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Respect the Triangle, Stop the Spark

Fires don't make triangles, they make flames... and a beautiful, warm glow on crisp, fall evenings as friends huddle together around the warmth of a campfire, right? Absolutely! And when the conditions are right, we all love a crackling bonfire, its cozy warmth, a cup of hot cider, and roasting marshmallows over a golden flame.

Experiences like these are what memories are made of, because fire, in a controlled environment, is beautiful. It's cozy. It provides warmth and light to anyone near it. But it's also powerful, a raging force consuming everything in its path with an unmatched ferocity and terror.

When we think of fires, we might think of the cozy glow from the campfire, or even the powerful force of nature that consumes everything in its path as it devours homes and acres of land. But how often do you think of a fire in the operating room?

It's true that fires are a rare event in the operating room, but they do still happen. According to the ECRI Institute, it is estimated that 550-600 surgical fires occur every year. (source) But regardless of how often they might occur, a surgical fire is always devastating - for the patient, the surgical staff, and the facility.

Which is why education is the key to these preventable disasters. All of the surgical team, from the surgeon and anesthesiologist, to the circulator and scrub, to the other staff within the department MUST know what is required of them should a fire occur. Equally as important, however, is that all of these same team members know what role they play in fire prevention.

And that's where the fire triangle comes in. The picture of a triangle is a simple way of understanding the different elements of fire, with the three sides representing the three elements needed for a fire to occur. In the operating room, a fire can occur any time all three of the following elements are present:

  1. Ignition Source

  2. Fuel Source

  3. Oxidizer

Ignition Source

What do we have in the operating room that is considered an ignition source? Electrosurgical units, fiberoptic light sources, lasers, defibrillators, and high-speed drills are a few examples of the ignition sources we work with every single day. Typically, the surgeon is operating the ignition source, but everyone needs to be aware that these units are part of the fire triangle.

Fuel Source

If it can burn, it's a fuel source. Drapes, linens, towels, hoods, clothing, hair, and skin are a few of the most obvious examples. Another serious fire risk, and fuel source, is the alcohol-based skin prep we're using for skin antisepsis. Allowing the prep to pool, or not allowing it to dry before using an electrocautery unit can spell disaster for your patient, and potentially your operating room.


Oxygen is the most common oxidizer, but nitrous oxide is a major oxidizer in the operating room as well. "The importance of oxygen content cannot be overemphasized as studies have revealed that nearly all objects can become fuel for a fire once the oxygen content increases to greater than 30%. Emphasis on oxygen delivery is critical not only because of increasing flammability but also because of increased rates of injury when operating close to an oxygen source and/or airway. A review of operating room fire claims found that 85% of fires occurred in the head, neck, or upper chest, and 81% of cases occurred with monitored anesthesia care." (source)

Respect the Triangle

A respected weatherman in Alabama, James Spann, is famous for telling his viewers to "respect the polygon" when he reports on tornadoes. Alabama gets ALOT of tornadoes. But in the operating room, we need to "respect the triangle." Not because we have so many surgical fires, but because we want to prevent them.

We need a foundational understanding of the components of the fire triangle, and we need to know how the equipment, soft goods, and chemicals within our OR build the fire triangle. We also must know how our actions can prevent these elements from coming together to spark a fire.

Here are a few examples:
  • Your team briefing and timeout should include the fire risk for the procedure

  • Alcohol-based skin preps must be dry before draping, with no solution allowed to pool under the drapes (follow the manufacturer's IFU for appropriate dry times)

  • Have sterile water/saline available on the back table

  • Minimize the use of open oxygen (mask/cannula) and keep oxygen concentration under 30%

  • Use a blender to mix oxygen and room air

  • Only activate the ESU, or "Bovie," when the tip is in view, and always use the holster

  • Light sources should always be on stand-buy before use and off before disconnecting

  • Remember that high-speed drills can cause a spark

  • Remember that defibrillators give off electric current that could create a spark

Surgical fires are preventable. Learn how the fire triangle comes together in the operating room to cause a fire, and respect the triangle!

Until next time,

Lindsey & Melanie

This blog post is the first in a three-part series brought to you by the OR Experts at First Case - Brenna Page, Melanie Perry, and Lindsey Joyce. Check back next week for part two!

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