Fatal inhalation injury caused by airway fire during tracheostomy

University of Helsinki, Helsinki, Uusimaa, Finland
Acta Anaesthesiologica Scandinavica (Impact Factor: 2.32). 05/2007; 51(4):509-13. DOI: 10.1111/j.1399-6576.2007.01280.x
Source: PubMed


A 45-year-old man needed emergency tracheostomy and cranioplasty. He was intubated with a cuffed oral polyvinylchloride endotracheal tube and ventilated with 100% oxygen before tracheal incision. During opening of the trachea using diathermy, a popping sound was heard and flames originating from the tracheal incision were observed. The endotracheal tube was charred and its lumen had melted. Immediately after the incident, bronchofibroscopic examination revealed inhalation injury. After remaining for 8 weeks in hospital, the patient was transferred to a health care centre, where he was found dead in his bed.

Download full-text


Available from: Virve Koljonen,

  • Acta Anaesthesiologica Scandinavica 12/2007; 51(10):1406. DOI:10.1111/j.1399-6576.2007.01458.x · 2.32 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Flash fires, mucosal injuries and commissure burns during otolaryngology procedures have been largely attributed to anesthetic and surgical errors. Reports of direct electrosurgical device related events are rare. The discovery of thermal damage to the oral commissure during routine suction cautery adenoidectomy at our institution prompted a detailed investigation of the device's thermal properties. We complement this analysis with a review of electrocautery device related injuries reported in otolaryngology literature. FLIR Systems Thermovision A40 infrared camera was used to evaluate temperature changes along the electrosurgical wand of suction cautery devices. Shaft temperatures were measured at specific times of continuous use, distances along the shaft, and cautery settings. A literature search of electrocautery-associated injuries during upper aerodigestive procedure was then performed. Nine pediatric otolaryngologists were then interviewed for historical experience with electrocautery injuries. Temperatures exceeding 60 degrees C, and sufficient to cause thermal soft tissue damage, occurred along the suction cautery wand at a setting of 40 Watts (W). These temperatures traveled far enough to appose the oral commissure when the device was simultaneously in continuous use, in the fulgurate mode, and with the suction turned off. Literature review identified eleven articles specifically pertaining to electrosurgical injuries during routine oropharyngeal procedures. Flash fires and their associated burns were the most frequently reported complication. Conversely, seven of ten cases elicited from peer interviews were oral or commissure burns attributed to improper insulation of electrocautery devices. Inadvertent electrosurgical injuries during routine otolaryngology procedures can result from inadequate equipment insulation. Techniques to reduce the likelihood of these events are discussed.
    International Journal of Pediatric Otorhinolaryngology 08/2008; 72(7):1013-21. DOI:10.1016/j.ijporl.2008.03.006 · 1.19 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Elimination of flammable anesthetic gases has had little effect on operating-room fires except to change their etiology. Electrocautery and lasers, in an oxygen-enriched environment, can ignite even the most fire-resistant materials, including the patient, and the fire triad possibilities in the operating room are nearly limitless. This review will: identify operating room contents capable of acting as ignition/oxidizer/fuel sources, highlight operating room items that are uniquely potent fire triad contributors, and operating room identify settings where fire risk is enhanced by proximity of triad components in time or space. Anesthesiologists are cognizant of the risk of airway surgery fires due to laser ignition of the endotracheal tube and/or its contents. Recently, however, head/neck surgery under monitored anesthesia care has emerged as a high-risk setting for operating room fires; burn injuries represent 20% of monitored anesthesia care-related malpractice claims, 95% of which involved head/neck surgery. Operating room fires are infrequent but catastrophic. Operating room fire prevention depends on: (a)understanding how fire triad elements interact to create a fire, (b) recognizing how standard operating-room equipment, materials, and supplemental oxygen can become one of those elements, and (c) vigilance for circumstances that bring fire triad elements into close proximity.
    Current opinion in anaesthesiology 01/2009; 21(6):790-5. DOI:10.1097/ACO.0b013e328318693a · 1.98 Impact Factor
Show more