perioperative fire safety

PERIOPERATIVE FIRE SAFETY

1968

1968PERIOPERATIVE FIRE SAFETY

STUDY GUIDE

DisclaimerAORN and its logo are registered trademarks of AORN, Inc. AORN does not endorse any commercial company’s products orservices. Although all commercial products in this course are expected to conform to professional medical/nursing standards,inclusion in this course does not constitute a guarantee or endorsement by AORN of the quality or value of such products or ofthe claims made by the manufacturers.

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video produced by Cine-Med, Inc.127 Main Street North, Woodbury, CT 06798

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Perioperative Fire SafetyTABLE OF CONTENTS

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OvERvIEW/OBJECTIvES .............................................................................................................4INTRODUCTION.............................................................................................................................5HISTORY OF OPERATING ROOM FIRES ....................................................................................5THE FIRE TRIANGLE.....................................................................................................................5

Oxidation Sources....................................................................................................................6Ignition Sources .......................................................................................................................6Fuel Sources ............................................................................................................................6

PREvENTION OF OPERATING ROOM FIRES............................................................................7Fire Risk Assessments .............................................................................................................7Fuel Management ....................................................................................................................7Management of Oxidizing Sources .........................................................................................8High-risk Procedures ...............................................................................................................9Management of Ignition Sources...........................................................................................10Preventing Equipment Fires...................................................................................................11Fire Drills ...............................................................................................................................11Education and Competency Evaluation.................................................................................11Fire Prevention and Management Plans ................................................................................12

RESPONDING TO OPERATING ROOM FIRES .........................................................................12Fires on Patients.....................................................................................................................12Fires Inside Patients...............................................................................................................13Fires Off Patients (Equipment Fires) .....................................................................................13Follow-up Activities for all Fires...........................................................................................14Fire Extinguishers..................................................................................................................14Gas Control valves ................................................................................................................14Evacuation .............................................................................................................................15

CONCLUSION and RESOURCES ................................................................................................15REFERENCES ................................................................................................................................16POST-TEST.....................................................................................................................................18POST-TEST ANSWERS .................................................................................................................21


OVERVIEWThe purpose of this study guide and accompanying video is to educate perioperative personnel on the history, epidemiology,and risks of surgical fires and essential fire safety practices for the perioperative environment.

OBJECTIVESAfter viewing the video and completing the study guide, the participant will be able to:

1. List types of fires that occur in the perioperative environment.2. Describe the components of the fire triangle and how these apply in procedure rooms.3. Explain how to prevent and respond to surgical fires.4. Discuss how AORN’s recommended practices can be used to develop a fire prevention program for the perioperative

environment.

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INTRODUCTIONFire is an ever-present risk in health care facilities. TheNational Fire Protection Association (NFPA) estimates thatduring 2006-2010, fire departments in the United Statesresponded to an estimated 6,240 structure fires per year thatoccurred in or on health care properties.1 On average, thesefires caused an estimated six deaths, 171 injuries, and $52million in property damage annually. Fully 23% of fires inhealth care facilities occurred in hospitals or hospices and 11%occurred in clinics or physician offices. The majority of firesin health care facilities have involved cooking equipment, butlaundry machines, heating equipment, and even lighting havebeen implicated.1

A fire anywhere in a health care facility represents a risk forpatients, personnel, and visitors; however, surgical fires areparticularly hazardous because they create an immediate andpotentially devastating risk for patients undergoing surgicalor other invasive procedures. Surgical fires every year causedeath, severe disability, or permanent disfigurement. TheUnited States does not have a central surveillance system foroperating room (OR) fires, which has made it challenging toestimate their incidence. The most recent results from the non-profit ECRI Institute, which has extrapolated data from thePennsylvania Patient Safety Authority, indicate that surgicalfires in US health care facilities have declined fromapproximately 500 to 600 in 2009 to 200 to 240 in 2012.2These data indicate that hundreds of surgical fires continue tooccur in the US every year – despite the fact that these firesare 100% preventable.3

Three overriding principles of operating room fire safety areto prevent, and extinguish fires, and to evacuate persons atrisk if necessary. Only by fully understanding the details offire safety concepts and practices can perioperative registerednurses and their colleagues implement these overridingprinciples when needed. This study guide describes the historyand causes of OR fires and reviews practices to prevent thesefires in contemporary health care settings. If an OR fire doesoccur, perioperative personnel must work quickly, effectively,and as a coordinated team to protect patients and staff.Therefore, the guide also reviews essential practices forresponding to OR fires, including ways to extinguish varioustypes of fires and to evacuate a surgical suite if needed. Firescan create panic and confusion, requiring personnel to thinkon their feet; therefore, in addition to standard educationalactivities, regular fire drills and competency assessments areindicated to enable all OR personnel to prevent and respondto fires.

HISTORY OF OPERATING ROOM FIRESOperating room fires have occurred for centuries, and writtenrecords of such fires date back to at least 1745.4 Earlyanesthetics such as cyclopropane and ether-based agents wereflammable, and their use contributed to explosions and firesduring operative and other invasive procedures.5,6

In an attempt to prevent fires during the era of flammableanesthetics, floors in operating theaters were constructed fromantistatic flooring but these floors were costly to install andmaintain.5 In addition, before approximately 1960 evidence-based consensus recommendations on surgical fire preventionwere lacking.6 Some anesthesia professionals during this timeperiod contended, for example, that ORs should not be air-conditioned and should be kept humid to prevent theaccumulation and conduction of static electricity.6 Thesemeasures were generally ineffective and the introduction ofsurgical diathermy and electrocautery intensified the risksassociated with use of flammable anesthetics.5

In 1956, the first nonflammable anesthetic, halothane, becameavailable and by the 1970s flammable anesthetics were nolonger being used in the US and numerous other countries.4,5

But despite the publication of national evidence-based firesafety recommendations, OR fires remain a serious concernin the 21st century.1

THE FIRE TRIANGLEPrevention is the best wayto fight a fire. A centralconcept in fire prevention isthe fire triangle, which isbased on the observationthat in order for a fire tostart, it requires oxygen (anoxidizing source), heat (anignition source), and fuel tobe in close proximity to oneanother.4

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All three components of the fire triangle are usually presentduring operative and other invasive procedures; thereforeperioperative personnel need to be aware of oxygen, heat, andfuel sources in the OR and understand how to manage thesesources to promote patient and staff safety.

Oxidation SourcesOxidation sources in the OR include oxygen and nitrousoxide.4 The perioperative use of either gas has the potential tocreate an oxygen-enriched environment, defined as anenvironment in which there is any increase in theconcentration of oxygen above room air level and/or in whichany concentration of nitrous oxide is present.7 An oxygen-enriched environment makes combustion possible at lowertemperature and energy levels than in room air, therebyincreasing the probability and intensity of fires.7,8 In ananalysis of more than 20 years of medical malpractice claimsfrom the American Society of Anesthesiologists ClosedClaims database, 95% of electrocautery-induced firesinvolved the use of oxygen, and 84% involved the use of openoxygen delivery systems.9

Several conditions can contribute to the formation of anoxygen-enriched environment. Drapes that are not properlypositioned can trap oxygen or nitrous oxide underneath them,creating a localized, highly oxygen-enriched environmentwhere the risk of fire is increased.7 Oxygen also can leak fromendotracheal tubes or other parts of the anesthesia circuit.7 Atleast one surgical fire occurred when electrocautery was usedin proximity to oxygen leaking from around an uncuffedendotracheal tube.10

During open thoracic surgeries, lung tissue itself can cause anoxygen-enriched environment.11 In one reported case, a fireoccurred in a patient’s open chest cavity while the left internalmammary artery was being dissected prior to coronary arterybypass graft.11 Oxygen had entered the surgical field throughopen pulmonary blebs, causing gauze to ignite in the presenceof an electrosurgical unit. A review of the case determined that

perioperative personnel did not promptly notify the surgeonof the decrease in tidal volumes caused by the ruptured blebs.This case underscores the importance of fire training andprevention strategies, and the need for vigilance,communication, and rapid response when electrosurgical unitsare used in an oxygen-enriched environment.11

Ignition SourcesA number of heat (ignition) sources are used regularly in theOR. These include:4,7,12

• Electrocautery devices• Active electrosurgical electrodes• Lasers• Fiber-optic light cords• Defibrillators• Flexible endoscopes• Ultrasonic hemostatic or cutting devices• Heated probes• Devices that create heat (and possibly sparks) during

use, such as orthopedic drills and saws

Electrocautery and electrosurgical units are the most commonignition sources involved in reported OR fires.9,13 The analysisof the American Society of Anesthesiologists Closed Claimsdatabase identified 103 claims related to OR fires, of which90% involved the use of electrocautery.13 The majority ofelectrocautery fires involved the head, neck, or upper chest,and open oxygen delivery systems were used prior to 84% ofelectrocautery induced fires. In an analysis of 106 airway firesreported by otolaryngology surgeons, the most commonignition sources were electrosurgical units (59%), lasers(32%), and light cords (7%).13

Fuel SourcesModern ORs also contain numerous potential fuel sources.Examples include:4

• Flammable prep agents, including tinctures (benzoin,thimerosal, iodophor, chlorhexidine gluconate)

• Gauze and surgical sponges• Fabric or paper drapes• Gowns, masks, and hoods• Adhesive tape• Ace bandages• Towels• Aerosols• Dressings• Plastics, such as endotracheal tubes (a fuel source

during airway fires)• Petroleum or oil-based lubricants or ointments• Flammable gases, such as alcohol vapor• Patients’ hair• Gases (primarily methane) from the gastrointestinal

tract• Paraffin and white wax• Collodion (a mixture of pyroxylin, ether, and alcohol)

Different perioperative team members have primary controlover different components of the fire triangle during operativeand other invasive procedures.4 Surgeons, first assistants, andscrub personnel have primary control over ignition sourcessuch as lasers or electrocautery devices. Anesthesiaprofessionals have primary control over oxygen and nitrousoxide. Perioperative registered nurses, scrub personnel, andsurgical technologists have primary control over fuel sources,including antiseptic solutions, drapes, and gauze. Thesedistinct domains of responsibility mean that perioperativeteam members need to communicate and collaboratebefore and during operative and other invasive proceduresto ensure consistent awareness and control of allcomponents of the fire triangle.12 Operating room fires aremore likely when perioperative personnel are complacent,inattentive or distracted, slow to react, unaware of proper

firefighting techniques, or lack the appropriate tools forfighting fires.4

PREVENTION OF OPERATING ROOM FIRES

Fire Risk AssessmentsTo prevent OR fires, before every invasive procedure a firerisk assessment should be conducted and the resultscommunicated to the entire perioperative team.12 The firerisk assessment should identify the components of the firetriangle that are present in the OR, including fuels, ignitionsources, and the potential for an oxygen-enriched environmentto develop. The fire risk assessment should also determine thetype of fire extinguisher required and whether additional fireprevention measures, such as saline or wet towels, areindicated based on specific fuel sources and presence orabsence of electrical current. Fire extinguishers and practicesfor responding to fires are discussed in detail in the section ofthis study guide titled Responding to Operating Room Fires.

Fuel ManagementManagement of fuel sources in the OR is the primaryresponsibility of perioperative registered nurses and is crucialto prevent fires. Perioperative personnel should preventphysical contact between fuel sources and ignition.12 Thispractice helps prevent fires by breaking the fire triangle. Whenmanaging fuels, it is also important to keep in mind thatsubstances that would not ignite at room air concentrations ofoxygen can ignite in an oxygen-enriched environment.8,12 Inone study, researchers burned multiple samples of fivedifferent surgical fuels at oxygen levels of 21% (room air),50%, and 100%.8 As oxygen concentration increased, ignitiontimes and total burn times significantly decreased (p< 0.001).The researchers concluded that common OR materials canignite in oxygen-enriched environments, and that the risk ofignition and speed of fire propagation increase as oxygenconcentration increases.8

Two additional concepts related to fuel management are flashpoints and the difference between flammability and


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combustibility. A flash point is defined as the minimumtemperature at which a liquid will vaporize and form anignitable mixture in the presence of ambient air.12 Flammablesolutions have flash points that are ≤100° F.14 In contrast,combustible substances have flash points that are >100° F,which means they do not burn as easily.14 Like all chemicals,flammable and combustible solutions should be handledaccording to the manufacturer’s written instructions for use,and according to the relevant safety data sheet (SDS) from theOccupational Safety and Health Administration (OSHA).15

The SDS provides information on the flammability orcombustibility of solutions.16 For flammable liquids, the SDSspecifies the lower and upper explosive limits, which are thelower and upper limits of vapor and air concentrations (inpercentage form) at which an explosion could occur.16

Flammable substances such as alcohol-based skin antisepticsolutions, hand sanitizer, alcohol, acetone, and collodion haveserved as fuel sources in OR fires.9,17-20 Flammable solutionsrequire careful handling and oversight. They should not beallowed to pool or soak into linens or a patient’s hair.12

Sterile towels should be used to absorb drips and excessliquid. Before a patient is draped, any material that issaturated with flammable solutions should be removed andthe surgical area fully dried with sterile towels. The dry timefor flammable solutions ranges from three to 60 minutes,depending on the presence of hair at the site.21

Flammable solutions can be highly volatile, meaning that theyevaporate easily.16 Gases or fumes from flammable solutionshave ignited during surgery, causing fires.17,20 In one report, apatient sustained partial-thickness scalp burns after aflammable alcohol-based prep gel was allowed to wick intothe patient’s uncut hair prior to surgery. When the surgeonbegan using electrocautery to resect a retroauricular scalpmass, fumes from the gel ignited, causing a sponge to catchfire and burning the patient.18 In the analysis of closedinsurance claims, 15% of OR fires were associated withalcohol-based prep solutions and other volatile compounds.9

Adequate time should be provided to allow flammable skinantiseptic agents to dry completely and to allow any fumesto dissipate before surgical drapes are applied or apotential ignition source is used.7,12,22

Local and state regulations specify how flammable liquidsshould be stored, as well as volume limits and locations ofdispensers for flammable liquids; these regulations should beconsulted and carefully followed.12

Liquids rated as combustible also merit specific handling.12

Formalin, which is commonly used in the OR to fix tissuesamples, is combustible and should not be used near ignitionsources.12 Formalin is subject to additional precautionsbecause it contains the carcinogen formaldehyde, and cantrigger sensitivity reactions leading to asthma, bronchitis andcontact dermatitis.23 These precautions are described inAORN Recommended Practices for a Safe Environment ofCare.

Hair is also a potential fuelsource.4,12,18 To preventhair from catching fire inthe presence of an ignitionsource, a water-based gelshould be used to coverfacial hair during head andneck surgery.12 In addition,any eye lubricants that areused should be water-soluble. These actions help

decrease the risk of fire by increasing the temperature requiredfor hair to ignite.24

Management of Oxidizing SourcesProper management of oxidizing sources is critical to preventOR fires. Perioperative personnel should evaluate thepotential for an oxygen-enriched environment to occur andcommunicate this risk to team members.12 Oxidizers shouldbe used with caution when they are near any ignition or firesource. To decrease the likelihood of an oxygen-enrichedenvironment in the OR, patients who require supplementaloxygen should receive the lowest possible concentrationthat ensures adequate oxygen saturation.12,25,26 If a patientrequires more than 30% supplementary oxygen, a laryngealmask airway or endotracheal tube should be used, unlesscontraindicated, such as if the patient is required to be able torespond verbally during the procedure.

The flow of oxygen should be turned off at the end ofprocedures.12 In addition, the anesthesia circuit – includingthe endotracheal tube, the seal between the tube and the


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patient’s airway, the bagreservoir, and the tubingbetween the endotrachealtube and the anesthesiamachine – should be keptfree of leaks. Leaks in theanesthesia circuit permitoxidizers to accumulatebeneath drapes, whichincreases the risk offire.27-29

Additional precautions are indicated for operative andother invasive procedures in which open oxygen or nitrousoxide are used, particularly when drapes are placed overthe patient’s head.12 During these procedures, a secondsystem should be used to deliver 5-10 L/min of medical air toflush oxygen from under the drapes. Drapes should bepositioned in such a way as to allow oxygen to flow freelyrather than accumulating under the drapes.12,24,25,27 During useof a warming blanket with an attached head drape, a holeshould be cut in the drape around the endotracheal tube, thepatient’s head should be lifted and repositioned frequently ifpossible, and the warmer blower should be kept on while thedrape is in place.12,25 These practices help prevent oxygenfrom building up under the drape.25

Proper storage of oxidizers is essential to avoid fire hazards.Oxygen, nitrous oxide, and other medical gases should bestored based on volume, need for immediate use, andregulatory requirements.12,22 The NFPA and regulatoryagencies publish and enforce requirements for storage ofmedical gases. Requirements related to fire safety include thefollowing:22

• Medical gas cylinders that are not intended forimmediate use should be stored indoors in a locationaway from heat sources.

• The room used for storage should have a fireresistance rating of at least one hour; negativepressure; and at least eight air exchanges per hour.

• The cylinders should be secured with chain-likedevices or placed in racks to prevent them fromtipping and falling.

• Cylinders should not be stored in an egress hallway. In addition, valves on gas cylinders should be closed properlyto prevent leakage during storage.12 Containers of liquidoxygen must be handled, filled, stored, and transported inaccordance with state and federal regulations andmanufacturers’ written instructions and labeling.12,22 Liquidoxygen containers should be stored in a cool, dry place that iseither outside the building, or inside the building if thecontainers will not be exposed to open flames or high-temperature devices, will be secured to prevent tipping, willbe kept away from foot traffic, and will not be in danger ofsustaining damage from falling devices.

High-risk ProceduresSome operative and other invasive procedures are associatedwith a greater risk of fire on (or in) a patient compared withother procedures.12 The greatest risk of fire occurs duringprocedures above the xiphoid process and in the oropharynx.30

Examples of such procedures include removal of lesions onthe head, neck, or face; tonsillectomy; tracheotomy; burr holesurgery; and laryngeal papilloma removal. Procedures of thehead and neck are associated with increased risk of firesbecause anesthetic gases are most likely to accumulate in thisarea, resulting in an oxygen-enriched environment near thesurgical site. In a study of 106 airway fires reported byotolaryngologists, 27% percent of fires occurred duringendoscopic airway surgery, 24% during oropharyngealsurgery, 23% during cutaneous or transcutaneous head andneck surgery, and 18% during tracheostomy.13 Fully, 81% offires occurred while supplemental oxygen was in use.


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In one study, researchers evaluated the risk of fire duringoropharyngeal surgery by grounding an electrosurgical unit toa whole raw chicken, inserting an endotracheal tube into theempty central cavity of the chicken, and performingelectrocautery on the tissue near the endotracheal tube whiletitrating varying concentrations and flow rates of oxygenthrough the tube.26 Fire (defined as ignition with a sustainedflame) started inside the chicken cavity at oxygenconcentrations as low as 50%, if electrocautery was used forapproximately two minutes. At higher flow rates andconcentrations of oxygen, fires began after only 15-60 secondsof electrocautery use. These results highlight the role of anoxidizing source in the fire triangle—an oxygen-enrichedenvironment makes ignition possible at decreased heat orenergy levels. Notably, the researchers were unable to achieveignition with a sustained flame at oxygen concentrations lessthan 50%, regardless of the amount of time electrocautery wasused. The researchers concluded that decreasing the fractionof inspired oxygen to less than 50% could markedly decreasethe risk of airway fires during oropharyngeal surgery.

Bowel surgeries also are associated with increased fire riskbecause the bowel contains hydrogen and methane gases,which are flammable.24,29,31 In patients withpneumoperitoneum, the increased risk of fire in the patientextends to the peritoneal cavity.32 In a recent report, explosivecombustion occurred in the patient’s peritoneal cavity when ahandheld electrosurgery electrode was used to enter theabdomen.32 The patient had small bowel perforation withsecondary peritonitis and pneumoperitoneum. Perioperativepersonnel need to be alert to the risk of bowel gas ignitingwhen opening the bowel, and when opening the peritoneumin cases of bowel perforation.32

Additional precautions should be taken during surgeriesat high-risk sites.12 Incisions in an oxygen-enrichedenvironment might be made with a scalpel instead of an activeelectrosurgical electrode. An ignition source should NOT beused to enter the bowel when distended with gas.30 Duringsurgical procedures above the xiphoid process and in theoropharynx, radiopaque sponges should be placed at the backof the throat to help stop oxygen leaks, and endotracheal tubesshould be inflated with tinted solutions so that cuff rupturescan be promptly identified.12 In addition, beforeelectrocautery, battery-powered hand-held cautery units, orlasers are used, supplemental oxygen or nitrous oxide shouldbe stopped for one minute and an adhesive incise drape shouldbe placed between the surgical site and the oxygen source.30

Management of Ignition SourcesTo prevent fires, it is crucial to understand various ignition

sources in the OR and precautions related to use of thesesources. Electrosurgical units and lasers can become ignitionsources, particularly when used in the presence of oxidizers,flammable solutions, or volatile or combustible chemicals orliquids. Fiber-optic light cables can become ignition sourcesif the light source is left on while connected to the powersource; is disconnected from the working element; and is thenallowed to touch drapes, sponges, or other fuel sources.12,33,34

Perioperative team members should follow AORNrecommendations and manufacturer instructions whenusing ignition sources.12

Electrosurgical units should be used at the lowest possiblepower setting that is appropriate for the procedure.35 Theactive electrode should be kept clean to prevent ignition ofdebris on its tip, and should be kept away from surgical drapes,linens, oxygen, nitrous oxide, or combustible anestheticgases.36 Active electrodes, return electrodes, and protectivecovers for the electrode tip should be approved by themanufacturer for the particular electrosurgical unit being used.In addition, the active electrode should only be activated whenit is close to the target tissue and away from other metalobjects that could conduct heat or cause arcing.37 Minimallyinvasive electrosurgical electrodes should be inspected andremoved from service if the insulation is not intact.

When lasers are used, wet towels and saline should alwaysbe kept on the sterile field and moist towels, sponges, anddrapes should be placed around the surgical site.38 Both waterand the appropriate type of fire extinguisher should be readilyavailable. Laser-resistant endotracheal tubes should be usedwhen a laser is used during upper airway procedures. Neitherlasers nor active electrodes should be activated in the presenceof flammable solutions until the solutions have dried andfumes have dissipated.

Other potential ignition sources include defibrillators, drills,burrs, saw blades, lights, and light cables.12 Saline should beused to cool drills, burrs, saw blades, and other devices thatcreate heat when operated.12,24 These devices should be placedon the Mayo stand or back table when not in use. Light


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sources that are not in use should be placed in standby modeor turned off. Light cables should be inspected before use andremoved from service if broken light bundles are detected.Defibrillator paddles and pads should be the correct size forthe patient and should only be used with manufacturer-recommended lubricants in order to prevent sparking anddecrease the amount of energy needed for defibrillation.12,24

Preventing Equipment FiresEquipment fires are a serious risk in the OR. For example, anoverheated ventilator circuit has been determined to be thecause of at least two surgical fires.39 Several essential stepscan help prevent fires on or in equipment. Personnel shouldinspect electrical cords and plugs and remove damagedequipment from service.12 Power cords need regularinspection because they are likely to be damaged during dailyuse.22 There also have been reports of OR fires resulting fromimproper cleaning or malfunctions of booms and otherequipment.40,41

Personnel should check equipment to ensure that biomedicalinspection stickers are current. Equipment that is not currentshould be removed from service.12 In addition, fluids shouldbe kept off lasers, electrosurgical equipment, and otherelectrical devices. Equipment safety features such as audiblealarms should NOT be bypassed or disabled. Finally,manufacturer’s written instructions for use and AORNrecommended practices should be followed when using anyignition source, including lasers, electrocautery devices, activeelectrosurgical electrodes, and fiber-optic light cords.12

Smoke in the OR can indicate an immediate risk of fire.12 Ifequipment begins smoking unexpectedly, it should bedisconnected from the source of electrical current. Theequipment should then be moved out of the OR if it is safe todo so. Moving the equipment out of the OR decreases the riskof injury to patients and personnel in the room.34

Fire DrillsTo ensure that all personnel understand their responsibilitiesin the event of fire, health care facilities should schedule firedrills at least as often as required by the local authority

with jurisdiction;12 however, it is important to recognize thatthe local authority may not have adopted the most currentguidelines from the NFPA. These guidelines state that firedrills should occur during every shift at least quarterly andthat drills should include evacuation at least once annually oras specified by the relevant codes.42

Planning for a fire drill is crucial. Every drill should be ameaningful learning experience for personnel and for thehealth care organization as a whole. Drills should includechallenges such as blocked exits, malfunctioning equipment,heavy or unwieldy OR tables or stretchers, and crowdedrooms.4 A number of observers should be on hand during firedrills to observe and evaluate the response of personnel.12

Observers can be given the AORN Fire Drill Evaluation formwith as much information filled in and completed beforehandas possible. Furthermore, a debriefing session should occurafter every fire drill to identify any concerns and plan actionsfor future improvement.

Education and Competency EvaluationAt the first sign of an OR fire, perioperative personnel needto work together rapidly to perform several stepssimultaneously.43 For this reason, it is important that allmembers of the OR team understand the risks of fire, how tomitigate these risks, and how to respond to various types offires. Education and competency evaluation programs areessential to achieve these outcomes.


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Fire safety education and competency validation shouldinclude the following:12

• The fire triangle• Perioperative fire risk assessments• Locations and use of fire extinguishers and other fire-

fighting equipment• Evacuation routes for every room• Location and operation of medical gas panels,

instruction on how to turn them off in an emergencyand who is responsible for determining if they shouldbe turned off

• How and when to turn off ventilation and electricalsystems

• Location of fire alarm pull stations• How and when to activate the fire safety and

evacuation plan and contact the local fire department• Roles and responsibilities of team members during

specific fire scenariosSome studies point to educational gaps in perioperative firesafety.43,44 For example, an assessment of OR fire safetyawareness programs in New Orleans, Louisiana, and theUnited States overall indicated that more than half ofprograms surveyed did not involve all OR staff, and that manyhealth care institutions did not involve key persons such assurgery and anesthesia personnel in fire safety education andpreparation activities.43 In an evaluation of a fire simulationin a obstetric OR, personnel did not know where fireextinguishers or fire safe zones were located.44 AORNrecommends that perioperative team members receiveeducation and competency validation related to firesafety.12

Fire Prevention and Management PlansAORN recommends that health care facilities developwritten plans for preventing and managing OR fires. A fireprevention and management plan should specify policies,procedures, and team member responsibilities for preventingand responding to fires. These responsibilities includecommunicating with other team members, following policiesand procedures to prevent fires, and responding appropriatelyand safely to different fire scenarios, including: activating firealarms, extinguishing fires, and following evacuation routesand levels.

The fire prevention and management plan should also clarifythe required content for and frequency of fire safety educationactivities, including fire drill procedures. Furthermore, the planshould include details of the facility’s fire risk assessment tool.

Creating a fire prevention and management plan requires time,expertise, and multidisciplinary collaboration. AORNrecommends that fire prevention and management plansbe developed by a multidisciplinary group of keystakeholders.12 Group members should include perioperativeregistered nurses, unlicensed assistive personnel, anesthesiaprofessionals, physicians, local fire department representative,risk management personnel, the safety officer, and facilitiesand engineering personnel.

RESPONDING TO OPERATING ROOM FIRESOperating room fires are categorized by type and proximityto the patient. It is useful to consider three major categoriesof OR fires – those that occur on, in, and off the patient.Fires on the patient affect the hair, skin, or overlying drapes.Fires in the patient affect a body cavity. Fires off the patientdo not directly involve the patient but occur in close proximity.

Approximately 70% of fires directly involving patients arefires on the body, usually the head, neck, or chest.24 Theremaining 30% of fires ignite inside the patient—usually inthe endotracheal tube and the airway, but also in the bowel.Operating room fires that occur off the patient typicallyinvolve a piece of equipment. The majority of fatal OR firesare airway fires.27

Operating room fires of all types represent an immediate riskto the safety of patients and personnel; however, each type offire requires a different response. The following sectionsdescribe how to respond to fires on, in, and off patients. Thesepractices may vary in order or might occur simultaneously,depending on the fire and the number of personnel involved.

Fires on PatientsIf a fire starts on a patient, perioperative personnel should alertteam members and then extinguish the fire by pouring non-flammable liquids such as saline on the fire or by smotheringthe fire with a towel.12 At the same time, the anesthesiaprofessional should cease administration of airway gases.3,12,24

Fire extinguishers should not be used as a first line of defensein an OR fire, because obtaining the fire extinguisher canrequire additional time, which translates to additional risk tothe patient and staff. In addition, fire blankets should not beused in the OR for several reasons:12,24

• Fire blankets are made of wool, which can ignite inan oxygen-enriched environment.

• They can potentially spread fire or cause woundcontamination.


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• They can trap fire next to or under a patient.• They can potentially dislodge instruments, causing

further harm to the patient.

If a small fire starts on a patient, water or normal saline canbe poured slowly on the base of the fire to extinguish it;12

however, if the fire is underneath a waterproof drape, the drapewill need to be removed in order to fight the fire. A secondmethod is to smother the fire: a perioperative team memberholds a towel between the fire and himself/herself andbetween the fire and the patient’s airway. The team memberthen leans toward the patient, places one arm at the droppedend of the towel, and drops the other end of the towel over thefire. Next, the free hand is swept over the towel to extinguishthe fire. When the fire is extinguished, the towel is lifted offthe patient to allow heat accumulated underneath to disperse.The team member’s face and body should be kept as far awayfrom the fire as possible. The fire should NOT be pattedbecause this will fan the flames and could cause the fire tospread.

If a large fire starts on a patient, the flow of anesthetic gasesto the patient should be stopped and the breathing circuitdisconnected from the anesthesia machine.12 The personcontrolling the oxygen source to the patient should turn offthe flow as soon as possible and switch to room air. If a drape

is on fire, it should be removed to the floor in a location awayfrom the designated evacuation routes, and then rolled on itselfto smother the fire. After the fire is extinguished, the surgicalfield should be checked to be sure other materials have notcaught fire. The patient should be assessed for injuries and thephysician should be notified if injuries are identified. Alarmsshould be activated if necessary.

Fires Inside PatientsIf a fire occurs in a patient, team members should bealerted and the anesthesia professional should help todetermine the necessary response.12 If an airway fire occurs,perioperative registered nurses should assist anesthesiaprofessionals to disconnect and remove the anesthesia circuit,and turn off the flow of oxygen. The endotracheal tube shouldbe removed to eliminate the fuel source and saline should bepoured in the airway to cool the burned tissue.12,24,27 Thesesteps should be performed in collaboration with the anesthesiaprofessional. 12 Perioperative registered nurses should thenhelp to re-establish and examine the airway.12 The surgicalfield should be assessed for secondary fire, the patient shouldbe assessed for injuries, and the physician should be notifiedas needed.

Fires Off Patients (Equipment Fires)Equipment fires in the OR typically occur off but in theproximity of the patient. If a fire occurs on a piece of


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equipment, team members should be alerted and theequipment should be disconnected from its electricalsource.12 If the plug cannot be removed from the outlet, theappropriate electrical panel should be shut off. Any gases thatare flowing to the equipment should also be shut off. Basedon the size of the fire, the equipment either should be removedsafely from the OR, or the room should be evacuated. A fireextinguisher should be used to put out the fire, if appropriate,and alarms should be activated if needed.

Follow-up Activities for all Fires

Perioperative managers and administrators should beinformed of all OR fires in accordance with the facility’sprotocols.12 Leadership personnel should be notified even ifthe fire is small and is immediately extinguished. In addition,it is important that all materials that were involved in the firebe saved so that the fire department and risk managementofficers can investigate and determine the cause of the fire.24,27

These steps are often the responsibility of the circulatingregistered nurse who is responsible for the OR where the fireoccurred.

Fire ExtinguishersAORN recommends that fire extinguishers be selected forthe OR based on the directives of the NFPA and the localauthority with jurisdiction.12 The NFPA classifies fires asfollows.4,45

Class A fires involve combustible materials, such as wood,paper, cloth, most plastics, and human tissue.

Class B fires involve flammable liquids or grease.Class C fires involve energized electrical equipment.

When the equipment is unplugged, the fire becomesa class A or B fire because the electrical current isdisconnected.

Fire extinguishers are labeled with a letter or combination ofletters according to the types of fires for which their use is

indicated.4 According to theNFPA, either a water mistextinguisher or carbondioxide extinguisher may beused in the OR.12,45 Watermist extinguishers are ratedClass 2A:C. Carbon dioxideextinguishers are rated ClassB and Class C, but may alsobe used for Class A fires.

To operate a fire extinguisher, personnel should follow thePASS technique:4

• Pull the pin.• Aim at the base of the fire.• Squeeze the handle.• Sweep the fire extinguisher from side to side.

Fire extinguishers should be located no more than 30 to 75feet from the center of the OR, or as determined by the localauthority with jurisdiction, depending on the type of hazardand extinguisher.12,45 Fire extinguishing equipment andsupplies should be regularly inspected, tested, andmaintained.12,45

Gas Control ValvesTurning off the gas supply to a room can help contain a firebecause removing the oxidizer (source of oxygen) helps breakthe fire triangle.22,24 Shut-off valves are used to stop the flowof gases into ORs.43 Gas control panels are usually located inthe hallway near each OR. There is usually a different valvefor each type of gas used in the room; however, facilitypolicies and procedures should specify who has the authorityto decide when the gas supply to a room should be turned off.Generally persons with this authority are anesthesiaprofessionals.12,43 Circulating registered nurses and otherpersonnel should only turn off the gas supply to a room if theyhave been directed to do so by a designated staff member.12

Perioperative registered nurses and other personnel shouldrecognize medical gas control valves and the areas theycontrol.12 In addition, medical and other equipment such ascarts, stretchers, and beds should not be placed in locationsthat block access to medical gas control valves, pull alarms,or electrical panels.12,42

EvacuationEvacuation in the event of OR fire is rarely necessary;however, a specific set of steps should be performed in in theevent an evacuation is required.12 A useful mnemonic forremembering these steps is RACE, which stands for Rescue,Alarm, Contain, and Evacuate if needed.4

If a designated professional determines the need to evacuate,perioperative personnel should first perform Rescue byremoving patients and staff from the site of fire.4 Patientsshould be carried or transported on procedure beds or gurneysif necessary. Patients should be initially evacuated to a safeplace that is located beyond the first set of smoke barriers.

After rescue, the Alarm at the pull station should be activatedto alert all personnel in perioperative areas, particularlyadjacent rooms, to the presence of fire.4

The next step is to Contain (or confine) the fire.4 The ORdoors should always be kept closed,4 and should be closed aspersonnel leave the room. Containing a fire also means turningoff the electrical and medical gas supply to the affected roomor rooms.

Finally, the entire operating suite should be Evacuated if fire,smoke, and/or fumes pose a danger to patients in adjoiningareas.4 Examples of situations that could merit evacuationinclude a drape fire on the floor that has not been extinguishedor a fire in the overhead lights.4 Patients and personnel shouldbe evacuated to a designated area that is beyond the first setof smoke barriers. Health care providers should go to theclosest safe location where they can resume caring for

patients.12,24 Personnel should follow additional facilityguidelines and designated evacuation routes.12

Evacuation routes should be developed in collaboration withlocal authorities, guided by NFPA regulations, and clearlyposted in multiple locations.12,42 Health care personnel andemergency responders should be educated about how toimplement the evacuation plan, which should specify the rolesand responsibilities of personnel in the event ofevacuation.12,22

CONCLUSION AND RESOURCESOperating room fires pose a serious risk to the safety ofpatients and personnel. The risk of surgical fires persists inmodern ORs because perioperative and other invasiveprocedures commonly involve all three elements of the firetriangle – fuel, heat, and oxygen. An OR fire can cause death,injury, or substantial property damage within seconds tominutes after ignition. To prevent OR fires, perioperativeregistered nurses and their colleagues need to implementrecommended practices to prevent fires and collaboraterapidly and effectively to extinguish fires on, in, or nearpatients. In the event of an evacuation because of fire,perioperative personnel are responsible for rescuing patientsand staff, activating alarms, containing the fire, and evacuatingpersons at risk if needed.

To carry out these responsibilities, perioperative personnelneed to understand the components of the fire triangle andhow they interact to start a fire, recognize their own and teammember roles and responsibilities in the event of fire, andcommunicate effectively with colleagues to perform fire riskassessments and alert team members of hazards or thepresence of a fire.

The AORN fire safety toolkit and additional AORNpublications provide numerous resources for OR managers,nurse educators, and other personnel tasked with fire safetyplanning, education, and competency evaluations. These toolsare available to AORN members at the AORN website,www.aorn.org.


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REFERENCES1. National Fire Protection Association. Fires in health care facilities. http://www.nfpa.org/research/statistical-

reports/occupancies/fires-in-health-care-facilitiesn Accessed October 10, 2013.2. ECRI. Surgical fire prevention. https://www.ecri.org/Products/Pages/Surgical_Fires.aspx Accessed October 12,

2013.3. Watson DS. Surgical fires: 100% preventable, still a problem. AORN J. 2009;90:589-593.4. Everson, CR. Fire prevention in the perioperative setting. In: Watson DS, ed. Perioperative Safety. St Louis:

Mosby; 2011:172-199.5. Brown TC. Farewell! flammable agents – ether and cyclopropane. Paediatr Anaesth. 2013;23:195-196. 6. Thomas G. Fire and explosion hazards with flammable anesthetics and their control. J Natl Med Assoc.

1960;52:397-403.7. Apfelbaum JL, Caplan RA, Barker SJ, Connis RT, Cowles C, Ehrenwerth J, Nickinovich DG, Pritchard D,

Roberson DW, Caplan RA, Barker SJ, Connis RT, Cowles C, de Richemond AL, Ehrenwerth J, Nickinovich DG,Pritchard D, Roberson DW, Wolf GL; American Society of Anesthesiologists Task Force on Operating RoomFires. Practice advisory for the prevention and management of operating room fires: an updated report by theAmerican Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology. 2013;118:271-90.

8. Culp WC, Kimbrough BA, Luna S. Flammability of surgical drapes and materials in varying concentrations ofoxygen. Anesthesiology 2013; 119(4): 770-776.

9. Mehta SP, Bhananker SM, Posner KL, Domino KB. Operating room fires: a closed claims analysis.Anesthesiology. 2013;118:1133-1139.

10. Kaddoum RN, Chidiac EJ, Zestos MM, Ahmed Z: Electrocautery-induced fire during adenotonsillectomy: Reportof two cases. J Clin Anesth. 2006;18:129-131.

11. Moskowitz M. Fire in the operating room during open heart surgery: a case report. AANA J. 2009;77:261-264.12. Recommended practices for a safe environment of care. In: Perioperative Standards and Recommended Practices.

Denver, CO: AORN, Inc; 2013:217-242. 13. Smith LP, Roy S. Operating room fires in otolaryngology: risk factors and prevention. Am J Otolaryngol.

2011;32:109-114.14. Esser AC, Koshy JG, Randle HW. Ergonomics in office-based surgery: a survey-guided observational study.

Dermatol Surg. 2007;33: 1304-13; discussion 1313-4. 15. 29 CFR 1910.1200 Hazard Communication.

https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10099 Accessed October25, 2013.

16. Purdue University. How to read and understand a material safety data sheet.https://engineering.purdue.edu/ECE/Safety/RTK/msds_info.pdf Accessed October 20, 2013.

17. Barker SJ, Polson JS. Fire in the operating room: a case report and laboratory study. Anesth Analg. 2001;93:960-965.

18. Meltzer HS, Granville R, Aryan HE, Billman G, Bennett R, Levy ML. Gel-based surgical preparation resulting inan operating room fire during a neurosurgical procedure: case report. J Neurosurg. 2005;102:347-349.

19. Rocos B, Donaldson LJ. Alcohol skin preparation causes surgical fires. Ann R Coll Surg Engl. 2012;94:87-89.20. Weber SM, Hargunani CA, Wax MK. DuraPrep and the risk of fire during tracheostomy. Head Neck. 2006;28:649-

52.21. CareFusion. ChloraPrep with tint 3mL applicator.

http://www.carefusion.com/pdf/Infection_Prevention/Labels/3mL_Orange_Label_260415.pdf. Accessed February24, 2014.


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22. Bielen RP, Lathrop JK. Health Care Facilities Code Handbook. 9th ed. Quincy, MA: National Fire ProtectionAssociation; 2012.

23. Electronic Code of Federal Regulations: Occupational safety and health standards. 29 CFR 1910.48.http://www.ecfr.gov/cgi-bin/text-idx?c=ecfr&sid=a2957f4bc33030914c70c953dfa0ca4a&rgn=div8&view=text&node=29:6.1.1.1.1.1.1.31&idno=29 Accessed October 25, 2013.

24. ECRI. New clinical guide to surgical fire prevention. Health Devices. 2009;38: 314-332. 25. Chapp K, Lange L. Warming blanket head drapes and trapped anesthetic gases: understanding the fire risk. AORN

J. 2011;93:749-760. 26. Roy S, Smith LP. What does it take to start an oropharyngeal fire? Oxygen requirements to start fires in the

operating room. Int J Pediatr Otorhinolaryngol. 2011;75 227-230. 27. ECRI. Fighting airway fires. https://www.ecri.org/Documents/RM/HRC_TOC/SurgAn10ES.pdf Accessed October

24, 201328. Waters T, Spera P, Petersen C, Nelson A, Hernandez E, Applegarth S. AORN Ergonomic Tool 3: lifting and

holding the patient’s legs, arms, and head while prepping. AORN J. 2011;93:589-592. 29. Nishiyama K, Komori M, Kodaka M, Tomizawa Y. Crisis in the operating room: fires, explosions and electrical

accidents. J Artif Organs. 2010;13:129-133. 30. AORN. 2013 AORN Fire Safety Toolkit: Fire Prevention in the Perioperative Practice Setting.

http://www.aorn.org/Clinical_Practice/ToolKits/Fire_Safety_Tool_Kit/Supporting_Documents/Fire_Prevention_Slideshow.aspx Accessed October 26, 2013.

31. Rinder CS. Fire safety in the operating room. Curr Opin Anaesthesiol. 2008;21:790-795. 32. Thomas GP, Willson PD. Electrosurgery ignition of a pneumoperitoneum secondary to prior spontaneous

perforation of the small bowel: a cautionary tale. Ann R Coll Surg Engl. 2012;94:e70-133. AORN. Recommended practices for minimally invasive surgery. In: Perioperative standards and recommended

practices. Denver, CO: AORN;2012:143-176.\34. ECRI. Reducing the risk of burns from surgical light sources. Risk Management Reporter. 2009;28(6): 15-17.35. ECRI. Electrosurgical safety: Conducting a safety audit. Health Devices. 2005;34:414-420.36. ECRI. Ignition of debris on active electrosurgical electrodes. Health Devices. 1998;27:367-701.37. http://www.valleylab.com/education/hotline/pdfs/hotline_0706.pdf . Accessed October 26, 2013.38. ECRI. Laser safety. https://www.ecri.org/Documents/RM/HRC_TOC/SAQ18.pdf Accessed October 26, 2013.39. Laudanski K, Schwab WK, Bakuzonis CW, Paulus DA. Thermal damage of the humidified ventilator circuit in the

operating room: an analysis of plausible causes. Anesth Analg. 2010;111: 1433-1436. 40. ECRI. Hazard report: Prevent surgical boom fires with routine maintenance. Health Devices. 2008;37:24-26.41. Kuczkowski KM. Anesthesia machine as a cause of intraoperative “code red” in the labor and delivery suite. Arch

Gynecol Obstet. 2008;278: 477-478. 42. National Fire Protection Association. NFPA 101: Life Safety Code. [Quincy, MA]: National Fire Protection

Association; 201243. Hart SR, Yajnik A, Ashford J, Springer R, Harvey S. Operating room fire safety. Ochsner J. 2011;11:37-42.44. Berendzen JA, van Nes JB, Howard BC, Zite NB. Fire in labor and delivery: simulation case scenario. Simul

Healthc. 2011;6: 55-61.45. National Fire Protection Association. Technical Committee on Portable Fire Extinguishers. NFPA 10: Standard for

Portable Fire Extinguishers. 2010 ed. Quincy, MA: National Fire Protection Association; 2010.


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1. The average estimated number of surgical firesevery year in the United States isa. 20 to 30b. 200 to 240c. 700 to 1000d. 2000 to 2500e. 2500 to 2700

2. Choose the FALSE statement about perioperativefire prevention and management plans.a. They should be developed by a

multidisciplinary group of key stakeholders.b. They should describe key content and

frequency of fire safety education activities.c. They should specify policies and procedures

for fire prevention and response.d. They generally are not needed unless required

by a health care facility’s insurance policy.e. They should specify team member roles and

responsibilities during fire prevention andresponse.

3. The three components of the fire triangle areoxidizing source, ignition source, and fuel source.a. Trueb. False

4. The three overriding principles of operating roomfire safety are a. awareness, communication, teamworkb. oxidizing source, heat source, fuel source c. inspect, check, respond d. prevent, extinguish, evacuatee. source, extinguish, safety

5. Examples of ignition sources includea. electrocautery units and active electrosurgical

electrodesb. fiber-optic light cordsc. lasersd. a and ce. a, b and c

6. A fire risk assessment should be performeda. only before procedures involving

electrocautery, an electrosurgical unit, or alaser

b. only if requested by the surgeon or firstassistant

c. before all operative proceduresd. only before surgical procedures above the

xiphoid process and in the nasopharynxe. only if the patient requires more than 30%

supplemental oxygen

7. The flash point of flammable materials is ________,while the flash point of combustible materials is_____________

a. less than 100° F, greater than 100° Fb. greater than 100° F, less than 100° F c. equal to 100° F, greater than 100° Fd. less than 120° F, greater than 120° Fe. greater than 120° F, less than 120° F

8. Oxidizing sources in the operating room includea. oxygenb. nitrous oxidec. carbon dioxided. a and be. a, b and c

9. Fuel sources in the operating room includea. gauze spongesb. floor gluec. ceiling tiled. scrubse. surgical instruments

10. Perioperative registered nurses and scrub personnelhave primary control over which component of thefire triangle during an operating or other invasiveprocedure?a. oxidizing sourcesb. fuel sourcesc. ignition sourcesd. a and be. a and c

POST-TEST


Multiple choice assessment. Select the response that best answers each question.

11. Choose the FALSE statement about fire risks in theoperating room.a. Patients with their heads draped are at

increased risk of fire because supplementaloxygen can accumulate under drapes.

b. Substances that would not ignite in room ormedical air can do so in an oxygen-enrichedenvironment, which may occur in theoperating room.

c. Evaporated gases from flammable prepsolutions can ignite, especially if they areallowed to accumulate under drapes.

d. Bowel surgeries are associated with thehighest risk of surgical fires.

e. A piece of equipment that is smokingunexpectedly represents an immediate firerisk.

12. Fire blankets should NOT be used in the operatingroom because theya. are made of wool, which can catch fire in an

oxygen-enriched environmentb. can cause wound contamination or move

instruments at the surgical sitec. can trap fire next to or under a patientd. all of the abovee. b and c

13. Which of the following fire safety practices shouldbe implemented when a laser is used duringsurgery?a. keep wet towels and saline on the sterile fieldb. place moist sterile towels, sponges, and drapes

around the surgical sitec. use standard endotracheal tubes for upper

airway procedures involving laserd. allow fumes from flammable solutions to

dissipate before activating the lasere. a and b onlyf. a, b, and c onlyg. a, b, and d onlyh. a and d onlyi. c and d only

14. Which type of fire extinguisher is most appropriateto extinguish a fire on or in a patient?a. carbon dioxide extinguisher b. ammonium phosphate or other dry powder

extinguisherc. water mist extinguisherd. foam extinguishere. a or c

15. Patients and personnel must be evacuated becauseof an operating room fire. The proper order of stepsto take isa. alarm, confine/contain, rescue, evacuateb. rescue, alarm, confine/contain, evacuatec. rescue, evacuate, alarm, confine/containd. confine/contain, alarm, rescue, evacuatee. alarm, rescue, evacuate, confine/contain

16. If evacuated because of a fire, health care personnelshould goa. to the front doors of the buildingb. outside the buildingc. behind at least two sets of fire doorsd. to the nearest stairwelle. to the nearest safe location where they can

resume caring for patients

17. A scrubbed perioperative registered nurse observesa fire start on a patient in the operating room. Afteralerting the team, the nurse should immediatelya. obtain and operate the nearest fire

extinguisher by using the PASS techniqueb. pat the flames with a drapec. smother the fire with a towel or pour

nonflammable liquid on the fired. lift the patient and transport him or her out of

the roome. turn off the oxygen source


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18. Which practice is NOT recommended to preventfires during surgeries at high-risk sites?a. use an ignition source to enter gas-distended

bowelb. pack the back of the throat with radiopaque

sponges prior to tonsillectomyc. stop supplemental oxygen or nitrous oxide for

one minute before using an ignition sourced. place an adhesive incise drape between the

surgical site and the oxygen sourcee. inflate endotracheal tubes with tinted solutions

prior to tracheotomy

19. If an airway fire occurs, perioperative team membersshould be prepared to help the anesthesiaprofessional do which of the following a. disconnect and remove the anesthesia circuit

and turn off the flow of oxygenb. remove the endotracheal tube from the airway,

including any burned fragments c. pour saline or water into the airway d. examine and re-establish the airway e. assess the surgical field for secondary firef. all of the above

20. All of the following are appropriate practices tomanage oxidation sources in the operating roomEXCEPTa. administer the lowest concentration of oxygen

needed to maintain adequate oxygensaturation

b. use a laryngeal mask or endotracheal tube ifthe patient needs more than 30% supplementaloxygen

c. ensure that there are no leaks in the anesthesiacircuit

d. turn the warmer blower off when using awarming blanket with an attached head drape

e. prevent oxygen from accumulating underdrapes


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POST-TEST ANSWERS


1.b2.d3.a4.d5.e6.c7.a8.d9.a10.b11.d12.d13.g14.a15.b16.e17.c18.a19.f20.d


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