Endotracheal tube fire during tracheostomy: a case report.

Electrosurgery in the presence of volatile anesthetic gases has been associated with operating-room fires. We report a case in which an operating-room fire occurred while an intubated patient underwent electrosurgical tracheostomy. The fire in this case was caused by a combination of an oxygen-rich environment, a polyvinyl chloride tube, and heat generated by an electrosurgical unit. We also discuss factors that increase the risk of this type of fire and the management steps that should be undertaken in the event that such a fire occurs, and we briefly review the literature on this subject.