A fire that occurs in the operating room (OR) area is an obvious emergency with potentially devastating consequences. Not only are patients at risk, but staff as well, including surgeons, anesthesiologists, nurses, and other support personnel. Patients are especially vulnerable, however, because they are unable to flee or take shelter, or otherwise take any steps to protect themselves from the effects of an OR fire. Consequently, fire prevention and the response, should a fire occur, is everyone’s responsibility.

There are essentially two mechanisms of injury due to fire. The first is thermal injuries, that is, burns, and the second is from smoke inhalation. Burns cause direct injury to skin and underlying tissues, while smoke injury results in lung injury that can compromise respiratory function. Fires in the OR can be caused by a variety of sources, but all fires share one common characteristic: three elements must be present for a fire to occur. This is known as the fire triangle (Fig. 62.1). For a fire to occur, there must be a fuel, an ignition source, and an oxidizer (Table 62.1). Preventing OR fires is addressed in detail in the chapter on fire safety (Chapter 52); however, prevention essentially comes down to eliminating one or more elements from the fire triangle. For example, limiting the amount of oxygen will eliminate the risk of combustion in many circumstances. Alternatively, eliminating the fuel, such as removing an endotracheal tube (ETT) from the airway during laser surgery, or the source of heat, such as ensuring that fiber-optic light sources are not placed on surgical drapes, will also prevent a fire from occurring.

Several different types of fires can occur in the OR. One of the most concerning is the airway fire. This occurs most commonly when a laser is used to perform surgery in the airway, but it can also result when an electrosurgical device is used during airway surgery, for example, tracheostomies. The laser or electrosurgical device serves as the ignition source, an ETT is the usual fuel, and oxygen (or a combination of oxygen [O₂] and nitrous oxide [N₂O]) flowing through the ETT is the oxidizing agent. These fires produce both a thermal injury to the airway from the blowtorch-like flame that comes out the end of the ETT and injury to the lungs from the toxic products of combustion of the ETT (Fig. 62.2). A second type of fire involves the ignition of surgical drapes or other flammable materials, such as gauze or towels. These fires may be ignited by lasers, electrosurgical devices, or light sources, such as from a headlamp or laparoscopic instrument, usually in the presence of an oxygen-enriched atmosphere. Finally, the patient can also be directly involved in a fire, such as when alcohol-based surgical prep solutions remain on the patient. Once ignited, a fire can spread rapidly to other areas of an OR and, if not immediately managed, pose a threat to all present. It may even extend beyond the room in which it began.

The generic response to a hospital fire is encapsulated in the acronym RACE: Rescue, Alarm, Contain, and Evacuate (or Extinguish). The first priority is to rescue the patient, removing him or her from the dangerous situation. Several rescuers will likely be needed. However, it is not recommended that rescuers place themselves at severe risk. Second, sound the alarm; alert others as to what is happening. Nearby staff should be aware of what is happening, and kept informed in case they will need to evacuate their patients. In addition, fire alarm systems should be activated. Often, these will summon assistance from within the facility, and may also
call the fire department. Next, efforts should be made to contain and control the situation, such as by closing fire doors. Medical gas valves should be shut off, and air duct dampers can help to prevent the spread of smoke. Central smoke evacuator systems (used to remove surgical smoke) should also be shut off. Also, electrical power should be shut off at the circuit-breaker panel, as this will prevent electrical fires from being sustained, and reduce the risk of an electrical shock. Finally, an attempt may be made to extinguish the fire; however, it may be necessary instead to first evacuate patients and any personnel from the area. The evacuation should be orderly and patients taken to a preplanned area.

In the OR the response may be somewhat different, however, depending on the specific type of fire. The response will also depend on the extent of the fire. Does it involve only the patient, or a single OR room? Is the entire suite of ORs involved, or the larger facility, such as a hospital or freestanding surgical center? The consequences of a fire in the OR are several. The risk of injury has already been mentioned. In addition, there are costs due to damage from the fire: damaged equipment and facilities, for example. There is also the impact on OR operations, including whether they can continue on that day or whether damage has been extensive enough to curtail operations for an extended period of time.

The response to a fire in the OR will depend on the type of fire. Each of these will be considered separately below, although it may not be possible to specify every possible type of fire that can occur in the OR. Regardless, if any type of fire occurs, it should be quickly announced so that the entire surgical team is aware that there is a fire. The easiest fire to deal with is one that is small and confined to a specific area, for example, a gauze pad that has been ignited. If the fire
is not on the head or neck, and the full extent of the fire is easily seen, it is reasonable to pat it out or smother it with a gloved hand or towel, thus extinguishing it. It is still important to check for embers or smoldering material that could reignite, especially if there is a possibility of an enriched oxygen atmosphere.