On account of the holidays, we’re starting July off with a bang with a Triple Pearl. There is a significant increase in firework-related injuries this time of year, but the distribution of injuries may surprise you. If you’re expecting to see a bunch of teenagers blowing their hands off, or intoxication related injuries, think again.

Of all the ED chief complaints that surge on July 4th, firework injuries are not the most significant.

It’s not the nighttime festivities that bring people in, but the daytime ones. Food poisoning and heat exhaustion from BBQs are #1 and #2 on the July 4th list.

  • Food Poisoning Pearl: The time to onset of symptoms can help differentiate food poisoning (usually self-limiting) from more emergent pathologies. Organisms that make a toxin in the food before it is consumed (S. aureus, B. cereus, botulism) cause rapid onset of symptoms within 6-12 hours of ingestion. Organisms that make a toxin after it is consumed ( choleraeor Enterotoxigenic E. coli) cause delayed onset of symptoms up to 24 hours later. Organisms that damage the epithelial cell surface or invade across the intestinal epithelial cell barrier can have a wide variety of presentations. If someone has extremely rapid onset of symptoms within minutes to hours of eating, consider alternate pathologies (such as allergy/anaphylaxis) instead.

Teenagers are not the most frequently injured by fireworks.

Nor are children. It’s actually grown adults age 25-44, who account for 35% of all injured patients. Burns to sensitive areas are the most common type of injury, particularly the hands/fingers and face.

  • Burns Referral Pearl: In general, burns involving the hands, feet, face or genitals should be referred to a Burns Unit. Referrals should also be made for: 1) they have partial thickness burns > 10% total body surface area (TBSA) in adults or >5% in children; 2) full thickness burns >5% TBSA in adults or children; 3) chemical or electrical burns; 4) any circumferential burn; 5) inhalation injuries; and 6) cutaneous burns in a pregnant patient.

Larger fireworks are not the ones that cause the most injuries.

It’s actually sparklers. Yes, sparklers. They account for 24% of all firework-related injuries, and the highest rate of injury for children under 5 years old. There’s just something about pretty lights that makes people want to touch them. But even small sparklers achieve temperatures >1000C, and have a chunk of molten metal at the tip that can cause serious injury.

  • Hand Burns Pearl: All partial thickness burns should be gently cleaned and covered with sterile gauze. Remember to separate the fingers and wrap them individually. Whether to debride/break blisters on the hands is a controversial topic. Some surgeons advocate for breaking the blisters in the ED in order to accurately assess depth of burn. Some advocate for leaving the blisters because they may act as a natural barrier. There are, to date, no large prospective studies demonstrating a clear advantage for one method over another.

In summary, try to broaden your expectations about the types of complaints you may see around this time of year. Be prepared to treat food and heat-related injuries. Be comfortable treating burns on the hands or face. You can always refer your patients to the wonderful PSAs on the Consumer Product Safety Commission website: http://www.cpsc.gov/