Practitioners' Reporting News

WARNING: Ethyl Chloride is Flammable!

Issued Oct 22, 2004

USP's Medication Errors Reporting (MER) Program has received two reports concerning ethyl chloride when used with electrical cautery equipment. Below is a summary of these two cases:

Case 1

Error description: This event occurred with a young boy who was having an infected area on his toe lanced. The event occurred in a physician's office. A nurse practitioner (NP) sprayed the boy's foot with ethyl chloride spray. The NP then attempted to lance the area with a surgical cautery. As soon as she triggered the cautery, the surgical field went up in flames and the pad underneath the boy's foot ignited. The mother of the boy immediately pulled his foot away from the fire. He did not suffer any burns. The NP was aware that the cautery gets hot, but was not aware that ethyl chloride spray was highly flammable.

Reporter's recommendations: Physicians, NP's, and all healthcare practitioners need to be educated about the dangers of ethyl chloride spray, especially when using devices they may not realize pose risks.

Case 2

Image obtained from Gebauer's Web site

Error description: The physician applied ethyl chloride to the child's forehead, waited for it to dry, and turned on the cautery. The child's hair ignited, resulting in a first degree burn on the ear. The reporting practitioner believes Gebauer's Ethyl Chloride® is poorly labeled. According to the practitioner, the label reads, "Topical Anesthetic Skin Refrigerant: Controls pain associated with minor surgery." Also, in small letters the label reads, "FLAMMABLE and should never be used in the presence of open flame or electrical cautery equipment."

Reporting practitioner's recommendations: Better labeling that calls attention to the flammability of the product.

Gebauer's Ethyl Chloride does contain warnings about the product's flammable properties, including an image of a flame surrounded by a box. According to the manufacturer, the directions for use also contains a specific precaution that states, "Ethyl Chloride is FLAMMABLE and should never be used in the presence of an open flame, or electrical cautery equipment." Despite these warnings, practitioners have still used this product in the proximity of a device for which it is contraindicated.

If your facility uses ethyl chloride or cautery equipment, educate staff on the dangers of using these products together. Apply brightly colored warning labels to these products to draw the staff's attention to the risks involved. It may also be necessary to restrict the availability of these products to certain practitioners within your facility.

Practitioner's can learn from your experiences. If you have similar cases to share, report them to MER at www.usp.org/patientSafety/mer/. Reporting forms can also be printed at that address, or requested by calling 1-800-23-ERROR (1-800-233-7767).

Another product that may ignite while being used with electrical equipment is Lacri-Lube® S.O.P®. In August 2001, USP issued a Practitioners' Reporting News item where Lacri-Lube® S.O.P® ignited during laser surgery.

Readers are advised that official USP cautions and warnings for drugs appear in the USP–NF or USP DI. Unless otherwise indicated, any advice or opinions expressed herein reflect solely the judgment of USP staff. Such statements are intended for further consideration and evaluation and may or may not be applicable to a particular practice. The USP Medication Errors Reporting Program is presented in cooperation with the Institute for Safe Medication Practices.