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Fire Attributable to a Defibrillation Attempt in a Neonate

2003; American Academy of Pediatrics; Volume: 112; Issue: 3 Linguagem: Inglês

10.1542/peds.112.3.677

1098-4275

Andreas Theodorou, Juan A. Gutiérrez, Robert A. Berg,

Respiratory Support and Mechanisms

A fire can occur during a defibrillation attempt because a spark can be generated in an oxygen-enriched atmosphere. Although the risk is small, a fire during patient care can have devastating effects. We describe a case of a fire attributable to a defibrillation attempt in a 10-day-old neonate following open-heart surgery. To our knowledge, this is the first published account of a fire during a defibrillation attempt in an infant or child. We review predisposing factors and preventive strategies, with special emphasis on the importance of removing oxygen from the immediate environment during defibrillation attempts.Fire is a rare but potentially devastating complication of defibrillation attempts.1–3 Despite the severe consequences of patient fires, this risk is not mentioned in standard critical care4,5 or cardiology textbooks,6,7 presumably because of the paucity of clinical reports.1,8,9 We present a case of a fire ignited by a defibrillation attempt in a 10-day-old infant, and discuss the contributing factors and recommended preventive measures. To our knowledge, this represents the first such report in an infant or child.The patient was a term newborn with a type II truncus arteriosus. Surgical correction on day 10 of life was complicated by myocardial ischemia attributable to an anomalous descending coronary artery that was severed during the surgery. Following the repair, the chest was left open and the median sternotomy was covered with a Gore-Tex tissue patch. She returned to the pediatric intensive care unit in an infant warmer and required high ventilator settings including fraction of inspired oxygen of 1.0, positive end-expiratory pressure of 12 cm H2O, tidal volume of 80 mL, and a respiratory rate of 20 breaths per minute. She was also provided with considerable inotropic support including epinephrine, dopamine, and dobutamine infusions. Inhaled nitric oxide was initiated for pulmonary hypertension.Shortly after arriving to the pediatric intensive care unit, the patient developed severe hypotension followed by ventricular fibrillation. Cardiopulmonary resuscitation with chest compressions was promptly initiated. The patient was disconnected from the Servo Ventilator 300 (Siemens-Elema AB, Solna, Sweden) and manually ventilated with a flow-inflating bag. The ventilator tubing with continuous high flow of oxygen was placed next to the child in the infant warmer. The initial defibrillation attempt with 10 joules (∼3 joules/kg) using standard adult paddles placed in the anterior/posterior position produced a spark. The infant's stocking cap and a small area of the bed sheets caught on fire, but the small flames were promptly extinguished manually with bare hands. Because the patient remained in ventricular fibrillation, cardiopulmonary resuscitation was continued. After removal of the ventilator tubing oxygen source from the bedside, 5 additional countershocks were provided at 20 joules (∼6 joules/kg), generating sparks that did not result in a fire. Despite continued aggressive advanced life support, the resuscitation efforts were not successful and the patient died. Autopsy did not reveal evidence of cutaneous burns or inhalational injury.This case confirms that a fire can occur during a defibrillation attempt because of a spark in the presence of oxygen and fuel (cotton).2,3,10,11 Importantly, fires did not recur during the next 5 defibrillation attempts for this child after the source of high flow oxygen was removed from the bed. Although this is the first report of a fire during a defibrillation attempt in a child, such occurrences may not be so rare.2,3 The following discussion will highlight the necessary ingredients of a fire and appropriate preventive strategies.The necessary ingredients to make a fire—the so-called fire triangle of heat, fuel and oxidizer—are well known.9,12–14 If one of those ingredients is eliminated, a fire cannot occur or will be extinguished. Unfortunately, these 3 elements may come together during defibrillation attempts.The source of heat during a defibrillation attempt is typically a spark/electric arc. When there is a poor electrode-chest wall interface, an electric arc may occur during the countershock.2,3 A poor interface can result from paddles that are too large for the chest wall or paddles that extend beyond the conducting electrode cream or conducting gel pads.3,15 Electric arcing can also occur when paddles are placed too close to an electrocardiographic electrode, when excessive electrode cream bridges from one paddle to another, or when a saline-soaked pad is placed between the paddle and the patient.2,3,15 In this case, the adult paddles may have contributed to the poor chest wall contact, thereby promoting a spark. Moreover, the saline-soaked dressings that covered the open chest wound probably contributed to the arcing. Nevertheless, no fire occurred after the supplemental oxygen source was removed from the bed despite sparks during repeat defibrillation attempts with the same adult paddles and saline-soaked dressings.The second important ingredient for a fire is oxygen. Each of the previously reported adult cases of fire during defibrillation attempts also occurred in oxygen-enriched settings.1,8,9 Interestingly, in one such previous report,9 that patient was also disconnected from a ventilator, and in the urgency of the resuscitation the ventilator tubing was similarly left in the bed near the patient's chest, resulting in continuous high-flow of oxygen in the vicinity of the spark.Not surprisingly, oxygen-enriched atmospheres are well-known major contributors for other hospital fires unassociated with defibrillation attempts.12,13 Therefore, a logical preventive strategy is to remove oxygen sources from the immediate vicinity of the patient during defibrillation attempts.3,15 Support for this strategy is the fact that no additional fires occurred in our case after the supplemental oxygen source was removed from the bed despite 5 further defibrillation attempts with higher defibrillation doses, recurrence of sparks, and no other substantial changes in the environment.Further information regarding the potential danger of oxygen sources during defibrillation attempts can be gleaned from a cardiopulmonary resuscitation mannequin defibrillation simulation study.16 Oxygen concentration was measured around the head and chest of the mannequin under a number of simulated conditions using a resuscitation bag or ventilator. As expected, substantial increases in the oxygen concentration were demonstrated near the defibrillator paddles on the chest wall when the ventilatory device was disconnected near the mannequin's mouth. In contrast, there was no increase in oxygen concentration near the paddles when the ventilator was left connected to the tracheal tube or when the ventilatory devices were 1 meter away from the mannequin's head.The third necessary ingredient for a fire is fuel, essentially anything that can burn. In the present case, the dry cotton cap and dry cotton sheets were readily available fuels for the fire. It should be noted that many potential fuels are at the bedside, including prepping agents, linens, dressings, ointments, and various plastic, rubber, and wooden supplies.12,13The paucity of publications on fires associated with defibrillation attempts does not reflect the absence of these events, in part because of the litigious nature of patient fires.2,3,14 For example, ECRI (formerly the Emergency Care Research Institute), a nonprofit health services research agency, reports that it continues to investigate fires that occur during defibrillation attempts. In its most recent review, ECRI states that "… the ignition danger during defibrillation has been forgotten or ignored—or was never learned—and must be periodically reemphasized… "3The recommendations from ECRI to prevent fires during defibrillation attempts follow logically from the discussion above.3 First and foremost, all supplemental oxygen should be removed from the vicinity of the bed before defibrillation attempts. This includes oxygen flowing through masks, nasal cannulae, resuscitation bags, and ventilator tubing. Second, follow the American Heart Association recommendations for defibrillation, including selection of the correct paddle size (pediatric size for children less than ∼10 kg), application of firm, even pressure during defibrillation attempts, and use of the appropriate conductive gel or conductive disposable pad.15,17 Saline or alcohol pads should not be used and electrocardiograph leads should be placed as far from the paddles as possible.15,17It is important to note that the development of a fire during patient care has a tremendous impact on all those involved, including immediate termination of resuscitative efforts for the patient, potential harm to other patients and health care workers, and acute and chronic psychological effects on all present during the event.14,18 Acute fear and disorientation adversely affect patient care and are unintended barriers to the necessary fire abatement procedures. In addition, posttraumatic stress disorder is a relatively common debilitating sequela of fires.18 Awareness of these potential psychological problems should lead to postincident stress debriefing for the health care providers immediately after the event and over the next few days. The need for further psychological support should be considered.This case report supports a recent change in the Pediatric Advance Life Support (PALS) course.17 In the past, the PALS course has taught a 3-step chant to insure all people are clear of the patient bed before delivering electric shocks.19 The present PALS course acknowledges the hazards of an oxygen-enriched atmosphere with the 4-step chant of "I'm going to shock on the count of four. One-I'm clear. Two-you're clear. Three-oxygen's clear. Four-everybody's clear."17This case establishes that fires can occur during defibrillation attempts in children. In addition, our findings provide further support for the preventive strategy of removing supplemental oxygen from the immediate environment during defibrillation attempts.We are indebted to Nancy Driesbock for her assistance in the preparation of this manuscript.