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ORIGINAL ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 1  |  Page : 1-6

A retrospective study on clinical profile of patients with firecracker-related injury presenting to the emergency department of a tertiary care center in South India


Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission31-Oct-2019
Date of Decision18-Nov-2019
Date of Acceptance25-Nov-2019
Date of Web Publication03-Feb-2020

Correspondence Address:
Dr. Darpanarayan Hazra
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_56_19

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  Abstract 

Background: Firecracker injuries are very common in India. They are mostly used during the various festivals celebrated in India. This study analyses the profile and outcome of firecracker injuries in the emergency department (ED).
Materials and Methods: This was a retrospective observational study of all firecracker-related injury patients presenting to our ED. Details of the incident, injuries, management, and outcome were noted. Data were extracted from the ED triage software and hospital electronic database.
Results: We received a total number of 13,604 trauma patients to our ED, among which 92 (0.7%) had firecracker burst-related injury. The mean age of the patient was 27 (standard deviation 11.6) years. Male (97.8%) predominance was noted. Majority of them were triaged to Priority II, i.e., 64 (70%) patients and 6 (6%) in Priority I. The mean number of incidents per month during the festive season of Diwali was 3.25 compared to 3.95 during the rest of the year. The majority of the injuries had sustained lacerations (78.5%), followed by abrasions (12.9%). Among all patients, only 4.3% (4) suffered second- and third-degree burns each. It was noted that the upper limbs (79.6%) were most commonly involved as expected, followed by the face (16.1%). The new injury severity score was more than 5 in (6.4%) of patients. Most patients were taken up for emergency procedures such as wound wash, debridement, suturing, or nailing of the fractures in the ED. Majority (81.5%) required hospital admission and had to undergo major surgical intervention. The rest were either discharged stable or discharged against medical advice after primary care.
Conclusions: This study has expressed the pattern of firecracker injuries. An alarmingly high number of young adolescents with significant upper limb injuries were noted. Public awareness and education along with increase legislative enforcement are needed for the betterment and well-being of the mass during the festival season to prevent the catastrophe since these injuries are prevalent in the productive age groups.

Keywords: Cracker burst, cracker-related injuries, crackers, firecrackers, hand injuries


How to cite this article:
Sethy A, Saha S, Hazra D, Abhilash KP. A retrospective study on clinical profile of patients with firecracker-related injury presenting to the emergency department of a tertiary care center in South India. Curr Med Issues 2020;18:1-6

How to cite this URL:
Sethy A, Saha S, Hazra D, Abhilash KP. A retrospective study on clinical profile of patients with firecracker-related injury presenting to the emergency department of a tertiary care center in South India. Curr Med Issues [serial online] 2020 [cited 2020 Mar 28];18:1-6. Available from: http://www.cmijournal.org/text.asp?2020/18/1/1/277527




  Introduction Top


Tamil Nadu reports the highest number of trauma from India, many of which are fire-cracker related.[1],[2] Firecrackers are commonly used during celebrations to express the festive mood. Around the world, Guy Fawkes Night in the United Kingdom, Bastille day in France, Independence day and Halloween in the USA, and many other festivals use firecrackers.[3],[4] Firecracker injuries are mostly caused by either mishandling of fireworks or a device-failure during use. India, as a country, celebrates a vast number of festivals which involve a firecracker light and sound show.[3] However, while handling these firecrackers, slightest of carelessness can cause moderate-to-severe injuries. The annual incidence of firecracker related injuries in India is 7 in every 100,000 population.[3],[4] Studies conducted in Delhi showed an increased incidence of firecracker-related injuries around the days of Diwali, despite targeted legislature being passed for it. Studies from the Northeast Indian (Guwahati) also found similar trend against festivals.[5],[6] Another study in Darwin, Australia, showed an increase in such incidents around the days of territory day (July 1). From previous studies, it has been noted that an alarmingly high number of young adolescents are involved in such incidents, and the upper limbs and face are the most common regions of the body to be involved.[4],[7],[8],[9] An injury to the hand and its underlying structures carry the potential for serious handicap and can have an adverse effect on the normal daily activities depending on the type and region of injury. To reduce this risk, even the smallest hand injuries require prompt medical and surgical care. This retrospective study was conducted to determine the prevalence of patients with firecrackers injury, severity of injury, regions of the body involved, and management in the emergency department (ED), leading to the different outcomes in the patient's life, functions, and disability. To the best of our knowledge, this is the first study that focuses on the profile and outcome of such victims in South India.


  Materials and Methods Top


Design

This study was a subanalysis of a large retrospective study on major trauma patients.

Setting

The study was conducted in the ED of Christian Medical College Hospital, Vellore, which is a tertiary medical care center. The ED is a 49-bed department and tends to about 300 patients per day, including trauma and nontrauma patients.

Participants

All patients with trauma related to firecracker injury over the study period from January 2017 to December 2018 were included in the study. All patients with trauma not related to firecracker injury and patients with inadequate data in charts were excluded from the study.

Variables

The charts were reviewed, and the relevant details of history, clinical findings, laboratory investigations, and X-rays findings were documented in the study form. The management in terms of conservative and surgical was noted like immediate management or procedures performed in the ED. The outcome of the patients from the ED with regard to admission, discharged, discharged against medical advice, or deaths was also documented.

Outcome variable

Predictors of severity according to the new injury severity score (NISS).

Bias

This is a retrospective study, and therefore, we could not control the exposure or outcome assessment and instead relied on others for accurate record-keeping.

Study size

To determine the seasonal pattern of firecracker injuries, we recruited patients from the 2-year period. In doing so, we included all ninety patients who presented to ED in the study duration.

Laboratory test

All patients had routine blood investigations and relevant radiological tests based on the initial primary and secondary surveys.

Statistical analysis

All categorical variables were expressed as frequencies and percentages. The data were analyzed using the Statistical Package for the Social Sciences for Windows software released 2015, version 23.0, Armonk, New York, USA. Data were summarized using the mean along with standard deviation (SD) for continuous variables and frequencies along with percentages were calculated and presented. Factors for the severity of injury were determined by univariate regression analysis, and their 95% confidence intervals were calculated. For all tests, a two-sided P < 0.05 was considered statistically significant.

Ethical considerations

This study was approved by the Institutional Review Board (IRB). Before the commencement of the study, approval from the Institutional Review Board Ethical Committee was obtained (IRB Min no: 12222 dated 22nd August 2019). Patient confidentiality was maintained using unique identifiers and by password protected data entry software with restricted users.


  Results Top


We analyzed the data of 92 patients, with a mean age of 27 (SD 11.6) years. As expected, there was a male 90 (97.8%) predominance. According to ED triage system, patients were categorized into Priority I, II, and III. Among these, majority were triaged as Priority II, i.e., 64 (70%), whereas 6 (6%) triaged as Priority I [Figure 1]. Most of them, i.e., 71 (77.2%) patients had not received any first aid before coming to our hospital, whereas the rest of them were referred from another medical center. It was noted that majority 46 (50%) of the incidence occurred in the morning hours (8 a.m.–5 p.m.) and about 30 (32.6%) occurred during the evening hours (5 p.m.–12 a.m.). However, most of these victims 49 (55.4%) presented to us in the evening hours (5 p.m.–12 a.m.) [Table 1].
Figure 1: Strengthening the reporting of Observational studies in Epidemiology (STROBE) diagram

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Table 1: Baseline characteristics

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The mean number of incidents during the festive month of Diwali was 3.25 compared to 3.95 during the rest of the year [Figure 2]. The majority of the injuries were lacerations 73 (78.5%), followed by abrasions 12 (12.9%). All the patients had some sort of burn injury. As expected, majority of all patients, i.e., 84 (91.3%) had first-degree burns, whereas only 4 (4.3%) suffered second- and third-degree burns each [Table 2]. Upper limbs 74 (79.6%) were the most commonly involved, followed by the face in 15 (16.1%) patients, abdomen in 5 (5.4%) patients, thorax in 4 (4.3%) patients, both lower limb and both upper limbs were affected in 5 (5.4%) patients each, neck involvement was seen in 2 (2.1%) patients, and back in 1 (1%) patient [Figure 3]. Predictors of severity of injury were calculated according to the NISS. The majority of these patients had a NISS of <6, and 6 (6.4%) had an average NISS of 7.4 [Table 2].
Figure 2: Monthly distribution of incidents

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Table 2: Type of injury and severity

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Figure 3: Regions of the body involved

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The ED team was involved in the primary evaluation and management of all the patients, whereas the remaining required interventions (major/minor) were done by various trauma surgical teams. The trauma specialties that were involved were hand reconstructive surgery in 62 (67.7%) cases, ear, nose, and throat (ENT) in 14 (15.1%) cases, plastic surgery in 9 (9.7%) cases, ophthalmology in 7 (7.6%) cases, and trauma surgery in 6 (6.4%) cases. Other departments such as orthopedics, urology, pediatrics surgery, spine, and neurosurgery were collectively managed 6 (6.4%) cases [Figure 4]. Most patients (70) were taken up for minor emergency procedures such as wound wash, debridement, suturing, or nailing of the fractures in the minor theater of the ED itself. There were 75 (81.5%) of all the study patients who were admitted into the ward, 34 (36.6%) had to undergo major surgical interventions in the main theater, and the rest were managed conservatively with daily dressing following minor surgery in the ED minor theater room. The mean duration of stay for admitted patients is 3.512 days with an SD of 4.288. Finger amputation was the most common amputation performed 72 (77.3%), whereas 13 (13.6%) patients had to undergo transmetacarpal amputation (13.6%). Most of the injuries caused due to the firecrackers were simple 65 (70%), whereas the rest of them were grievous in nature [Table 2]. Among the patients who were not admitted were discharged stable with advice to follow-up in OPD or plan for elective surgical procedures at a later date. There were no mortalities during this study period.
Figure 4: Departments involved in the management of patients

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  Discussion Top


Firecrackers are usually made of cardboard or plastic, with flash powder, cordite, and smokeless powder or back powder as the propellant, match heads, kerosene to lighter fluid, etc., The entire firecracker must be very tightly packed in order for it to work best. Firecrackers are extensively used in India during various festivals, ceremonies, and social events. Firecrackers find a special place during an important Hindu mythological event, i.e., “Diwali.” In the Gregorian calendar, the festival generally falls between mid-October and mid-November.[3],[4] Firecrackers are also used during Tihar in Nepal, Hari Raya in Malaysia, Day of Ashura in Morocco, Guy Fawkes Night or bonfire night in the United Kingdom, Independence Day and Halloween in the USA, Bastille Day in France, Spanish Fallas and New Year's Day in Guatemala, Chinese New Year by the Chinese, and many other festivals worldwide.[1],[2],[3],[4],[7]

India is a large country with a huge diversity in culture and social events. The epidemiology and pattern of firecracker injuries also differ from place to place. This study was based in a small town of South Indian, where there is no religious predominance; hence, these incidents were seen throughout the year with a mild increase during Diwali. To the best of our knowledge, this is the first retrospective analysis done from a study in Tamil Nadu that focuses on the prevalence of patients with firecrackers injury, severity of injury, regions of the body involved, and management in the ED.

In a major study conducted in Delhi national capital region from 2002 to 2010, there was a steady increase in the number of patients of firecracker-related injuries. During the study period, the hospital received approximately one patient with firecracker-related injury per 10,000 population of the city. Majority (90.87%) of them sustained < 5% total body surface area burns, which is similar to our study. Injuries ranged from digital nerve injuries to traumatic amputation.[1],[2] Literature available on firecracker injuries from developed countries (USA) concluded that approximately 10,000 persons annually were affected in firecracker-related injuries.[3],[4] The National Electronic Surveillance System reported that in the last decade, a total number of 85,800 pediatric firework-related injuries were treated.[7] In the UK, the number of firework-related injuries peaks during Halloween and Guy Fawkes Night.[8] In Denmark, there were 4447 patients of firecracker-related injuries during 2 days of New Year over a 12-year period from 1995 to 2007.[9] Injuries caused by fireworks are a national problem in Greece too.[10] The reported incidence is 7/100,000 children annually, of which 70% are in the age group of 10–14 years.[10] Studies from the USA demonstrated that the states, which are liberal in allowing fireworks for personal use, have seven times greater incidence than the states where more restrictions are imposed.[11] Hence, firework-related injuries have encountered the world over. These are the national statistics of different countries. Both developed and developing countries are facing the problem of firecracker-related injuries in large numbers.[10],[12]

However, unlike most other studies done in the West and India,[13] the prevalence of firecracker-related injuries is not so high in this study and goes to a probable reason that they these injuries are rampant in the mid-lower socioeconomic classes, which would preclude them from presenting to a private tertiary center such as ours. Another probable explanation could be that a large portion of these patients suffers ocular injury,[14] and they present directly to the eye hospital affiliated to out hospital and were not included in the study.

In our study, population age ranged from 3 to 58 years of age, with a mean age of 27 (SD 11.6) years, this is unlike most of the earlier studies[12],[13],[14] in which the most common group affected was formed by children <16 years of age. It was noted that the majority of these incidents took place in the morning hours and could probably be explained by the fact that in 2005,[13],[14] the apex court of India said that the right to live in an atmosphere free from noise pollution has been upheld as guaranteed by the constitution and thereby banning on all sound-emitting firecrackers between 10 p.m. and 6 a.m.

Soft-tissue injuries (contusions, abrasions, and lacerations) were the most frequent injuries seen with the upper limbs most commonly affected followed by the face as demonstrated in most of the studies.[1],[7],[8],[9],[10],[11] An injury to the hand and its underlying structures carry the potential for serious handicap and can have an adverse effect on the normal daily activities depending on the type and region of injury.

Majority of the patients who presented to us had burn injury and needed hospital admission for regular dressings and antibiotics. The victims sustaining gravely severe injuries had to undergo major surgical procedures. This was only possible due to qualified and efficient ED professionals, aided by the backbone of around the clock multispecialty team of hand reconstruction surgeons, trauma surgeons, neurosurgeons, orthopedics, plastic surgeons, ENT surgeons, and orthodontists. The mean duration of stay for admitted patients was 3.512 days with an SD of 4.288. Finger amputation was the most common amputation performed 72 (77.3%), whereas 13 (13.6%) patients had to undergo transmetacarpal amputation (13.6%).

This study demonstrates that there is an urgent need where government and nongovernment agencies have to take strict action in the form of legislations, amendments, prohibitive orders, educational programs, etc., in the festival seasons to prevent firecracker-related injuries. Policy-makers must also understand that rehabilitation, job retraining, and injury prevention play an important role in dealing with the tremendous economic impact of this public health issue.[15]


  Conclusions Top


We found that the incidence of firecracker injuries is not related to the festival of Diwali in this area. An alarmingly high number of young adolescents with significant upper limb injuries were seen and this may contribute to significant morbidity in this highly productive age group. This incidence can be decreased to an extent by ensuring better crowd control, increasing security and restricting the sale of firecracker during the festive season.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is IRB Min no: 12222 dated 22nd August 2019. We also certify that we have not plagiarized the contents in this submission and have done a Plagiarism Check.



 
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[PUBMED]  [Full text]  


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