What is the management plan for firecracker injuries?

Management of Firecracker Injuries

Firecracker injuries require immediate cooling with clean running water for 5-20 minutes, followed by urgent assessment for burn depth and extent, with mandatory referral to a burn center for any hand injuries, facial injuries, deep burns >5% TBSA, or TBSA >10% in children or >20% in adults. 1, 2, 3

Immediate First Aid (First 20 Minutes)

• Cool the injury immediately with clean running water (15-25°C) for 5-20 minutes to limit tissue damage and reduce pain 1, 2
• Remove all jewelry and constrictive items from affected areas before swelling occurs to prevent compartment syndrome 1, 2
• Monitor children closely for hypothermia during cooling, especially with larger burns 1, 2
• Do NOT apply ice directly to burns as this causes further tissue damage 4, 2
• Do NOT apply butter, oil, or home remedies as these increase infection risk 2, 3

Initial Assessment and Triage

Determine burn depth and total body surface area (TBSA) using the Lund-Browder chart (not rule of nines) to guide treatment decisions 1, 3:

Burn Depth Classification:

• Superficial (first-degree): Epidermis only, heals without scarring 1
• Partial-thickness (second-degree): Epidermis and part of dermis involved 1
• Full-thickness (third-degree): Complete destruction of epidermis with deeper tissue injury 1

Firecracker-Specific Injury Patterns:

• Flares/fountains and sparklers: Typically cause soft tissue burns only 5
• String bombs and rockets: Cause blast injuries with soft tissue disruption and bony injuries requiring emergency surgery 5
• Hand injuries: Often pluridigital, multistage, and/or bilateral with serious functional implications 6

Mandatory Burn Center Referral Criteria

Contact a burn specialist immediately for any of the following 3:

Adults:

• TBSA >20% OR deep burns >5% 3
• Smoke inhalation 3
• Burns involving face, hands, feet, or genitals (regardless of size) 1, 3
• High-voltage or low-voltage electrical burns 3
• Chemical burns 3
• Age >75 years with TBSA <20% 3
• TBSA >10% with severe comorbidities 3

Children:

• TBSA >10% OR deep burns >5% 3
• Infants <1 year of age 3
• Burns involving face, hands, feet, or genitals 3
• Circular burns 3
• Any electrical or chemical burn 3
• Smoke inhalation 3

Direct admission to a burn center improves survival and functional outcomes compared to sequential transfers 3

Pain Management

• Administer over-the-counter analgesics (acetaminophen or NSAIDs) for minor burns 1, 2
• For severe burn pain, provide titrated intravenous opioids or ketamine as burn pain is often intense and difficult to control 3
• Short-acting opioids and ketamine are optimal for burn-induced pain 4
• Inhaled nitrous oxide can be useful when intravenous access is unavailable 4
• General anesthesia may be required for highly painful injuries or procedures 4

Wound Care (After Cooling and Before Transfer)

For Minor Burns (Managed at Home):

• Clean the burn area gently with tap water or isotonic saline 1, 2
• Apply petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera 1, 2
• Cover with clean, non-adherent dressing 1, 2
• Do NOT break blisters as this increases infection risk 2, 3

For Severe Burns (Awaiting Transfer):

• Perform wound care in a clean environment with appropriate pain control 2
• Clean with tap water, isotonic saline, or antiseptic solution 4, 2
• Cover loosely with clean, non-adherent dressing 3
• Avoid prolonged use of external cooling devices to prevent hypothermia 4

Fluid Resuscitation (For Severe Burns)

For burns requiring hospitalization, initiate early fluid resuscitation 4:

• Administer 20 mL/kg of balanced crystalloid solution (Ringer's Lactate preferred) within the first hour for adults with TBSA ≥20% or children with TBSA ≥10% 4
• Obtain intravenous access in unburned areas when possible; use intraosseous route if IV access cannot be rapidly obtained 4
• Balanced crystalloid solutions are preferred over 0.9% NaCl to reduce risk of hyperchloremia and metabolic acidosis 4

Monitoring for Complications

Compartment Syndrome:

• Watch for blue, purple, or pale extremities indicating poor perfusion 3
• Escharotomy should be performed only at a burn center within 48 hours if circulatory impairment develops 4
• Poorly performed escharotomy increases morbidity; obtain specialist advice before attempting 4

Infection:

• Monitor for increased pain, redness extending beyond burn margins, swelling, or purulent discharge 3
• Do NOT use prophylactic systemic antibiotics routinely 4, 3
• Reserve antibiotics for clinically evident infections only 3
• Avoid prolonged silver sulfadiazine use on superficial burns as it may delay healing 4, 3

Special Considerations for Firecracker Injuries

Hand Injuries:

• All hand burns with blanched skin or tissue loss require immediate specialist referral regardless of TBSA 3
• Hand injuries from firecrackers are typically pluridigital and may require tendon/neurovascular repair, fracture fixation, flap coverage, or amputation 6, 5
• Specialist care prevents permanent functional disability through specialized surgical techniques 3

Facial/Oral Injuries:

• Explosion injuries in the mouth require extensive soft tissue reconstruction, often with microsurgical techniques 7, 8
• Primary closure after complete debridement is essential 7
• Modified microstomia prevention appliances may be needed to prevent contractures 7

Ocular Injuries:

• Firecracker-related ocular injuries cause unilateral blindness in approximately 8% of pediatric cases 9
• All ocular injuries require immediate ophthalmology consultation 9

Critical Pitfalls to Avoid

• Do NOT delay specialist referral for hand, facial, or severe burns as undertriage increases morbidity and mortality 3
• Do NOT send patients home with serious injuries (fractures, penetrating wounds) without medical evaluation 4
• Do NOT apply ice directly to burns 4, 2
• Do NOT break blisters 2, 3
• Do NOT use topical antibiotics prophylactically on uninfected wounds 2, 3
• Do NOT underestimate TBSA; use Lund-Browder chart for accuracy 3