Patterns of Firework-blast Injuries: A Descriptive Case Series

Abstract

Fireworks are commonly used during holidays in the United States. Firework related injuries (FWRIs) have been rising throughout the country since 2012. Here, we describe injury trends and patterns in patients with FWRIs. The trauma registry at Desert Regional Medical Center’s Level I Trauma Center was queried from July 2016 to August 2021. Injury patterns and procedures performed were reviewed. The data were reviewed, and a description of the most common injury types and the association between FWRIs and holiday celebrations, alcohol use, and toxicology results is presented. Ten patients were identified for inclusion during the study period. Fifty percent of the patients were found to be under the influence of alcohol, and 40% had other substances on board. The most common drug found was methamphetamine, accounting for 30% of patients. Ninety percent of patients suffered injuries to hands. Fifty percent of the injured patients presented around the time of either New Year’s or Independence Day celebrations. Neither holiday and alcohol use nor toxicology results were associated with differences in Injury Severity Score. Patients with injuries related to fireworks are presenting to our nation’s emergency rooms at an increasing rate. In this descriptive case series, we found that hand injuries are the most common, followed by face injuries. Most patients had either alcohol or drugs on board at the time of presentation. Findings from this paper will help trauma programs prepare for the presentation of these patients and design outreach programs and future research.

INTRODUCTION

In the United States, fireworks are used to celebrate the country’s Independence Day, New Year, and other special events. However, the explosive nature of fireworks places the general population that handles them at risk of traumatic blast injuries. Data from the National Electronic Injury Surveillance System (NEISS) and National Emergency Department Sample (NEDS) show a continual increase in firework-related injuries (FWRIs) every year over the last decade.[1,2,3] There is little recent literature from Level I trauma centers focusing on both demographic and toxicology findings among FWRIs.

This descriptive case series utilized a retrospective review of a prospectively collected database of trauma patients at a Level 1 Trauma Center in Palm Springs, California. The patient data were available in a deidentified dataset that was created from the trauma registry. IRB approval was obtained for this review. The dataset included all information needed for the analysis, such as age, sex, disposition, injury description, procedures, and length of hospital stay.

All patients from the trauma registry were assessed for inclusion based on the keyword “firework” as a mechanism of injury. Other patients in the dataset were found using the keywords “explosive,” “explosion,” and “blast.” However, these patients were ultimately excluded from this case review because the traumatic injury was not directly caused by a firework explosion.

We describe the outcomes of patients who presented to the emergency department (ED) due to trauma from firework explosions between July 2016 and August 2021. Mechanism and injury timeframe were reviewed. The dataset was organized based on demographics, injury, procedure, and length of stay. We compared our outcomes to data patterns of FWRIs in published literature. A review looking at the association between Injury Severity Score (ISS) scores and proximity to holiday, alcohol use, and positive toxicology is presented.

CASE REPORT

A deidentified dataset was retrieved from our trauma registry from July 2016 to August 2021. Motor vehicle collisions were excluded, leaving 3149 patients. Those patients with limited or incomplete data were excluded. Ten patients with FWRIs were identified for a descriptive case series.

The age of the patients was between 18 and 57 years, with an average age of 38.60 years. Nine patients were male, and one was female. Injury severity score ranged between 1 and 9, with an average injury severity score of 3.90. Most patients were admitted to the hospital, with one patient discharged home from the ED. The hospital length of stay ranged from 0 to 25 days, with an average hospital length of stay of 4.80 days. Two of the 10 patients required intensive care unit (ICU) admission, with ICU length of stay of 5 and 7 days. All patients were discharged home after receiving care. There were no deaths in the group of described patients. Alcohol use was reviewed within the group of patients with FWRIs. Fifty percent of the patients who presented to the ED with FWRIs had elevated blood alcohol levels. The average blood alcohol level was 0.07 g/dL. Forty percent of the patients had positive toxicology results, with the most common drug being methamphetamine. Demographic data are presented in Table 1.

Table 1.

Demographic data for patients seen in the emergency department with firework-related injuries

Patient	Age	Sex	ISS	LOS	ICU LOS	Disposition	Blood alcohol level	Toxicology
1	57	Male	9	3	0	Home	0.00	Negative
2	46	Male	5	2	0	Home	0.14	Negative
3	34	Male	5	25	5	Home	0.00	Methamphetamine
4	35	Male	5	1	0	Home	0.13	Negative
5	52	Female	1	1	0	Home	0.00	Negative
6	50	Male	1	0	0	Home	0.00	Negative
7	18	Male	2	1	0	Home	0.05	Negative
8	19	Male	2	10	7	Home	0.14	Cannabis
9	24	Male	4	1	0	Home	0.19	Methamphetamine, cocaine
10	51	Male	5	4	0	Home	0.00	Methamphetamine, oxycodone
Average	38.60		3.90	4.80	1.20		0.07

ISS: Injury Severity Score, ICU: Intensive care unit, LOS: Length of stay

The most common body part injured among the patients with FWRIs was hand injuries. Ninety percent of patients presented with hand injuries. Facial injuries were the second most common type of injury, with 30% of patients presenting with injuries to the face. Many patients had multisystem injuries, with 30% of patients having more than one body part injured. Back and feet were not injured in this patient group See Table 2.

Table 2.

Body parts injured per patient

Patient	Face	Chest	Abdomen	Back	Hand	Feet	Multisystem
1	✓	✓			✓		✓
2					✓
3	✓		✓		✓		✓
4					✓
5					✓
6	✓
7					✓
8		✓			✓		✓
9					✓
10					✓
Percentage	30	20	10	0	90	0	30

✓= body region affected

Proximity to holiday celebrations was described for this case series. Fifty percent of the patients had injuries on or within 24 h of a holiday. Many patients were injured on the holiday but presented the following day after delays in transfer. Fifty percent of the patients did not have injuries on holidays and are listed as “other” in Table 3. Of those injured on a holiday, Independence Day was the most common holiday to suffer a FWRI. Table 3 describes our case series patients See Table 4.

Table 3.

Trauma injury date proximity to holiday

Patient	Date	New years	Independence day	Other
1	July 5th	✓
2	February 8th			✓
3	November 29th			✓
4	November 1st			✓
5	January 1st	✓
6	April 3rd			✓
7	July 4th		✓
8	July 4th		✓
9	July 5th		✓
10	August 22nd			✓
	Percent	20	30	50

Those marked “Other” were on dates not associated with a holiday ✓= body region affected

Table 4.

Subset analysis of Injury Severity Score and holiday, alcohol, and toxicology use

	Holiday	Nonholiday
n	5	5
Average ISS	3.60	4.20
P		0.69
	Alcohol	No alcohol
n	5	5
Average ISS	3.60	3.40
P		0.87
	Toxicology	Negative toxicology
n	4	6
Average ISS	4.00	3.80
P		0.92

ISS: Injury Severity Score

A review was prepared to assess if proximity to holiday, alcohol, or toxicology use affected injury severity. A Student’s t-test was used for statistical analysis, and P value was calculated. Patients who arrived during a holiday period did not show difference in ISS. Neither alcohol use nor toxicology results were associated with differences in ISS.

We present the ten patients reviewed during our study below. The injuries and presenting complaints are described. Hand injuries were most common, with 9 of the 10 patients suffering a hand injury. Three of the 10 patients had facial injuries. All patients survived to discharge.

Patient 1

Fifty-seven-year-old male was transferred by ambulance due to left-hand amputation injury from firework explosion. He presented with 10/10 pain and bleeding controlled with a tourniquet. He was found to have complete amputation of his left thumb, second finger, third finger, and fifth finger. He suffered burns to his head and chest wall as well as blast injury to his inner ear. He was taken to the Operating Room (OR) for a left-hand amputation at the wrist. He recovered and was sent home.

Patient 2

Forty-six-year-old male who consumed approximately eight cans of beer before arrival presented with right-thumb amputation. He reported holding a firecracker for too long while moving it away from a crowd. He was found to have a partial amputation of his right thumb with a 4 cm laceration over his right hand. He was taken to the operating room, where he underwent completion amputation of the right and repair of a simple right-palm laceration. He recovered and was discharged home.

Patient 3

Thirty-four-year-old male was brought in by ambulance due to right-thumb amputation and index-finger degloving injury after a firework ignited in his hand. He presented with a tourniquet that was placed in the field. He was found to have a first-degree burn to his abdominal wall, right abdominal wall contusions, left eyelid, and nasal abrasions as well as partial amputation of his right thumb, index, and middle fingers with dislocation. He was initially taken to the OR, where his right hand was debrided and irrigated. He returned to the OR later for a free flap with microvascular anastomosis to his right hand. And finally on hospital day number 18, the patient returned to the OR for a split thickness skin graft from his left forearm to his right hand wounds. He recovered and was later discharged home.

Patient 4

Thirty-five-year-old male was brought in by ambulance due to active bleeding of his right thumb, index finger, and middle finger, with soft-tissue and dislocation injuries after a firework exploded in his right hand. He was taken to the OR with hand surgery for irrigation and excisional debridement with open reduction and internal fixation of his right thumb. His radial nerve was repaired. He underwent revision amputation of his right middle and index fingers. His other right-hand lacerations and wounds were closed, and splint was placed. He later recovered and was discharged home.

Patient 5

Fifty-two-year-old female presented with right eye pain and blurry vision after a firework exploded near her right face. The patient was found to have a right ocular laceration and ruptured globe. She was taken to the OR by ophthalmology, where she underwent repair of her ruptured globe. Postoperatively, she recovered and was sent home.

Patient 6

Fifty-year-old male patient was transferred to our trauma center for right-sided facial trauma after a firework explosion. He was found to have a large laceration extending from her right face to his right temple. His eye was not affected. He underwent repair in the ED and was sent home to recover.

Patient 7

Eighteen-year-old right-handed male presented after a mortar-type firework was fired at the vehicle in which he was traveling and exploded near his right hand. He was found to have an open right-hand wound extending into the thenar eminence muscle. He was taken to the OR and underwent washout of his right hand complex wound with repair of the thenar eminence muscle and closure. He recovered and was sent home.

Patient 8

Nineteen-year-old right-handed male presented with bilateral hand injuries after a homemade firework exploded. He was found to have an open right second, fourth, and fifth phalanx fracture, closed left index finger fracture, and chest wall abrasions. Hand surgeons completed the amputation of the patient’s right thumb and index, middle, and ring fingers. He also underwent an open reduction with internal fixation of his right thumb, right fifth finger, and right second metacarpal fractures. He later recovered and was sent home.

Patient 9

Twenty-five-year-old male presented with partial amputation of the right thumb after a homemade firework exploded in his right hand. He received an open reduction and percutaneous pinning of the right thumb, and his thenar muscle was repaired by a hand surgeon. He later recovered and was sent home.

Patient 10

Fifty-two-year-old male presented with a right-hand blast injury after FWRI. He was found to have a closed trapezium fracture, dislocation of his right carpometacarpal joint, as well as open wounds to his right hand. He was taken to the OR and underwent a laceration repair, right-hand skin graft, and an open reduction internal fixation of his right-hand fractures. Postoperatively, he recovered and was sent home.

DISCUSSION

FWRIs are a serious mechanism of injury with increasing prevalence, requiring complex care at our nation’s trauma centers. These injuries often increase in frequency during the months of January, July, and December due to holiday celebrations. The most affected population is young males between the ages of 10 and 30.[1,2,3]

These injuries add a significant cost burden to an already stressed system. A cost analysis published in 2023 reported a median ED charge of $914 and median hospitalization charge at $30,743.[4] Hence, FWRIs place preventable and unnecessary strain on the health care system and patient finances.

According to literature, the most common injuries associated with fireworks are hand injuries, followed by head and eye injuries.[1,2,5] These injuries to areas of complex anatomy often require specialists such as hand surgeons, orthopedic surgeons, or ophthalmologists at tertiary care centers.

The ten cases we present here are consistent with the published major patterns of FWRIs observed from 2012 to 2022. As seen in the literature, most of the patients (90%) were male and experienced hand trauma (90%).[1,3] Fifty percent of our patients suffered an amputation of either a finger or extremity. Twenty percent of patients had a tourniquet when they arrived. An increase in injury prevalence was observed in 2021 compared to previous years, thought to be related to the COVID-19 pandemic.[1,3] Our patients were older than the anticipated age reported by NEISS data of 20–24, with the average age for this descriptive case series being 38.60 years old.[1] There were no pediatric patients in our cases despite NEDS data from 2021 reporting a peak incidence of 15–19 years of age.[3] The ISS of our patient population was lower than that of published reports. Nunziato et al. presented a review of the National Trauma Databank data in 2021 with an average ISS score of 6 as compared to our patients with an average ISS of 3.90.[6]

Fifty percent of the reviewed cases had positive blood alcohol levels, implying a potential association with alcohol use and FWRIs. In 2022, Galet et al. reported a positive correlation between alcohol and FWRIs observed in Iowa after changes to legislation that led to increased leniency for purchasing fireworks. This same study reported an increase in alcohol use in patients sustaining FWRIs from 6.9% to 24.2% in 2019.[7]

Substance use is not only limited to alcohol use. Thirty percent of the patients in this case series had toxicology studies positive for methamphetamine. With the rising use of methamphetamine seen among trauma patient’s this is an area of opportunity for injury prevention and outreach program development. The 24-year-old male in our study had a detectable amount of both cocaine and methamphetamine in his toxicology screening. The loss of inhibition and critical thinking seen in patients with substance use increases their risk-taking behavior, leading to injury. Future research should focus on the role of substances in the severity and frequency of FWRIs.

The frequency of FWRIs in this case series also increased from 2020 to 2021, aligning with the pattern observed throughout the United States following the pandemic.[1,8] The Los Angeles Times suggests that this increase is due to the cessation of public firework demonstrations, leading individuals to use their own fireworks to celebrate the festivities. There is concern that this trend will continue, leading to an increase in FWRIs, as NEISS data from 2022 showed a rise of 2.6 cases per 100,000 nationwide.[1,9]

One solution to decrease FWRIs is increasing legislation restricting the use of fireworks. FWRIs have been shown to increase when legislation becomes lenient. After the passing of the Michigan Fireworks Safety Act in 2011, which allowed the sale of consumer fireworks, FWRIs increased from 14.3 to 21.0 per 100,000 from 2012 to 2018. Similarly, there was a 39% increase in FWRIs when legislation passed in 2016 allowed access to class C fireworks in Virginia.[10] A similar trend has been seen in pediatric patients. Myers and Lehna reported an increase in pediatric FWRIs nationwide with the decreased restriction in firework laws.[11] Notably, increasing restrictions through legislation has been shown to decrease the number of FWRIs. A study done in Hawaii reported that by restricting access to fireworks with high explosive energy and limiting use to those over 18 years of age decreased FWRIs.[12] Similarly, the Netherlands reduced FWRIs by 50% with a multi-faceted approach, including increasing regulation on the sale of fireworks.[13] California passed a new bipartisan law, AB1403, in October 2023, which redefines “safe and sane fireworks” to meet new criteria based on the state fire marshal’s assessment and classification of fireworks. It also increases the fine for possessing illegal fireworks.[14] Whether these added fines and legislation assist in reducing the number of FWRIs in California remains to be seen.

By understanding the epidemiology of FWRIs and the patterns in this case series, health care providers can better prepare during peak seasons. Preparations should focus on treating digital dislocations, amputations, and dermal wounds with skin grafts. Ophthalmic contributions would also be required, as the national trend reveals a high rate of ocular traumatic injuries. Moreover, blood alcohol levels and toxicology screening should be required, as many cases in this series involved the consumption of substances before injury. Another approach is to continue to work toward preventative strategies, such as legislation and education, to reduce permanent disabilities in patients and strain on the healthcare system.

It is imperative to continue monitoring the progress of FWRIs throughout the nation and their impact on the health care systems. To gain more insight into these patterns, trauma centers should record specific firework types and categories. Moore et al. have established six categorical groups: firecrackers, aerial devices, Roman candles/fountains, sparklers/novelty devices, illegal fireworks, and unspecified types.[15] Availability of this data could enable future providers to identify the severity and nature of wounds based on firework types and better anticipate the management they will require. Our trauma center is located near the Mexico-United States Border, which raises the concern that fireworks may be brought into our community from across the border. The larger and more dangerous fireworks would not be sold locally in our community. Understanding where patients obtained fireworks from could also provide important information, facilitating the assessment of how often illegally obtained fireworks contribute to FWRIs.

This descriptive case series offers important insight into traumatic injuries suffered by patients injured by fireworks but is not without limitations. The small sample size of 10 individuals and single-center data provide useful insight but do not allow for a strong applicable conclusion for the general population or other trauma centers with varying practices. Although statistical analysis is presented here, the power of the studies is limited and strong conclusions cannot be made. There is also a lack of standardized classification of firework types, making it difficult to assess patterns correlated with specific firework types and specific injuries. The deidentified trauma dataset has limited access to details such as patient history, treatment specifics, and imaging results. Details regarding specific surgical treatment or tourniquet times were not available. Some patients may not have been included if keywords were not entered correctly. The retrospective design of the study further limits the study. A larger multicenter prospective study should be performed before conclusions can be made.

We present the injuries and outcomes of ten patients who suffered FWRIs at our trauma center. The complex nature of their injuries and the growing incidence of this trauma mechanism highlight the need for increased research and prevention efforts.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Research quality and ethics statement

The authors followed applicable EQUATOR Network (https://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.