Cause of Device-Related Incident
Device factors; User errors

Clinical Specialty or Hospital Department
CCU / ICU / NICU; Emergency Medicine; Nursing; Radiology / Ultrasound / Nuclear Med.

Device Factors
Device interaction

Document Type
Hazard Reports

External Factors
*Not stated

Mechanism of Injury or Death
Fire

Support System Failures
*Not stated

Tampering and/or Sabotage
*Not stated

User Errors
Incorrect clinical use

UMDNS
Defibrillator/Monitors [11-129]; Defibrillator/Monitors, Line Powered [15-029]; Defibrillators [11-132]; Defibrillators, Battery Powered [11-134]; Defibrillators, Line Powered [11-137]

Defibrillation in Oxygen-Enriched Environments



Hazard [Health Devices Mar-Apr 1987;16(3-4):113]

Problem

A member hospital reported that a fire occurred after a lengthy (40 min), unsuccessful resuscitation attempt on a cardiac arrest patient. The fire was confined to the patient's treatment cubicle, but the spread of noxious smoke forced the evacuation of the entire ICU. The patient had been declared dead moments before the fire was observed, and no other patients or personnel were injured as a result of the incident. The fire destroyed the ventilator that had been attached to the patient prior to defibrillation, charred the CPR board under the patient, and caused smoke damage to the patient monitor suspended over the bed.

Discussion

A review of the incident by hospital and municipal fire department personnel suggested that the fire was ignited by an arc seen at one of the external defibrillator paddles during the fifth and final defibrillation attempt. The arc may have shunted to an ECG lead draped over the patient's shoulder and ignited a small area in the bedsheet.

Hospital personnel believe that inadequate pressure on the paddles may have caused the arcing. They also determined that a member of the resuscitation team had disconnected the ventilator tubing from the patient's endotracheal tube before the first defibrillation attempt. In the haste of the rescue effort, the tubing was left on the bed near the patient's chest and an ECG lead. During the resuscitation attempt, the ventilator continued to deliver 100% oxygen through the tubing at an approximate rate of 75 L/min, creating an unsuspected oxygen-enriched environment. After the bedsheet ignited, the fire quickly spread through the tubing to the ventilator and along the hose connecting the ventilator to the wall-mounted oxygen supply assembly.

Failure to use proper defibrillation technique and to prevent high concentrations of oxygen from collecting near a patient prior to defibrillator discharge increases the risk of a fire. Such a fire could seriously injure the patient or attending staff, delay or terminate the resuscitation attempt, damage or destroy medical devices, and threaten the safety of others in the area.

As a result of the reported incident, the hospital has rewritten its protocol for advanced cardiac life support to help its attending staff mitigate the increased risk of fire when defibrillating a patient in the presence of oxygen.

Because incomplete details about this fire are available, we are unable to verify the hospital's conclusions about its cause. We have previously discussed precautions to take when defibrillating a patient receiving oxygen (see Health Devices 9:48 (December 1979)). The Canadian Bureau of Medical Devices study referenced in this article concluded that arcing is more likely to occur when the paddles are tipped (this reduces the surface area of the paddle electrode contacting the patient's chest) or when inadequate pressure is applied to the paddles (this increases impedance, which increases the risk of arcing). An ECG electrode may become the target of an arc generated at a defibrillator paddle when an excess of gel is under the electrode (this forms a conductive bridge), when saline pad impedance is greater than 10W , when the electrode becomes saturated with conductive fluid, if the electrode is poorly insulated on its external surface (button snap-on type), or if saline solution or gel gets on the electrode's upper surface.

We still do not advocate any change in resuscitation or defibrillation procedures, such as turning off the oxygen supply, because prompt application of the defibrillation pulse and ventilatory exchange with high oxygen concentrations are both essential. Current CPR guidelines for advanced cardiac life support also recommend that ventilatory support to the patient should not be interrupted for longer than 7 sec during each defibrillation attempt. Nevertheless, we strongly advise resuscitation personnel to be aware of the risks involved in defibrillating any patient receiving oxygen, including by means of a ventilator, and to use appropriate and accepted techniques to minimize the risk of fires.

Recommendations

  1. To reduce the risk of fire during the defibrillation of a patient receiving oxygen, apply defibrillator paddles firmly (i.e., with at least 25 lb of pressure) and with adequate gel or conductive pads to prevent arcing. To further reduce the risk of arcing, position as much of each paddle electrode's surface as possible against the patient's chest. Do not defibrillate if the chest is coated with enough gel or saline solution to form a conductive bridge between the paddles; wipe off the excess from the chest and the paddles before defibrillating.
  2. Apply ECG electrodes to the patient's chest as far away as practical from the defibrillator paddle sites. Never place a defibrillator paddle on top of an ECG electrode (i.e, avoid direct contact with any metal). Do not attempt defibrillation if an ECG electrode has become saturated with gel or saline solution. Whenever possible, ensure that the patient's ECG leads are not draped near an area of the body where delivered oxygen is likely to pocket or go undetected (e.g., patient's head, face, neck, gown, bedsheet).
  3. To prevent pockets of high oxygen concentration from collecting in the gowns and sheets or around the heads of patients receiving oxygen, remove any oxygen-administration device, manual resuscitator, or ventilator tubing from the patient prior to defibrillation. Direct the escaping gas away from the defibrillation area; do not leave these devices or tubes on the bed. In order to rapidly diffuse and dilute high oxygen concentrations, areas around the patient's head, neck, and chest, and outlet ports of oxygen-powered devices (e.g., cardiac compressors, masks, nasal cannulas, ventilator tubing) should be as open and well ventilated as possible when defibrillating.
  4. Whenever possible, review and revise existing advanced cardiac life-support protocols to include appropriate and accepted techniques to reduce the risk of fires likely to occur during or related to defibrillation in oxygen-enriched environments.

UMDNS Terms

  • Defibrillator/Monitors [11-129]
  • Defibrillator/Monitors, Line Powered [15-029]
  • Defibrillators [11-132]
  • Defibrillators, Battery Powered [11-134]
  • Defibrillators, Line Powered [11-137]

Cause of Device-Related Incident

Device factor: Device interaction

User error: Incorrect clinical use

Mechanism of Injury or Death

Fire


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