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Fireworks Injuries: Ooh, Aah...Ouch!

Nicole Cimino-Fiallos, MD | June 29, 2017 | Contributor Information

Adapted images from (1) Wikimedia Commons/Fcb981 (top left), (2) Flickr/Mike Mozart (bottom left), and (3) Siemers F, Mauss KL, Liodaki E, Ottomann C, Bergmann PA, Mailander P. Eplasty. 2012;12:e33. [Open access.] PMID: 22848777, PMCID: PMC3406748. 

The patient shown suffered a blast injury that embedded multiple foreign body tattoos within the eyes, eyelids, nose, and forehead.

Fireworks are used around the globe in times of celebration—often accompanied by injuries ranging from relatively minor to severely traumatic, with almost half of these wounds the result of misuse or inappropriate use. [1] However, injuries can occur even when fireworks are used properly: 35% of all firework injuries are a result of device failure. [1]

Fireworks are engineered with a combination of pyrotechnic components and self-sustained high-speed chemical reactions that produce a special effect such as light or sound upon ignition, resulting in an explosion. [2] The terminology used to describe the initiation of the firework's reaction is termed either a deflagration or a detonation on the basis of the speed of the explosion. [2] The severity of potential fireworks injuries is affected not only by the type of explosion but also the kind of firework, how it was created (homemade vs commercially produced), and the age of the victim (child vs adult).

Image from Ng NY, Abdullah A, Milner SM. Eplasty. 2015;15:ic15. [Open access.] PMID: 25834695, PMCID: PMC4364261.

This photograph shows a phosphorus burn.

Firework Seasons

Firework seasons vary by country. For example, in the United Kingdom, fireworks are most commonly used from October to January, whereas in the United States, January and July are the primary months. Diwali, the festival of lights, marks peak firework season in India; its exact dates depend on the Hindu lunar calendar, but they generally fall between the middle of October to the middle of November. [1]

Unsurprisingly, the increased use of fireworks during such times directly correlates with the number of firework injuries presenting to emergency departments (EDs). On average, 67% (8,000) of US fireworks injuries occur in the month around the July 4th/Independence Day holiday, with 230 people presenting daily to the ED with fireworks-related injuries in this period. [3]

Adapted infographic from the US Consumer Product Safety Commission (left); photograph from Pixabay/confused_me (right).

Categories of Fireworks

Many different types of fireworks exist, each causing different injury patterns. A fuse device consists of explosive material wrapped in paper with a string or wire that produces a loud bang when lit. [4] Sparklers are handheld devices with a pyrotechnic coating that burns slowly, showering colored sparks from the distal tip. Fountains are designed to rest on the ground and spray colored sparks; however, they are often inappropriately held by hand, usually resulting in injury. A grenade, frequently homemade with a plastic or metal bottle, is a shell that contains explosive material and generates a loud sound when thrown. [4] Aerial devices such as rockets and missiles shoot upward and explode to create noise and sparks [4]; these fireworks cause 17% of all firework-related accidents. [5]

Adapted infographic from the US Consumer Product Safety Commission.

US Fireworks Injuries Data

Between years 2000 and 2010 in the United States, an estimated 97,562 patients presented to a hospital for a firework-related injury. [4] In 2015 (the most recent data available), approximately 11,900 injuries were treated in EDs. [3]

Males are predominantly affected (two- to three-fold more often than females [3,5]), and children and adolescents account for over one quarter [3] to half [4] of these injuries. The majority of the pediatric injuries occur in patients ages 10-19 years. [3,5]

Adapted infographic from the US Consumer Product Safety Commission (left); photograph of a second-degree burn from Wikimedia Commons/Westchaser (right). 

Most Frequently Injured Body Parts

More than three quarters of all US firework-related injuries affect the head, neck, or upper extremities, with over half of the injuries being burns. [3,5] The eye itself is the most commonly injured body part, [3,4,6] comprising 1,300-2,000 injuries per year. [3,6]

Although fireworks injuries infrequently cause death, wounds affecting the eye and hands can result in significant morbidity. These are largely preventable.

Image from Siemers F, Mauss KL, Liodaki E, Ottomann C, Bergmann PA, Mailander P. Eplasty. 2012;12:e33. [Open access.] PMID: 22848777, PMCID: PMC3406748. 

 

This image shows the same patient as in slide 1 who suffered a blast injury with resultant embedded multiple foreign body tattoos to the face, including the eye.

Eye injuries

As noted earlier, the eye is the most commonly injured body part in fireworks accidents, and the cornea is the most frequently affected site. In a 2016 report of fireworks-related ocular injuries seen at a level I US trauma center over a period of 11 years (2003-2013), more than two thirds involved corneal injuries. [7]

Penetrating trauma to the globe is also not uncommon and can result in retained intraocular foreign bodies, which places patients at risk for infection and vision loss. [8] These injuries can also cause corneal edema, macular scarring, traumatic cataracts, and choroidal rupture. [8]

Image from Wikimedia Commons/E van Herk.

A small piece of iron is lodged near the margin of the cornea in this image. Some rust can be seen around the iron fragment.

All patients with complaints of eye pain after a firework accident should undergo a slit-lamp examination and Seidel test (application of a fluorescein dye strip to an eye injury site) to assess for corneal abrasions, foreign bodies, and open globe injuries. [9,10] Avoid testing for intraocular pressure until an open globe injury has been ruled out.

Patients with corneal foreign bodies should undergo thorough evaluation, irrigation, and subsequent removal of the foreign body. [9,10] Note that metallic foreign bodies may leave a rust ring (shown) that will require ophthalmologic follow-up.

Image from Wikimedia Commons/Rakesh Ahuja, MD.

 

A cloudy lens consistent with a traumatic cataract is revealed under slit-lamp examination.

Traumatic cataracts can result from a blast wave that creates a pressure differential across the various ocular tissues. [11] These lesions usually resolve without intervention after 1 week; however, in some cases, the lens swells and requires extraction of the cataract.

Ocular burns are less frequently caused by fireworks, usually prevented by the eyelid reflex. Unfortunately, some explosions can overcome this response and result in thermal injury to the eye. [11]

Image from Wikimedia Commons/dbenzhuser.

A right-eye hematoma and laceration are shown.

Eye injuries require detailed and, sometimes, emergent ophthalmologic evaluation. The initial management should include pain control, infection prophylaxis, lubrication, eye pressure control, and inflammation reduction. [10,11] Eye lacerations should be repaired. Thorough assess the eye for any penetrating injuries. Canthus or lacrimal duct injuries should be repaired by an ophthalmologist, if available. [11]

Patients with ocular wounds may require topical antibiotics and corticosteroids. Swelling may prevent the eyelids from fully closing; therefore, encourage the frequent application of lubricant. Contact lens wearers should not use their lenses until cleared by their ophthalmologist. [10]

Fireworks-related eye injuries cause significant pain and will likely require systemic pain control. However, avoid sending topical anesthetics home with patients as these agents can allow injuries to worsen without the patient realizing it. [11]

Images from Wikimedia Commons/1Veertje (left) and Egro FM, Jaring MR, Khan AZ. Eplasty. 2014;14:e6. [Open access.] PMID: 24501620, PMCID: PMC3899806 (right and center). 

Left: Second-degree burn. Center and right: Right dorsal and palmar views of a hand with clinical indications of compartment syndrome, including marked swelling of the entire hand; pale digits (with tenderness to palpation); mottling and delayed capillary refill of the index, ring, and little fingers; and limited range of motion at the metacarpophalangeal and interphalangeal joints.

Hand injuries

Firework accidents involving the hand require quick, competent management to prevent long-term complications. Many of these injuries are due to inappropriate handling (eg, holding the devices by hand rather than planting them in the ground) or premature device explosions, in which the firework detonates while the person is still lighting the fuse (with the intent to throw).

Emergently/urgently consult a hand surgeon for most firework-related hand injuries. [12] Firework explosions can result in fractures of the thumb, injury to the first web space, and destabilization of the carpometacarpal joint. In addition, burns to the hand lead to significant pain and may result in contractures that ultimately require surgical management. Compartment syndrome, a surgical emergency, can also develop. [12]

Images from (top to bottom) (1) United States Army/DR Richmond, via Wikimedia Commons; (2) Siemers F, Mauss KL, Liodaki E, Ottomann C, Bergmann PA, Mailander P. Eplasty. 2012;12:e33. [Open access.] PMID: 22848777, PMCID: PMC3406748; (3) Karimkhani C, Amir M, Dellavalle RP, Ipaktchi K. Patient Saf Surg. 2014;8:22. [Open access.] PMID: 24855490, PMCID: PMC4030045; and (4) Wikimedia Commons/Snickerdo. 

 

Right column images, from top to bottom. Top: A visible blast wave from a conventional explosion. Blast waves cause primary blast injuries. Second from top: Right hand of a patient who suffered a blast injury from a fireworks explosion. Note the embedded foreign bodies. Third from top: Hand crush injuries involving the flexor tendons, neurovascular bundles, and bone. Bottom: Burn injury 2 days following blast trauma.

Blast Injuries

Multiple types of injuries are caused by explosions, including those from commercially available fireworks, and they are classified as primary, secondary, tertiary, or quaternary. A primary injury is the result of barotrauma from a blast wave on the body—gas-filled organs (eg, ears, lungs, bowel) are especially affected. [2,13]

Image from MedPix/David M Danielson, Madigan Army Medical Center.

This radiograph reveals numerous metallic shrapnel fragments embedded in the soft tissue.

Secondary and tertiary blast injuries can cause blunt trauma similar to that found in victims of motor vehicle accidents, gunshots, stabbings, and assaults. [13] Secondary injuries result from shrapnel and displaced debris from the explosion, usually culminating in penetrating and lacerating wounds but also blunt trauma. [2,13] Secondary injuries are the most common wounds sustained from an explosion, and they inflict injury wherever the foreign objects penetrate. [2,13] When the extremities are involved, an evaluation for neurovascular deficits should be performed. The wounds should be thoroughly irrigated, and a tetanus vaccine administered, if applicable. For thoracic and abdominal wounds, multiplanar imaging studies may aid in identifying the location of the foreign bodies. [13]

Tertiary blast wounds, such as crush injuries and blunt trauma, occur from the body being thrown by the blast force or from the collapse of surrounding structures onto a victim. [2,13] Quaternary blast injuries, as they apply to fireworks, mainly include burns. [14]

Image from Migirov L, Wolf M. BMC Pediatr. 2015;15:32. [Open access.] PMID: 25884359, PMCID: PMC4387589.

 

This is an endoscopic view of a medium-sized perforation in a tympanic membrane.

Tympanic membrane injuries

The tympanic membrane is at high risk for a blast injury because it acts as a pressure transducer in the body. [14] After a blast, patients may complain of hearing loss, ear pain, and/or tinnitus. [13,14]

A ruptured tympanic membrane is often used as a sign of a blast wave effect; it can indicate to medical providers that the patient needs to be evaluated for more severe injuries, such as blast lung (unobvious external chest injury with respiratory difficulty and hypoxia following a blast exposure [13]). [2] Note that patients with preexisting patent eustachian tubes may not rupture their tympanic membranes even when exposed to a large blast wave; therefore, lack of eardrum perforation should not dissuade clinicians from evaluating for other injuries in patients subjected to blasts.

Image from the United States Army Medical Department via Wikimedia Commons.

This chest radiograph depicts blast lung. Note the bilateral infiltrates from pulmonary contusion.

Pulmonary injuries

Firework accidents that occur indoors place victims at higher risk of blast injury(ies) to the lungs as a result of shearing of the alveolar-capillary borders. [13] Patients may present with respiratory distress, hypoxia, or hemoptysis as a result of pneumothorax, pulmonary edema, bleeding, or even air embolism. The ventilation-perfusion mismatch in these patients is secondary to vascular shunting and poor gas exchange. [13]

In patients with blast lung injury, imaging studies will likely reveal bilateral pulmonary infiltrates, classically in a “butterfly” pattern and, possibly, a pneumothorax. Because these patients are at high risk for acute respiratory distress syndrome, clinicians should employ lung-protective ventilation strategies. [14]

Image from Daignault MC, Saul T, Lewiss RE. Crit Ultrasound J. 2012;4(1):9. [Open access.] PMID: 22870918, PMCID: PMC3411373.

This ultrasonographic view of the right upper quadrant Morison pouch in a patient with a ruptured urinary bladder demonstrates free fluid between the liver and the right kidney.

Gastrointestinal injuries

Firework accident-related gastrointestinal injuries, such as visceral perforation, vascular trauma, or solid organ injury, are less common than lung injuries but do occur. [2,13] Patients may present with abdominal pain, vomiting, hematemesis, or peritonitis. Examination using focused assessment with sonography for trauma (FAST) may reveal the presence of intraperitoneal free fluid. [13]

Patients should receive volume resuscitation, and they may require advanced imaging studies and/or surgical intervention. [2,13] The liver, kidneys, and spleen are less likely to suffer injury from a blast wave than other abdominopelvic organs because of their homogeneous density, but they can sustain lacerations, contusions, subcapsular bruising, and even frank rupture, depending on the size of the blast load. [2]

Images from Raza M, Abbas Y, Devi V, Prasad KV, Rizk KN, Nair PP. World J Emerg Surg. 2013;8:14. [Open access.] PMID: 23561288, PMCID: PMC3636075. 

These images were obtained in a 6-year-old girl who sustained multiple traumatic injuries following blunt abdominal trauma. She had injuries to both kidneys ( a), the liver and spleen ( d), as well as the pancreatic body ( e). In addition, the patient had bilateral hemothorax ( b, c), and bilateral acetabular fractures ( f).

In a 2017 report, the annual rate of nonfatal US pediatric firework-related injuries fell by 30.4% between years 1990 and 2014. [15] In addition, some studies have shown that aggressive legislation for firework safety reduced the number of burn injuries over that from previous decades. [16] However, noncompliance with the laws persisted, and several states have relaxed the regulations previously enacted, thereby leading many public health officials to anticipate not only a rise in the numbers of firework injuries but also in their wound severity. [16]

As discussed, fireworks cause a large number of preventable injuries each year, with children disproportionately affected. [3-5] Therefore, it is essential to educate all patients in fireworks safety before and during firework seasons, including emphasizing always supervising children when using fireworks, not using fireworks indoors, and not experimenting with homemade fireworks. [15,17] The National Council on Fireworks Safety provides safety tips on the use of these devices at: http://www.fireworkssafety.org/blog/2017/6/21/national-council-on-fireworks-safety-urges-consumers-to-do-their-part-to-promote-fireworks-safety.

Contributor Information

Author

Nicole Cimino-Fiallos, MD

Resident

Department of Emergency Medicine

University of Maryland Medical Center

Baltimore, Maryland

Disclosure: Nicole Cimino-Fiallos, MD, has disclosed no relevant financial relationships.

References  

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Image Sources

  1. Slides 1 right, 6, and 11 (second image): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3406748/. Accessed June 14, 2017.
  2. Slide 1 left images: https://commons.wikimedia.org/wiki/File:Fireworks_PDX_1.jpg (top); https://www.flickr.com/photos/jeepersmedia/14022492332 (bottom). Accessed June 27, 2017.
  3. Slide 2: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4364261/. Accessed June 14, 2017.
  4. Slides 3 left, 4, and 5 left: https://www.cpsc.gov/s3fs-public/Fireworks-Infographic-2015-web.pdf. Accessed June 14, 2017.
  5. Slide 3 right: https://pixabay.com/en/sparkler-fireworks-colors-diwali-500007/. Accessed June 15, 2017.
  6. Slide 5 right: https://commons.wikimedia.org/wiki/File:Major-2nd-degree-burn.jpg. Accessed June 15, 2017.
  7. Slide 7: https://commons.wikimedia.org/wiki/File:Foreign_body_in_eye.jpg. Accessed June 15, 2017.
  8. Slide 8: https://commons.wikimedia.org/wiki/File:Slit_lamp_view_of_Cataract_in_Human_Eye.png. Accessed June 15, 2017.
  9. Slide 9: https://commons.wikimedia.org/wiki/File:H%C3%A4matom_und_Naht.jpg. Accessed June 15, 2017.
  10. Slide 10: https://commons.wikimedia.org/wiki/File:1Veertje_hand_burn.jpg (left); https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3899806/ (right). Both accessed June 15, 2017.
  11. Slide 11: https://commons.wikimedia.org/wiki/File:Explosion-blast_wave.JPG (top); https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4030045/ (third); and https://commons.wikimedia.org/wiki/File:Scaldburn.jpg (bottom). All accessed June 15, 2017.
  12. Slide 12: https://medpix.nlm.nih.gov/case?id=1e1eea73-5c94-4d21-8cd2-3b9b2763689b. Accessed June 15, 2017.
  13. Slide 13: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4387589/. Accessed June 15, 2017.
  14. Slide 14: https://commons.wikimedia.org/wiki/File:Blast_lung-chest_radiograph.jpg. Accessed June 15, 2017.
  15. Slide 15: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3411373/. Accessed June 15, 2017.
  16. Slide 16: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636075/. Accessed June 15, 2017.

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