Fire, Emergencies, Lasers and Precautions

This is Unit Nine of Tech in Surgery Prep. Unit Eight ended with a haze over the field, caused by a switch left off. This unit takes up the most serious form of that hazard, fire, and the other emergencies the team prepares for before they happen. Carry one idea through this lecture. The federal guidance calls surgical fires preventable, because their causes and solutions are known, and fire safety depends on routine more than on reaction. A worked example near the end shows a small fire that stayed small because the routine was done first. By the end you will be able to explain the fire triangle and who controls each side. To prevent fire at the field and respond if one starts. To apply laser, equipment and gas safety. And to explain the scrub person's part in cardiac arrest and other crises.

Five entries on the fire triangle, the three things a fire needs, and the team member who controls each.

Three things, almost always present.

TSC 201 The Fire Triangle in Surgery

A fire needs fuel, an oxidizer and an ignition source together, and an operating room almost always has all three. Fuel includes drapes, sponges, alcohol-based preps, ointments, hair and the patient. The oxidizer is oxygen, often enriched, and nitrous oxide. Ignition comes from electrosurgical units, lasers, light cables and drills. A surgical fire is one in, on or around a patient, in any procedural setting. Oxygen-rich air makes materials ignite more easily and burn harder, even ones labelled flame resistant. The FDA calls surgical fires preventable.

Almost everything can burn.

TSC 202 Fuels on the Field

Almost everything on and around the field can fuel a fire. Drapes, gowns, sponges and dressings burn; so do alcohol-based preps, ointments, the patient's hair and tissue. Wet sponges and towels burn far less readily than dry ones, which is one reason they are kept moist near ignition sources.

The oxygen-enriched zone.

TSC 203 Oxidizers and the Oxygen-Rich Zone

Supplemental oxygen and nitrous oxide make the area around the face and upper body oxygen-enriched. The FDA advises the minimum oxygen the patient needs, closed delivery where possible, and clearing oxygen from the field before an ignition source is used. The risk is highest at the head, neck and upper chest.

What lights the fire.

TSC 204 Ignition Sources

Ignition sources include electrosurgical units, lasers, fiber-optic light cables, drills and burrs, and defibrillators. A light cable lying on drapes can scorch them, so connect it before switching on and switch off before disconnecting. An active pencil left on the drapes, not in its holster, is a common ignition source.

Three sides, three controllers.

TSC 205 Who Controls Which Side

Each side of the triangle is controlled by a different person. The anesthesia provider controls oxygen and nitrous oxide, the surgeon controls ignition sources, and the surgeon and nurses control fuels such as prep and drapes. So the FDA advises a fire risk assessment at the time out, so every controller hears the plan.

Five entries on preventing fire at the field and on the response if one starts.

Waiting for prep to dry.

TSC 206 Letting Prep Solutions Dry

Alcohol-based preps are flammable until fully dry and their vapours have dispersed. Use the correct amount, avoid pooling, especially under the patient, remove soaked materials, and wait the label's drying time before draping. Drying takes longer on hairy skin and in folds, so the label time is a minimum.

Small habits, every time.

TSC 207 Preventing Fire at the Field

Fire prevention at the field is a set of small habits used every time an ignition source is. Holster the pencil, keep sponges moist, keep saline ready, warn anesthesia before using energy near the airway, and never coil cords around metal instruments. Anyone who sees a fire risk speaks up, whatever their role.

If fire starts on the patient.

TSC 208 If a Fire Starts on the Patient

Everyone should know their role before a fire ever happens. Say it aloud so the whole team knows. The anesthesia provider stops oxygen and other gases at the source. Burning materials are removed and small fires put out with saline or water from the field, which is why a basin is kept within reach. If the fire is not out, use the correct extinguisher, and if it spreads, move patient and team out under the evacuation plan. Then the patient is assessed and the event reported. Learn the sequence in a drill, as the FDA recommends, not in a real fire.

A memory aid.

TSC 209 Rescue, Alarm, Contain, Extinguish

Many hospitals teach fire response as RACE: rescue, alarm, contain, extinguish or evacuate. Remove people from danger, sound the alarm, close doors to contain smoke and fire, then extinguish if safe or evacuate. Know a safe way out first, and never let the fire come between you and it.

Pull, aim, squeeze, sweep.

TSC 210 Using an Extinguisher

Most portable extinguishers are used with PASS: pull the pin, aim low at the base of the fire, squeeze the handle, and sweep side to side until it seems out, then back away and watch. If you doubt you can fight it, or the extinguisher runs out, evacuate at once.

Four entries on lasers, equipment and compressed gases.

The highest hazard class.

TSC 211 Laser Safety

Nearly all surgical lasers are in the highest hazard class, Class Four, because they are designed to alter tissue. The hazards are eye injury from direct or reflected beams, skin burns, fire if the beam strikes fuel, and contaminants in the plume. The controls are warning signs on every door, eyewear matched to the laser for everyone in the room, smoke evacuation, the laser on standby unless the target is in view, and training, with use limited to credentialed users. Reflections are the hidden danger, because a shiny instrument can send a beam toward someone not looking.

Eyewear for this laser.

TSC 212 Eye Protection for Lasers

Laser eyewear must protect against the specific wavelength in use. Each pair is marked with its wavelength and optical density, and eyewear for one laser may not protect against another. Ordinary glasses are not protection, so check the marking whenever the laser changes.

Cords and machines.

TSC 213 Equipment and Cord Safety

Poorly maintained equipment can burn or shock staff and patients, so it is inspected before use. Do not use frayed or damaged cords, ground electrical equipment used near water, and follow the manufacturer's instructions. If something does not look right, take the machine out of service and call for help.

Cylinders under pressure.

TSC 214 Compressed Gas Cylinders

Mishandled compressed gas cylinders can cause fire, explosion or toxic exposure. Store them upright and secured, empty or full, never dropped or knocking together, and move them with caps on, never rolled or dragged. An unsecured cylinder that falls can break its valve and become a projectile.

Six entries on cardiac arrest, other crises and drills, then two worked examples. The opening idea is paid off at the first.

When the heart stops.

TSC 215 Cardiac Arrest in the OR

Cardiac arrest is the sudden stop of effective pumping, and in surgery its causes include heart attack, anaphylaxis, malignant hyperthermia and massive blood loss. The circulating nurse calls for help and the code cart and directs someone to start compressions. A leader is chosen, often the anesthesia provider. Defibrillator pads go on as soon as the machine arrives, and a shock is given on the leader's word. Others give medications and record events. If surgery continues, another nurse circulates and keeps the counts going. The scrub person stays sterile and protects the field, because the counts do not stop.

Responding to malignant hyperthermia.

TSC 216 Malignant Hyperthermia Response

When malignant hyperthermia is suspected, the triggering anesthetic is stopped and the antidote and cooling begin at once. The scrubbed team finishes quickly or packs the wound, while others bring the dedicated cart, prepare the antidote and cool the patient. Early signs include jaw rigidity and rising temperature, so a scrub person who sees unexpected rigidity says so.

A severe allergic reaction.

TSC 217 Anaphylaxis in the OR

Anaphylaxis is a severe, life-threatening allergic reaction, triggered in surgery by drugs, latex, antibiotics or blood products. Signs can include spreading hives, a rising heart rate, swelling and breathing changes, and the anesthesia provider leads treatment. A reaction under the drapes may first be seen by the scrub person, so new redness or hives are reported at once.

Practising before it is real.

TSC 218 Fire Drills and Evacuation Plans

Surgical teams prepare for fire with regular drills and an evacuation plan for patients and staff. The FDA recommends training and retraining everyone on the team, and making sure they know where the correct extinguishers are. Learn your facility's plan and alarm codes before your first case.

A flame near the chin.

TSC 219 A Flash Under the Drapes

A worked example, constructed for this course, pays off the opening idea. A chest lesion is removed under sedation with oxygen flowing. At the time out, the circulator names it a high fire-risk case, and anesthesia agrees to minimal oxygen, stopped before each activation. The prep dried the full label time, longer for chest hair, and Kai has saline and wet sponges ready. Then the surgeon activates the pencil without warning, oxygen pooled under the drapes ignites, and a small flame appears. Kai says fire aloud, anesthesia stops the oxygen, the surgeon pulls the drape away, and Kai pours saline. It is out in seconds, with no burn. The fire stayed small because the routine came first; it started because one warning was skipped.

A code with the abdomen open.

TSC 220 A Code With the Field Open

A worked example, constructed for this course, follows an open abdominal case. Twenty minutes after an antibiotic, blood pressure falls, hives spread, and the anesthesia provider announces a severe allergic reaction, then cardiac arrest. The circulator calls for help and directs compressions; anesthesia leads. Nadia, the scrub person, keeps the field covered and protected, her instruments ready, and stays clear of the compressions. A second nurse takes over circulating, and together they track every sponge. When a rhythm returns, the surgeon packs the abdomen to stop, and the count before temporary closure is correct. The scrub person's task in a code is to keep the field safe and the counts accurate while everyone else looks elsewhere.

Look at what you can now do. You can explain the fire triangle in surgery, the fuels, oxidizers and ignition sources, and who controls each side. You can prevent fire with dry prep and small habits, follow the sequence if fire starts, and use RACE and PASS. You can apply laser eyewear and controls, equipment and cord checks, and cylinder safety. And you can explain the scrub person's part in cardiac arrest, malignant hyperthermia and anaphylaxis, and why drills come first. Unit Ten turns to counts, records and reporting.