Flash and Flame at the Endotracheal Tube
A 7-year-old is undergoing adenotonsillectomy. Anesthesia is delivering 60% oxygen with 50% nitrous oxide through an uncuffed endotracheal tube; there is an audible leak around the tube. The surgeon uses monopolar electrocautery in the tonsillar fossa with a moistened sponge nearby. Suddenly a flash and flame appear at the tube and mouth area, and the surgeon pulls back. The monitor shows SpO2 99%, but you can see charring on the tube. The room goes quiet and everyone looks at you.
1. State your immediate priorities and assign each team member's role for the next 30 seconds.
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A fire on the patient means removing one leg of the fire triad as fast as possible - and on a patient, that leg is the oxidizer.
Roles, called out loud:
- Anesthesia: stop the oxygen and nitrous oxide, disconnect the breathing circuit from the tube, and remove the burning tube if it is still in the airway. Ventilation resumes with air or the lowest effective FiO2 once the fire is out.
- Surgeon: stop electrocautery, withdraw from the field, and be ready to reassess the airway and oropharynx.
- Scrub person: flood the surgical field and the patient with saline - saline, not a CO2 extinguisher, on the patient.
- Circulator: shut off the electrocautery unit, and if the fire is not immediately out, shut the oxygen at the wall valve; call for help and bring the fire extinguisher for drapes or room, not for the child.
I would say the sequence out loud once: 'Stop the gas, disconnect, saline, cautery off.' The reason to be that explicit is that the instinct in a quiet room is to freeze or to reach for the extinguisher, and both cost seconds that matter in an airway fire.
2. The fire is out. What is your immediate post-event assessment and plan?
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A fire in a 60% oxygen airway has almost certainly caused thermal injury to the trachea and possibly the bronchial tree, and the child is at risk for edema, soot, and obstruction over the next hours - not only in the next minutes.
- Airway first: reintubate if the tube was removed, using the smallest appropriate tube and a lower FiO2 now that the fire is out, and prepare for a difficult airway since edema will progress. Bronchoscopy to assess the extent of injury and remove soot and debris.
- Ventilation and oxygenation: monitor for bronchospasm and hypoxia; anticipate that the injury may look mild initially and worsen.
- Disposition: this child is no longer an ambulatory or short-stay patient - plan for ICU-level monitoring and a conversation with the family.
- Preserve the evidence: keep the tube and cautery tip, do not discard them.
The judgment point is resisting the relief that follows 'the fire is out.' The injury that kills these patients is airway edema and mucosal damage discovered hours later.
3. What goes in the documentation and event review, and what system factors would you examine?
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Documentation: an objective, timed narrative - what was burning, when it was recognized, who did what, how it was extinguished, the device settings and gas concentrations, the airway interventions, and the family notification. An incident report is filed separately per policy and is not referenced in the chart.
Review the fire triad rather than blaming an individual:
- Oxidizer: why 60% oxygen with nitrous oxide for a tonsillectomy? Was the lowest effective FiO2 used, and was the leak around the uncuffed tube addressed (a cuffed tube or better fit)?
- Ignition: could cautery have been avoided or the tip kept clear; was a wet sponge actually between the cautery and the tube?
- Fuel: were alcohol-based preps fully dry; was the tube type appropriate?
Also examine the human factors: does every circulating nurse know where the wall oxygen shutoff and saline are, and has the team ever practiced this? A fire drill that has been rehearsed is the difference between 10 seconds and 2 minutes.