At a Wednesday news conference, CPSC acting chairman Ann Marie Buerkle said an estimated 12,900 people suffered fireworks-related injuries last year, with 67 percent of those injuries occurring during the month surrounding the holiday. Moreover, sparklers were the number one cause of the injuries, accounting for 14 percent of cases.
A new report by the U.S. Consumer Product Safety Commission (CPSC) finds a significant upward trend in fireworks-related injuries. Between 2006 and 2021, injuries with fireworks climbed 25% in the U.S., according to CPSC estimates.
"It's imperative that consumers know the risks involved in using fireworks, so injuries and tragedies can be prevented," commission Chair Alex Hoehn-Saric said in a statement. "The safest way to enjoy fireworks is to watch the professional displays."
Emergency department-treated fireworks injuries surged to 15,600 in 2020, but regulators suggested that could be due to the fact that some public fireworks displays were closed during the COVID-19 pandemic.
Studying a one-month period last year that included the Fourth of July, the CPSC found that men were more likely to be injured than women, people ages 20-24 had the highest rate of injuries and victims most commonly injured their hands and fingers.
Last year, about 11,500 people were injured by fireworks in the U.S., and nine people died. Children 15 and younger accounted for 29% of injuries. The body parts most often damaged are hands and fingers.
Dr. Jennifer Hsu, an orthopedic surgeon and chief of microvascular upper extremity and hand surgery, treated 19 patients for traumatic fireworks injuries over the July 4 holiday, the most she has seen in her nine years at the hospital. Sixteen were children, who in many cases did not understand what they had picked up.
There were 944 fires and explosions involving illegal fireworks in Massachusetts in the past 10 years. These incidents caused 3 civilian injuries, 43 fire service injuries, and millions of dollars in damages.
The patient was admitted to the ICU. Consultation of neurosurgery, ophthalmology and plastic surgery were obtained. Post injury the patient developed persistent high fevers and was treated with antibiotics, he developed central diabetes insipidus, and was minimally responsive with only a cough and a gag. Eventually he was able to intermittently move his upper and lower extremities with stimulus. No surgical intervention was planned for his injuries.
As defined by the federal explosives laws, fireworks are separated into two broad categories: display and consumer fireworks. Consumer fireworks are those available to the general public and defined by as any small firework device designed to produce visible effects by combustion and which must comply with the construction, chemical composition, and labeling regulations of the U.S. Consumer Product Safety Commission.3 These include rockets, firecrackers, smoke balls, roman candles, sparklers, artillery shells, and air bombs. All consumer fireworks include a trade name and manufacturing information displayed clearly on them. In the state that these patients were treated, firework laws are quite strict, whereas the patients transferred from bordering states are more relaxed. Regardless, the force necessary to cause such damage was likely illegal in either state. Unfortunately, due to the retrospective nature of this study, information regarding the specific firework and method of injury was unavailable for each patient. Previous reports have been sparse in regards to the types of fireworks associated with injuries, making the mechanism and object of injury an important piece of history that can influence the management of these often complicated patients and vital to initial assessment of these patients.
The use of fireworks in the context of celebrations and holidays presents the ideal environment for accidents that lead to severe and dangerous injury. Studies conducted in China and Iran in conjunction with the Chinese annual spring festival and Iranian Last Wednesday Eve Festival respectively have found that private use of fireworks increases the incidence of injury.4,5 Further, the two most common causes of injury with firework were found to be due to illegal firework use and improper handling 4, with no reduction in incidence of firework injury in those with increased socioeconomic or education level. Another survey conducted in Iran found that during festival times, civilians that have a lower perceived injury risk and a higher perceived ability of managing injury were more likely to participate in the use of fireworks and had a higher incidence of injury.6 It can be concluded that firework use and associated injury is an individual choice, making education and awareness of safety and risk reduction methods all the more necessary.
Our case report confirms that males are highly likely to be victims of firework injury, although all of them were directly involved with the fireworks and were not innocent bystanders. The average age of victims was 26.7 years old, which is of young adult age, while literature states that children are the most frequent victims of these injuries. Reconstructive techniques documented for our patients match those cited as the most commonly used in the literature, with debridement, open reduction and internal fixation, eye enucleation, Z-plasty, and complex soft tissue repair being used in our patients.
According to Advance Trauma Life Support (ATLS) guidelines (ACS COT)12, one of the most important principles in taking care of patients with such severe facial injuries is management of their airway and a potential avoidance of early preventable death. As demonstrated with these 4 cases, airway management was immediately addressed in each of the patients with one patient receiving a cricothyroidotomy. Given the location and the extent of some of the blast injuries that can occur from fireworks or penetrating injuries to the face, swelling, anatomical distortion, obstruction and aspiration can be a consequence of the injury and an airway can be quickly compromised. When the lower part of the face is involved (i.e. mandible, neck), airway protection often becomes more challenging. In addition, the need for establishment of an airway and mechanical ventilation for airway protection in the event of a concomitant severe head injury is important to avoid exposure of the patient to secondary brain injury as a result of an unstable airway.
One of the most highly characterized areas of facial trauma is that of ocular injury. A recent meta-analysis of ocular blast injuries found that as much as 28% of blast survivors suffer from ocular injury.13 The most common injuries suffered by victims are corneal abrasions, deposition of foreign bodies on the conjunctiva, cornea and fornix, hyphema. Open globe injuries and the presence of intraocular foreign bodies are less prevalent, but are associated with loss of vision, occurring in a majority of patients. Other risk factors for poor visual outcome included poor initial visual acuity, retinal detachment and development of endophthalmitis.13,14 Ocular injuries were found to be most prevalent from secondary blast injuries, resulting not from direct injury to the eye, but from shrapnel and projectile debris, with periorbital location of injury having the highest associated morbidity.13,15
The use of antibiotics perioperatively has been shown to reduce the incidence of surgical site infection and is the current standard of care in elective clean-contaminated head and neck surgery.16,17 The most feared infectious complication in maxillo-facial injuries is meningitis due to the communication of the face with the intracranial space, making surgical site infection prevention an important part of management in these cases. However, there currently exists no guideline for management of surgical traumatic facial injury patients with prophylactic antibiotics. Some literature suggests the use of prophylactic antibiotics in complex traumatic oral and facial wounds.18 However, recent studies have found no difference between infection rates in surgical patients with maxillofacial fractures19 and midface or frontal sinus trauma20 between those who were given prophylactic antibiotics and those who were not. Overall, there is a severe lack of literature to address the use of prophylactic antibiotics for open skull or facial blast injuries. The authors believe that prophylactic antibiotics may have a role in reducing postoperative infection and support their use in complicated and open facial injuries caused by fireworks, but recognize the need for more research into this topic.
The utility of prophylactic antibiotics in basilar skull fractures is also not clear. Ratilal et al21 performed a Cochrane review of antibiotic use in basilar skull fractures with and without cerebrospinal fluid leak and noted there was no difference in the rates of meningitis, all-cause mortality, meningitis-related mortality and need for surgical correction in patient with cerebrospinal fluid leakage. The patients in this case series all had a combination of severe facial injuries and intracranial injury with basilar skull fracture. Even less literature exists regarding the severe combination of injuries that this case series of patients sustained. 781b155fdc