Airway fire during open tracheostomy74-year-old man, 82 kg, ventilated in ICU for 12 days after pneumonia
From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.
Know this first
- A fire needs three things: fuel, something to ignite it, and an oxidiser.
- Tracheostomy is a high-risk fire procedure.
- If over 30% oxygen is needed, cut it below 30% before diathermy; exhaled oxygen can take 5–6 minutes to fall at low flows.
- Advise the surgeon not to enter the trachea with diathermy.
- Airway fire: tube out, gas off, flammables out, saline in; then ventilate and bronchoscope.
The patient
The examiner asks
Answer aloud, then press Show.
Consider
What are your concerns?
Show the answerHide the answer
- A 74-year-old ICU patient on FiO2 0.6, for an open tracheostomy with diathermy. Patient
- At 74, after 12 days ventilated and on noradrenaline, he has no reserve for a lost airway.
- Tracheostomy is a high-risk fire procedure: diathermy beside an oxygen-rich airway. Surgery
- His fire triad: tube and drapes as fuel, diathermy to ignite, his oxygen to feed it.
- He needs FiO2 0.6, so cutting oxygen below 30% may not be possible. Disease
Prepare
How do you reduce the fire risk?
Show the answerHide the answer
- Team brief: everyone's role in a fire agreed; saline ready on the field. (Surgery)
- Surgeon asked not to open the trachea with diathermy; cold scalpel for the tracheal wall.
- Before any diathermy, oxygen lowered to the least he tolerates, and I wait a few minutes.
- Exhaled oxygen falls slowly; at low flows it can take 5–6 minutes.
- No nitrous oxide; prep solution dried before draping.
Plan
Take me through the airway at the moment of tracheal entry.
Show the answerHide the answer
- TIVA and full relaxation, with his ICU ventilator settings matched. (Airway)
- Surgeon tells me before entering the trachea; I confirm I have heard.
- Oral tube withdrawn under vision until its cuff sits just above the stoma.
- Tracheostomy tube in, capnography confirmed, before the oral tube comes out.
- Spare tubes, a bougie and a flexible scope on hand.
Crisis
As the trachea is opened with diathermy, a flame shoots from the stoma. What do you do?
Show the answerHide the answer
- Airway fire: I say it aloud; diathermy and surgery stop. Crisis
- Gas flow off and circuit disconnected, and the burning tube pulled out at once.
- Sponges and burnt material out; saline poured into his airway.
- Ventilate again through the stoma with a new tube, at the least oxygen he tolerates.
- The removed tube is checked for pieces left in his airway.
- Bronchoscopy for burns and debris; check for carbon monoxide and cyanide exposure.
- Back to ICU; burns or ENT review, incident report and team debrief. After surgery
Fatal mistakes
- Diathermy into the trachea with a high oxygen concentration.
- Gas flow continued during an airway fire.
- Ventilating before saline has gone into the airway.
- No bronchoscopy after the fire.
Checked against: Practice Advisory for the Prevention and Management of Operating Room Fires: An Updated Report by the American Society of Anesthesiologists Task Force on Operating Room Fires (2013) · Prevention of and response to surgical fires (2019)
Report a problem with this case
Mark Got it only if you said every point. Again brings the case back tomorrow; Got it brings it back in 3, then 7, 14 and 30 days.