge) can be
extinguished by patting out the fire with a gloved hand or towel.

1. Large fires on or in the patient require a more comprehensive response: Stop the flow
of oxidizers to the patient. In many cases, this will cause the fire to go out or at least
lessen in intensity.
2. Remove the burning materials from the patient, and extinguish them. This is the only
way to protect the patient from the heat of these materials.
3. Care for the patient swiftly. Restore breathing if necessary (with air, if available) and
deal with any injuries.

(There is some debate over this sequence--specifically, the order in which the first two
steps should be carried out. The guideline developers (see acknowledgements) believe
they should be performed simultaneously; others disagree. In any case, they should both
be done as close to instantaneously as possible.)

If Evacuation is Necessary

In some very rare cases, extreme smoke and fire conditions may force the evacuation of
the operating theatre where the fire occurs. In such cases, the acronym RACE defines the
actions that should take place: Rescue the patient if possible, Alert staff in nearby theatres
and activate fire alarm systems, Confine the smoke and fire by shutting all doors and
closing off gas, vacuum, and power systems, and Evacuate the theatre and, if necessary,
the surgical suite.

Putting Out the Fire

If the fire cannot be extinguished by the methods discussed under First Response in the
original guideline document (see acknowledgements), then other means may be required.

Fire Extinguishers

Although they should not be the first resort when dealing with a surgical fire, fire
extinguishers may be needed to deal with fires that engulf or that have migrated off the
patient.

The correct procedure for using any fire extinguisher can be recalled by the acronym
PASS: Pull the pin, Aim the horn or nozzle, Squeeze the trigger, and Sweep out the fire.
The basic type of fire-extinguishing devices commonly available in theatres is CO2.

Other Ways to Put Out a Fire

Other, less common means of extinguishing surgical fires include, aqueous solutions
found in theatre, sprinkler systems, and hoses. Again, these are not all equally safe or
effective.
 Guidance Notice No. GI 02/07: page 5 of 6
Aqueous solutions include bottled saline solution, bottled water, and tap water.

Sprinkler systems are often found in the operating theatres. They may activate only in
response to large fires. Like water from extinguishers, sprinkler system water is not sterile
and could, under some circumstances, present an electric shock hazard. If sprinklers
have activated, the fire is substantial and all personnel should have evacuated.

Fire hoses are sometimes found in hallways and stairwells of older facilities. Health unit
on-site training will state that fire hoses are primarily for use by trained fire fighters or
response teams.

In the Aftermath

After the fire, the operating theatre and all materials and devices involved in the fire should
be secured until an investigation can be completed. Statements from the staff should be
taken as soon as possible after the incident.

Fire Drills

Fire drills not only allow staff to practice for a fire but also help troubleshoot any difficulties
that might occur. Some elements to consider in planning a fire drill are:

• The proper response of each surgical team member and the operating suite staff
• How the patient can easily and safely be moved to another theatre
• How the spread of smoke should be prevented (for example, through the use of smoke
doors and air duct dampers)
• The location and operation of fire extinguishers, fire alarm pull stations, and exits
• What the response of additional fire-fighting personnel (such as the fire response team
and local fire department) should be.

Further Information

• ECRI Poster “Only You Can Prevent Surgical Fires, available free of charge from
http://www.mdsr.ecri.org/static/Surgical_fire_poster.pdf

• ECRI Health Devices Guidance Article, Surgical Fire Safety; February 2006.

Or

Please contact Christy Pirone, Safety and Quality Unit, Department of Health 8226 6698
or email [email protected]
 Guidance Notice No. GI 02/07: page 6 of 6

Prepared 3 April 2007

by the SA Department of Health
Quality and Safety Unit
Tel, 08 8226 7454
Fax 08 8226 0725
http://www.safetyandquality.sa.gov.au/

Acknowledgements:

The information given this Safety Information notice has been sourced from a National Guideline
Clearinghouse http://www.guideline.gov/ document titled – A clinician’s guide to surgical fires: how
they occur, how to prevent them, how to put them out. This document was prepared by ECRI
http://www.ecri.org/. from a Guidance Article - A clinician’s guide to surgical fires: how they occur,
how to prevent them, how to put them out. Health Devices 2003 Jan;32(1):5-24. The guideline article
represents expert consensus on the subject of surgical fires.

Development of this Safety Notice has assisted by contributions and advice from the Department of
Microbiology and infectious Diseases, Flinders Medical Centre; Royal Adelaide Hospital, Engineering
& Building Services; Murray Bridge Hospital, Operating Theatre; and the Department of Health’s
Asset Services, Infection Control Service; and Country Health Division.