Clinical anaesthesia
Fires and explosions
Neil A Muchatuta
Steven M Sale
Abstract
Fire and explosions require three elements in order to occur (the ‘fire
triangle’): oxygen, fuel and a heat or ignition source. Fuel reacts with
an oxidizing agent to release energy that may sustain the reaction. An
explosion is a rapid physical or chemical change accompanied by a large
pressure increase. In the operating theatre environment different team
members have control over the three limbs of the fire triangle; good
teamwork is paramount in the management of fire. It is the anaesthet-
ist’s responsibility to use oxygen and nitrous oxide judiciously to avoid
oxygen-enriched environments in proximity to ignition sources. Potential
fuels include surgical drapes and PVC tracheal tubes. Heat and ignition
sources include surgical diathermy, lasers, defibrillators and static elec-
tricity. Small fires can be patted out or extinguished with sterile saline
or water. With larger fires, burning material must be removed and extin-
guished and oxygen must be stopped, after which ventilation should be
re-established with air until the fire risk is removed. The acronym RACE
is helpful if evacuation becomes necessary: Rescue patient, Alert other
theatres, Confine smoke and fire and Evacuate theatre.
Keywords fuel; heat; ignition; oxygen
The decline in the use of flammable anaesthetic agents has led
to a decrease in the incidence of fires and explosions within the
operating theatre. Such events, although rare, do occur and are
associated with significant morbidity and mortality. In the USA,
approximately 100 surgical fires are reported annually, of these
20 cause severe injury, leading to 1–2 deaths each year. Most
of these fires take place during surgery of the head and neck as
a result of airway fires. Vigilance and knowledge of how fires
occur and how to deal with them will reduce their frequency
and severity.
Definitions
Fire occurs when a substance (fuel) reacts with an ­ oxidizing
agent with release of energy. This reaction requires initial
Neil Muchatuta, FRCA, BSc, is Specialist Registrar at the Bristol School
of Anaesthesia. He graduated in 1998 from the Royal Free Hospital
School of Medicine, London. His main interests are obstetric
anaesthesia and teaching.
Steven M Sale, FRCA, is Consultant Paediatric Anaesthetist at Bristol
Royal Hospital for Children. He qualified from the University of Bristol
and trained in anaesthesia in the South West of England.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:11
a­ ctivation energy. If sufficient heat energy is produced, the reac-
tion becomes self-sustaining (Figure 1).
An explosion is a rapid physical or chemical change accompanied
by a large increase in pressure (up to 2500 kPa). The occurrence of
an explosion depends on the amount of fuel and oxidizing agent
present, as well as the speed of reaction. The reaction spreads
quickly (faster than the speed of sound), ­producing large amounts
of heat (with temperatures up to 3000°C), light and noise.
A stoichiometric mixture is the proportion of fuel and oxidizing
agent that results in both substances being completely exhausted
by the reaction and is associated with the most violent reactions.
Flammability is the ability of a substance to support combus-
tion. Anaesthetic agents used in the past (e.g. diethyl ether
(C2H5OC2H5) and cyclopropane (C3H6)) as well as alcohol-based
skin preparations (e.g. isopropyl alcohol ([CH3]2CHOH)), all con-
tain C–C bonds that easily break down and release energy, with
heat and oxygen. In contrast, the C–F bond found in modern
inhalational anaesthetics is more resistant, and these agents are
therefore less flammable.
Flammability limits: a substance supports combustion with an
oxidizing agent (e.g. oxygen or air) over a range of concentra-
tions known as the flammability limits. Outside these limits,
the mixture will not burn. The stoichiometric concentration lies
between the two limits (Figure 2).
For substances such as ether (the flammability limits of which
lie within the concentrations used in clinical practice) there was
a significant risk of fires and explosions. However, with modern
volatile anaesthetics, the concentrations used in clinical practice
are below the lower limit of flammability.
The fire triangle
For a fire or explosion to occur and be maintained, the following
three elements are required to form the ‘limbs’ of the fire triangle
(Figure 3):
• oxygen
• fuel
• heat or ignition source.
Energy produced by initial reaction
Activation energy
+ Fuel Energy
+ Oxidizing agent
The energy produced by the initial reaction can act as the activation energy.
The reaction continues until one of the three components is exhausted
Figure 1
457 © 2007 Elsevier Ltd. All rights reserved.
 Clinical anaesthesia

oxygen concentrations. By avoiding positive pressure ventilation

Flammability limits of methane in air and limiting airway pressures this leakage may be reduced.
Flammability limits
Nitrous oxide also supports combustion and is broken down to
4
produce oxygen, nitrogen and heat. Diluting oxygen with nitrogen
(e.g. medical air) or helium reduces oxidizing agents. ­Strategies to
3
Spark energy (mJ)

reduce the risks posed by high oxygen concentrations include:

Flammable • judicious use of oxygen (using the lowest oxygen concentration
2 that provides acceptable haemoglobin oxygen saturations)
• avoidance of open-flow oxygen (e.g. nasal cannulae, Hudson
1
masks)
• use of well-applied incision drapes (e.g. antibacterial adhesive
0.5
Stoichiometric concentration drapes)
2 4 6 8 10 12 14 • tenting surgical drapes
Methane (%) • use of scavenging.
The lowest activation energy is associated with the stoichiometric
concentration Fuel

Figure 2
The supply of one or all of these limbs should be managed to
­prevent surgical fires. The control of each limb is largely the
responsibility of different members of the surgical team: oxygen by
anaesthetists, potential fuel sources by nursing staff and ignition
sources by surgeons. Tackling fires therefore provides unique chal-
lenges and requires careful communication and team working.
Oxygen
For most surgical operations an oxygen-enriched atmosphere
is delivered to the patient. Oxygen supports combustion, and
increased oxygen concentrations reduce the energy and heat
required to ignite fuels. Fuels that do not burn in air may do so in
an oxygen-enriched environment (e.g. polyvinylchloride (PVC)
tracheal tubes will burn in 26% oxygen).
Oxygen is heavier than air, and can therefore accumulate
under surgical drapes. This accumulation may be reduced by the
use of ‘incise drapes’ that protect the wound from high oxygen
concentrations and by tenting surgical drapes to dilute oxygen
with room air. Oxygen can leak around a laryngeal mask airway
or an uncuffed tracheal tube, resulting in higher oropharyngeal
Fire triangle
Fuel
There are a large number of potential fuels for combustion in the
theatre environment. Alcohol-based antibacterial skin prepara-
tions are one of the more common causes of surgical fires since
the withdrawal of flammable anaesthetic agents. They can pool on
the body surface (especially umbilicus and suprasternal notch), be
wicked into surgical drapes and produce flammable vapours that
can accumulate beneath the drapes. If ignited, ­alcohol can burn
with flames that are virtually invisible under operating lights, so
scrub staff should be aware of sudden flashes of heat.
Surgical drapes are the most implicated fuel in surgical fires.
There are many different types of drapes and all support combus-
tion, particularly in an oxygen-enriched environment. However,
disposable non-woven polymeric drapes are more likely to melt
than burn if ignited in room air. Fire retardants are used in the
manufacturing process of some drapes. However, they do not
eliminate the risk of ignition.
Tracheal tubes are usually made of PVC and are flammable.
When PVC burns, gaseous hydrogen chloride is produced. This
gas is toxic to the lower airways. Laser-resistant tubes made of
silicone and metal will also burn in an oxygen-enriched environ-
ment. Ignited tracheal tubes allow flames and thermal energy to
be transmitted to the lower airways.
Other potential fuel sources include methane from intestinal
gas, body hair (especially with hair spray or gel), dry swabs and
gauze, aerosol dressings and tincture of benzoin. The steps that
can be taken to reduce the risk of fuel ignition include:
• avoiding the pooling and wicking of flammable skin
­preparations
• ensuring skin prep has completely dried before applying drapes
• considering the use of aqueous-based skin preparations
• coating any body hair in the surgical field with an aqueous-
based lubricant jelly.

Heat and ignition source

Most surgical fires are caused by the improper or unsafe use of
Heat Fire Oxygen heat sources.

Surgical diathermy is the heat source most likely to cause igni-

tion. High temperatures are reached at the probe tip, which can
persist for several seconds after the probe has been deactivated.
Figure 3 In addition, arcing of electricity can occur. The cutting mode

ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:11 458 © 2007 Elsevier Ltd. All rights reserved.
 Clinical anaesthesia
of diathermy is more likely to ignite fuels than the coagulation
mode, and fires are more likely with monopolar diathermy than
bipolar (page 464). Risks may be reduced by:
• activating the diathermy only when the probe is under direct
observation
• placing the probe in a holster when not in use
• using bipolar diathermy when open oxygen sources are used
Lasers are the second most common ignition source in surgical
fires because of their high energy and power density. The risks of
a fire during laser surgery can be minimized by:
• using the lowest fraction of inspired oxygen for acceptable
oxygen saturation
• using fire-retardant, laser-resistant tracheal tubes
• using double cuffs inflated with saline (dye may be added to
alert to cuff puncture)
• avoiding use of nitrous oxide
• placing wet swabs or pledgets in oropharynx, and keeping
them wet
• having a sterile water source ready in case of ignition
• limiting intensity and duration of the laser
• allowing only the operator to activate the laser.
Defibrillators can act as an ignition source, particularly if open
oxygen sources are not removed. Ignition of transdermal patches
or glyceryl trinitrate ointment by defibrillator pads can cause
explosion.
Static electricity has become less of a problem since the decline
of the use of flammable anaesthetic agents, and antistatic pre-
cautions are no longer a necessity in modern operating theatres.
However, maintaining a relative humidity above 50% will reduce
the likelihood of spark formation.
Adiabatic change caused by sudden compression of gases, such
as when a gas cylinder is opened quickly, results in an increase
in temperature. If lubricants such as oil or grease are present, fire
or explosion may occur.
Other sources: electrocautery, fibre-optic light sources, malfunc-
tioning electrical equipment, drills, saws and high-speed burrs
have been implicated in starting surgical fires.
Management of surgical fire
The initial aim in the management of a surgical fire is to prevent
a small fire becoming out of control and causing damage to the
patient. Fires may become uncontrollable in seconds, so speed is
essential. Disruption of the fire triangle by removing one or more
of its limbs will lead to the fire being extinguished. The manage-
ment of surgical fire is summarized in Table 1
Airway fires carry the risk of inhalation of toxic products as
well as thermal injury. Table 2 summarizes the action to take in
the event of an airway fire.
Fire drills
Fire drills provide an inexpensive means of examining the ad-
equacy of fire control procedures, rehearsing the practicalities of
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:11
Management of surgical fire
Small fires
• Pat out the fire with gloved hand or towel
• Flood the area with sterile water or saline
 Large fires
• Remove burning material from patient and extinguish
• Stop flow of oxygen to patient
• Swiftly care for patient. Re-establish ventilation with air
(avoid oxygen until risk of fire has passed). Treat any injuries
 If evacuation becomes necessary use the acronym RACE
• Rescue patient
• Alert staff in other theatres. Activate alarm
• Confine smoke and fire: close doors; shut down gas, vacuum
and power systems as necessary
• Evacuate from theatre or suite to a predetermined area
Table 1
dealing with fires and evacuation and educating staff of their role
in the event of a fire. Fire drills should cover:
• how to keep minor fires under control
• management of major fires
• rehearsal of evacuation plans (ensure staff know their roles
in event of evacuation)
• liaison with fire brigade
• testing of fire alarms and communication systems
• use of fire-fighting equipment, medical gas valves, air-
­conditioning controls, electricity supply switches.
Fire extinguishers
Fire extinguishers should be available in all theatres. The choice
of extinguisher depends on the type of fire.
Fire classification in Europe divides fires into the following:
• Class A – fires involving flammable solids (e.g. paper, wood,
cloth, plastics)
Management of airway fire
• Disconnect the breathing circuit
• Flood oropharynx with sterile water or saline
• Consider flushing saline down tracheal tube to extinguish
intraluminal fire
• Consider removing tracheal tube (potential source of further
thermal injury or toxic products)
• Re-intubate and ventilate (airway swelling may make
intubation difficult)
• Perform bronchoscopy to inspect for damage and remove
foreign bodies (e.g. tube debris)
• Consider steroids and antibiotics
• Transfer to critical care if patient at risk of upper airway
swelling or acute lung injury
Table 2
459 © 2007 Elsevier Ltd. All rights reserved.
 Clinical anaesthesia
• Class B – fires involving flammable liquids
• Class C – fires involving flammable gases
• Class D – fires involving combustible metals
• Class E – fires involving energized electrical equipment (Class E
fires are equivalent to Class C in the USA classification)
• Class F – fires involving cooking fats and oils
Most surgical fires involve Class A, B and E fires.
Labelling: since 1997, under European legislation, fire extinguishers
are coloured red. However, a colour-coded panel may be attached
to the fire extinguisher to identify the extinguishing agent.
Carbon dioxide extinguishers are used for Class B and C fires
and are the best choice of extinguisher in a surgical fire. They are
portable, lightweight, leave no residue and are not harmful to the
patient or staff. They can also be used in Class A fires, but there
is a risk of re-ignition. Carbon dioxide extinguishers are identi-
fied by a black panel.
Water-based extinguishers are used for Class A fires. The
water used is not sterile and may pose an infection risk. There is
a risk of electrocution to patient or rescuer if used near live elec-
trical equipment. These extinguishers carry a red panel.
Dry powder extinguishers can be used in Class A, B, C and
E fires. The powder contaminates wounds and is an airway
­irritant. They are a last resort in a fire near or on a patient. These
extinguishers carry a blue panel.
Fire blankets should not be used on anaesthetized patients as
they may cause severe injury and desterilize wounds. They can
be used in the event of fire on a conscious person, such as a sur-
gical team member. ◆
Further reading
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tube ignition during tracheotomy. Ann Otol Rhinol Laryngol 1991;
100: 31–4.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 8:11
Bruley ME. Surgical fires: perioperative communication is essential to
prevent this rare but devastating complication. Qual Saf Health Care
2004; 13: 467–71.
ECRI. The patient is on fire! A surgical fires primer. Health Devices
1992; 21: 19–34.
ECRI. A clinician’s guide to surgical fires: how they occur, how to
prevent them, how to put them out. Health Devices 2003; 32: 5–24.
Keller C, Elliot W, Hubbell R. Endotracheal tube safety during
electrodissection tonsillectomy. Arch Otolaryngol Head Neck Surg
1992; 118: 643–5.
MacDonald A. A short history of fires and explosions caused by
anaesthetic agents. Br J Anaesth 1994; 72: 710–22.
MacDonald A. A brief historical review of non-anaesthetic causes of
fires and explosions in the operating room. Br J Anaesth 1994; 73:
847–56.
Pashayan A, Gravenstein J, Cassissi N, McLaughlin G. The helium
protocol for laryngotracheal operations with CO2 laser: a
retrospective view of 523 cases. Anesthesiology 1998; 68: 801–4.
Rogers M, Nickalls R, Brackenbury E, et al. Airway fire during
tracheostomy: prevention strategies for surgeons and anaesthetists.
Ann R Coll Surg Engl 2001; 83: 376–80.
Wolf G, Sidebotham G. Airway fires during surgery. In: Adams AP,
Cashman JN, eds. Recent advances in anaesthesia and analgesia.
Edinburgh: Longman, 1994, p. 77–80.
Acknowledgement
This article is based on a previoulsly published version by Guy
Bayley and Andrew K McIndoe.
460 © 2007 Elsevier Ltd. All rights reserved.