目的：乾粉滅火器是醫療院所、機關學校、一般建物常用的消防設備，對於火災的控制至關重要，通常僅於緊急或必要時使用，因此多未被視為潛在危險性化學物質。然而新聞媒體與醫學文獻偶會報導滅火器相關的爆炸、噴撒、吸入、或誤服事件，引起輕重程度不等的健康效應。本文報告一起發生在醫院的患者噴灑乾粉滅火器事件，分析受到暴露員工的臨床症狀，並檢討適當的預防與處置措施。

方法：利用臨場服務員工關懷門診收集事故發生的詳細資料，分析臨床症狀與血液鈣、磷及鎂等電解質變化，結合乾粉的理化特性，進行分析討論。

結果：計有47位員工吸入與皮膚黏膜接觸乾粉，其中27人出現呼吸道症狀如喉嚨痛、咳嗽，12位出現鼻部嗅覺症狀，10人抱怨眼睛刺激，2人感到皮膚不適，其中以護理人員人數最多，清潔人員次之。血液檢查未發現高血磷合併低血鈣或低血鎂情形。除一人主動就醫外，其餘自主清洗處理。47人之中並未出現少數文獻所報告的嚴重病況，例如高血磷低血鈣症、急性腎衰竭、呼吸衰竭、心律不整或癲癇。

討論與結論：對於職場所放置的磷酸二氫銨乾粉滅火器，建議比照毒性化學物質進行標識、張貼物質安全資料表、調控各型滅火器數量，指導使用適當的個人防護具，進行員工教育訓練，避免蓄意或人為疏失而導致乾粉噴灑，並在萬一事故發生時採取標準處理程序與防護清理措施。

Objective: Dry powder fire extinguisher (DPFE) is an important and indispensable equipment against ABC type fire. It is found in many places and easily accessible, a fact which contributes to anectodal reports of explosion, spraying, inhalation, and ingestion events. Here we reported a case-series of accidental exposure related to the misuse of DPFE by a patient, leading to adverse health effects among 47 staff. Blood phosphorous, calcium and magnesium were monitored to investigate potential electrolyte imbalance, such as hyperphosphatemia, hypocalcemia, and hypomagnesemia.

Materials and Methods: A cross-sectional study of 47 exposed workers was conducted through the collection of on-site, clinical, and laboratory informations. The data were analyzed to discern the patterns of adverse health effects, the use of personal protective equipment and how to handle such emergent situation appropriately.

Results: Among 47 exposed workers, 27 exhibited respiratory symtomes、12 had nasal & smelling complaints, 10 suffered from eye irritation, the remaining 2 persons felt mild skin irritation. Nursing staff topped the complaining list, followed by cleaning workers. Except one nurse, no other victims visited outpatient clinic. Severe consequeces as reported in the literature such as hyperphosphatemia, hypocalcemia and hypomagnesemia did not occur.

Discussion & Conclusion: In view of the potential toxicity and easy accessibility of DPFE, it is advised to label them on site, to prevent misuse as is feasible, to provide safety education, to instruct correct use of personal protective equipment, as well as to set up standard operating procedure. These measures aim to avoid potential harm to human health, while preserving the usefulness of DPFE as fire-extinguishing apparatus.