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LIFE THREATENING EXPLOSION OF OXYGEN REGULATOR

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    Posted: 02 Oct 2009 at 2:02pm
LIFE THREATENING EXPLOSION OF OXYGEN REGULATOR

    
Dr Joe Mellor,
Consultant Anesthetist., Leeds
General Infirmary, Leeds. UK.


Oxygen supports combustion. Chemistry students will have witnessed the re-ignition of a glowing splint in an atmosphere of 100% oxygen. Any flammable substance may become dangerous when exposed to an atmosphere of 100% oxygen and this effect is worsened either in the presence of high pressure or in the presence of heat. The following short report describes a life threatening incident that occurred during the handling of oxygen. It is written with the intention of demonstrating the danger we face when dealing with oxygen in the operating theatre.

The incident occurred in a 200 bed hospital in South East Asia. Two operating theatres were supplied with oxygen from two large oxygen cylinders situated in the hospital basement, a floor below the operating rooms. Each cylinder was connected to a pressure regulator converting the cylinder pressure, maximum 137 atmospheres, to pipeline pressure of 4 atmospheres. The two regulators were then connected to a pressure gauge and to a common pipeline, supplying the operating rooms upstairs.

Oxygen was supplied from one cylinder until it was nearly empty. At this point, the full cylinder was switched on and the old one replaced. (Figure 1)


Cylinders


A close up view of the oxygen regulator is also shown. The model was a variable output type regulator but the point of discussion is relevant to the variable and fixed output types. (Figure 2)


Oxygen regulator



An oxygen regulator was found to be faulty some time before the incident. It was sent to be serviced. The service was carried out by technicians who may have been unfamiliar with this equipment. They may have been unfamiliar with precautions needed when servicing oxygen regulators.

The oxygen regulator was returned and was attached to the top of a full cylinder of 100% oxygen. The cylinder was switched on and there was immediately an explosion, which completely destroyed the body of the regulator. The pressure gauges were thrown upwards with sufficient force to shatter them on the ceiling. The explosion was accompanied by a flash fire which burnt the anesthetist who was changing the regulator. His shirt was burnt away and he sustained second degree burns to his trunk as well as superficial injuries from flying metallic debris. He sustained more serious injuries to his exposed arms. Fortunately, his burns were mostly second degree, with a small patch of third degree burning over his right wrist. (See figure 3). Fortunately, the anesthetist's face was spared and he suffered no burns to his airway.


Burn

Explosions in the operating theatre environment are not a new phenomenon. Explosive anesthetic agents like ether are a well known risk. I believe the mechanism of this explosion is oil having been used as a lubricant on the pressure regulator or pressure gauge. The fact that oiling mechanisms that come in contact with high oxygen concentrations is dangerous is sufficiently well known that the gauges have warnings written on them. However, despite written warnings on the gauge, on questioning, it appears likely that oil was used in its maintenance.

Gas flowing through the mechanism of the regulator will have aerosolized the oil. The combination of high pressure, 100% oxygen and this aerosol will have produced an explosive mixture. It is hard to speculate on the mechanism that ignited this mixture to cause an explosion. Indeed oxidation and explosion may have occurred spontaneously in such conditions, without the need for a spark or similar stimulus.

This demonstrates a clear learning point:

Service of oxygen regulators and other anesthetic apparatus, must only be carried out by those with adequate training. Oil, grease or flammable lubricants must never be used on any apparatus which may be exposed to a high concentration of oxygen.

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Edited by JCole - 02 Oct 2009 at 2:05pm
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