Burns associated with e-cigarette batteries: A case series and literature review

Labelling and composition of contraband electronic cigarettes: Analysis of products from Australia

BACKGROUND

The sale of nicotine-containing electronic cigarettes (e-cigarettes) is prescription only in Australia, regulated under the Standard for Nicotine Vaping Products (TGO110). Australian e-cigarette users, however, are purchasing e-cigarette products outside of the intended pathways.

METHODS

The labelling of e-cigarette packaging (N = 388 boxes) and the chemical composition of disposable e-cigarettes and pods (N = 428) were analysed for adherence to the current Australian regulations. These samples were confiscated from over-the-counter retailers in NSW by the NSW Ministry of Health during 2022 for non-compliance with Australian regulations.

RESULTS

Following the announcement of the prescription only model for nicotine-containing e-cigarettes in Australia in mid-2021 there was a clear shift in the labelling of products. Any mention of the word 'nicotine' was removed from e-cigarette packaging by early 2022 and nicotine warnings were replaced with generic underage sale warnings. Despite this labelling, the vast majority (98.8 %) of devices analysed contained nicotine, most (89 %) at high concentration (>30 mg/mL) and 4.2 % contained at least one chemical prohibited by the TGO110.

CONCLUSIONS

It appears that manufacturers have removed any mention of nicotine from the original packaging of nicotine-containing disposable e-cigarettes to circumvent restrictions on nicotine-containing products and continue their sale. The packaging of e-cigarette products in Australia is generally not indicative of their contents, particularly nicotine, and most did not display required warnings. Ingredients with associated health risks, prohibited in legal vapes by the TGO110, were found in samples. Consequently, the risks of e-cigarette use cannot be appropriately identified from the information supplied on the packaging or device.

E-cigarette explosions: patient profiles, injury patterns, clinical management, and outcome

Background

E-cigarette abuse, also known as vaping, is a widespread habit. Recently, there have been increasing reports of explosions of these devices resulting in serious burn injuries, especially to the groin, hand, and face. Overheating rechargeable lithium-ion batteries are supposed to be the responsible mechanism, especially in low quality fabrications.

Methods

In this single-center retrospective study, data of 46 patients are presented and analyzed. In addition to information on demographics, injury patterns, and treatment options, this is the first study investigating outcome after an average of 13 months via a standardized telephone interview of 31 patients (67%). Patients were specifically asked regarding their outcome, vaping habits, technical modifications to their devices and supply source.

Results

Patients were mainly male (98.2%) with a median age of 36 years. Typical injury patterns included the groin region (n = 32; 69%), hands (n = 12; 25%) and face (n = 3; 7%). All patients underwent debridement, in nine cases hydrotherapeutically. 61% (n = 28) underwent consecutive tangential necrectomy and subsequent split thickness skin graft transplantation. Wound infection was observed in 18 patients (39%), with burn depth as a significant risk factor (p < 0.001). 91% of the followed-up patients were satisfied. Surprisingly, 38% were still using e-cigarettes. 42% (n = 13) reported manual modifications of their devices to prolong battery life or increasing smoke production.

Conclusions

Injuries from exploding e-cigarettes can be serious and should be treated in a specialized burn center. E-cigarette explosions lead to characteristic injury patterns and often need surgical treatment. This should be made more public to reduce their use and keep people from modifying the devices. The counterintuitive and irrational observation of a high rate of abuse even after the injury underlines their addiction potential.

Puff bars: a dangerous trend in adolescent disposable e-cigarette use

PURPOSE OF REVIEW

Puff Bars, a brand of disposable e-cigarettes, have skyrocketed in popularity recently, presenting significant health and safety risks to adolescents. Puff Bars and other disposable e-cigarette products are attractive to children and teenagers because of their vibrant colors and flavors, low cost, and ease of access. This review examines the rise in Puff Bar popularity, describes notable health and safety concerns, and provides advice for parents and pediatricians in identifying and preventing adolescent Puff Bar use.

RECENT FINDINGS

Puff Bars have increased in popularity as their product design evaded strict regulations imposed on alternate e-cigarette products, such as Juul. In addition, Puff Bars' sweet and fruit flavors and marketing on social media have made their use pervasive among youth. Puff Bar use can lead to increased risk of e-cigarette product use-associated lung injury (EVALI) and potential exposure to carcinogens. Furthermore, the developmental risks of nicotine use during adolescence include negative effects on cognitive function and detriments to short-term memory.

SUMMARY

Puff Bars present a significant danger to adolescents, and it is imperative that parents and pediatricians are aware of the health risks involved with vaping. Pediatricians should explore e-cigarette use during patient visits, and parents must communicate these dangers to their children and be able to identify these products to regulate their use.

Electronic Cigarette-Related Injuries Presenting to Five Large Burn Centers, 2015-2019

Electronic cigarettes are advertised as safer alternatives to traditional cigarettes yet cause serious injury. US burn centers have witnessed a rise in both inpatient and outpatient visits to treat thermal injuries related to their use. A multicenter retrospective chart review of American Burn Association burn registry data from 5 large burn centers was performed from January 2015 to July 2019 to identify patients with electronic cigarette-related injuries. A total of 127 patients were identified. Most sustained less than 10% total body surface area burns (mean 3.8%). Sixty-six percent sustained 2nd degree burns. Most patients (78%) were injured while using their device. Eighteen percent of patients reported spontaneous device combustion. Two patients were injured while changing their device battery, and two were injured modifying their device. Three percent were injured by second-hand mechanism. Burn injury was the most common injury pattern (100%), followed by blast injury (3.93%). Flame burns were the most common (70%) type of thermal injury; however, most patients sustained a combination-type injury secondary to multiple burn mechanisms. The most injured body region was the extremities. Silver sulfadiazine was the most common agent used in initial management of thermal injuries. Sixty-three percent of patients did not require surgery. Of the 36% requiring surgery, 43.4% required skin grafting. Multiple surgeries were uncommon. Our data recognizes electronic cigarette use as a public health problem with potential to cause thermal injury and secondary trauma. Most patients are treated on an inpatient basis although most patients treated on outpatient basis have good outcomes.

Injuries associated with electronic nicotine delivery systems: A systematic review

BACKGROUND

Since its introduction on the market in 2007, the number of reports on injuries caused by the overheating, ignition, or explosion of electronic nicotine delivery systems (ENDSs) has increased significantly. These injuries appear to have different causes, the most important one being lithium-ion battery overheating to the point of ignition or explosion.

METHODS

A literature search for all relevant studies concerning ENDS-related traumatic injuries of all kinds was conducted, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses protocol. The search started with the first introduction of ENDSs in 2007 and ended February 2020. Articles included were reports on patients who sustained flame, chemical, or traumatic injuries of the skin, soft tissue, and/or bone, related to the use of ENDSs.

RESULTS

This systematic review includes 180 patients from 41 case series and reports, published between 2016 and 2020. The mean age was 30.8 years (range, 17-59 years) with an overall male predominance (168 of 180 patients, 93%). In most injuries, multiple anatomical sites were affected, with the thigh/lower limb being the most commonly injured area (77%) followed by the upper limb/hand (43%). Eighty-two patients (51%) required a surgical treatment, 70 patients (43%) were managed conservatively with dressings or ointments, and 9 patients (6%) underwent enzymatic debridement. Thirty-five percent of all patients underwent skin grafting.

CONCLUSION

Injuries from overheating, ignition, or explosion of ENDSs are an emerging, underreported, and underresearched issue. There is a need for increased regulation of ENDSs and improved surveillance of related injuries. Both health care providers and consumers should be made aware of the risks and be advised about how to safely handle these devices. In contrast to other articles, this systematic review includes all types of injuries related to ENDS overheating, ignition, and explosion. To our knowledge, this is the most extensive systematic review performed to date.

LEVEL OF EVIDENCE

Review article, level III.

[Where there´s smoke - there´s no fire? - Burns from E-Cigarette explosions]

INTRODUCTION

The popularity of E-Cigarettes is increasing. Besides addiction and pulmonary health damage, reports of burn injuries from e-cigarette explosions are also increasing. Mostly, explosions of e-cigarettes are attributed to its lithium-ion battery. Due to increasing cases and missing guidelines we want to present three cases of our hospital and publish recommendations for the management of burn injuries caused by e-cigarette explosions.

PATIENTS/MATERIAL AND METHODS

Three cases of e-cigarette explosions which occurred between 2016 and 2019, are presented.

RESULTS

All three e-cigarette explosions occurred in the trouser pockets. Two patients were male one patient was female. The age ranged from 24 to 64 years, the burned total body surface area (TBSA) from 3 % to 12.5 %. All three patients required skin grafting and the length of stay in hospital ranged from five to eleven days.

CONCLUSION

In the synopsis of recent literature, we recommend the following management of burns due to e-cigarette explosions. The guidelines of the Advanced Trauma Life Support should be followed, signs of an inhalation trauma should be checked and litmus test should be performed prior to irrigation with aqueous solutions to prevent exothermic reactions with remaining metals. If litmus test shows alkali pH wounds should be irrigated by mineral oil.

Vaping implications for children and youth

PURPOSE OF REVIEW

The development and uptake of E cigarettes are a relatively recent phenomenon. Because of aggressive marketing, attractive designs, enticing flavors and primarily reactionary legislation, we are now seeing soaring rates of adolescent vaping with associated consequences. This review explores how E cigarettes work, their health implications, epidemiology among youth and current regulatory strategies.

RECENT FINDINGS

Recently, the Center for Disease Control and Prevention reported that 27% of high school students had used a tobacco product within the last month, the majority being E-cigarettes in 20.8% of high school students. Vaping has managed to reverse a decades long trend of declining nicotine use among youth. Long-term addiction is not the only concern related to youth vaping; there are also increasing reports of short-term health consequences, such as seizures, acute nicotine toxicity, burns and lung injury.

SUMMARY

Industry has created and aggressively marketed a product that is enticing to adolescents. E cigarettes have sleek designs, desirable flavors and social acceptability with perceived safety among youth. This has resulted in epidemic E cigarette use in youth with resultant significant short-term and long-term health concerns. Legislation must include regulations that strictly avoid marketing and sales to youth, as well as reducing access to these products.

A Systematic Literature Review of E-Cigarette-Related Illness and Injury: Not Just for the Respirologist

Following the recent electronic cigarette (e-cigarette) illness outbreak, the current review aimed to collect all related clinical cases for study and analysis and provide a critical synopsis of the proposed injury mechanism. Adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines, e-cigarette-related clinical cases were identified via Google Scholar and PubMed databases. Additionally, references of published case reports and previous review papers were manually searched, revealing 159 publications presenting e-cigarette-related case reports and 19 reports by the Centers for Disease Control and Prevention. 238 individual cases were identified; 53% traumatic injuries due to e-cigarette explosion or self-combustion, 24% respiratory cases, and 12% poisonings. Additional cases pertained to oral, cardiovascular, immunologic, hematologic, allergic reactions, infant complications, and altered medication levels. Case reports were mainly published between 2016-2019 (78%). The oldest case, a lipoid pneumonia, was published in 2012. The current review showed that e-cigarette-related health effects extend beyond the acute lung injury syndrome, including traumatic, thermal injuries and acute intoxications. Physicians should be aware of the distinct clinical presentations and be trained to respond and treat effectively. Regulators and public health authorities should address the regulatory gap regarding electronic nicotine delivery systems (ENDS) and novel tobacco products.

Ocular conditions and dry eye due to traditional and new forms of smoking: A review

Addiction to cigarette smoking has high prevalence rates recorded worldwide. Smoking has been linked to several life-threatening systemic conditions such as cancer, heart attack and stroke, in addition to a range of ocular pathologies. In recent years, electronic cigarettes (EC) have emerged as alternatives to smoking. ECs are nicotine delivery devices which produce an aerosol by heating, rather than combusting, a liquid which contains nicotine, flavours and preservatives. This review focuses on the association of traditional and new forms of smoking with dry eye disease, contact lens wear and four other common ocular diseases: cataract, age-related macular degeneration, glaucoma and Graves' ophthalmopathy. It is concluded that smoking and vaping appear as a risk factor for the aforementioned ocular conditions. An evidence-based, clear link between cigarette smoking, or EC vaping and ocular problems is yet to be discovered.

Bromelain-based enzymatic debridement of e-cigarette burns: a single unit experience

Objective:

It is widely accepted that the early debridement of burns improves outcome. There is increasing evidence that enzymatic debridement is an effective technique for removal of full-thickness and deep-dermal burns, reducing blood loss and often the need for autologous skin grafting by avoiding over excision of the burn. We aim to highlight the potential use of this form of debridement as an alternative to surgical management in patients with electronic cigarette (e-cigarette)-associated flame burn injuries.

Methods:

This case series presents the use of Nexobrid (MediWound Ltd, Israel), a non-surgical, bromelain-based enzymatic debridement technique, in patients with deep partial-thickness burns (range: 1–3% total body surface area), avoiding the need for autologous skin grafting.

Results:

Burn wounds in two patients healed within 14 days without complications or the need for further surgical intervention. Another patient required further dressings after discharge but failed to attend follow-up appointments. These results are comparable with those reported by others using conservative management of e-cigarette burns.

Conclusion:

The authors wish to raise awareness of the potential for a combination of thermal and chemical burns related to e-cigarette explosions. Chemical burns should be excluded by pH testing of the burn wound. From our experience, small e-cigarette-associated flame burns can be considered for management with enzymatic debridement.

E-Cigarette Battery Explosions: Review of the Acute Management of the Burns and the Impact on Our Population

Electronic cigarettes, also known as e-cigarettes (E-cig), are lithium-battery-powered devices, which became available for sale in the United States in 2017. It has gained significant popularity among younger-generation tobacco smokers due to its advertisement as a non-toxic inhalation property and a potential smoking-cessation aid. The US Food and Drug Administration (FDA) has been regulating e-cigarettes as tobacco products and not as drug-delivery devices, as many medical experts think it should be categorized. In the last few years, the medical community has encountered increasing episodes of burn injuries secondary to e-cigarette battery explosion. Explosions occur through a process known as a "thermal runaway.” This process occurs when the battery overheats and the internal battery temperature increases dangerously high, to the point of inner fire and explosion. Overcharge, puncture, external heat, short circuit, amongst others, are conditions that cause a “thermal runaway.”

This is a retrospective review and analysis of six patients with superficial, partial, and full-thickness burn injuries related to e-cigarette battery explosions managed at Johns Hopkins Bayview Burn Center over the course of one year. Lund-Browder diagrams and calculations were used to assess the total body surface area (TBSA) burns. Laser Doppler imaging (LDI) was used to evaluate the indeterminate depth of the burn.

Only one of our six patients required tangential excision and skin grafting. The rest of our patients were treated conservatively with complex wound care, which included the mixed combination of topical collagenase and bacitracin, collagenase and mafenide, or silver sulfadiazine as a single-agent treatment with an excellent response. Five patients were discharged home within a week, including the patient who required operative excision and auto-grafting. One patient stayed for eight days for pain control and complex wound care.

Our experience with these burns has been similar to what is previously reported. Most of these burns are managed with complex wound care without any surgical interventions. The e-cigarette batteries seem more prone to failure due to an inherent weakness in their structural design. This makes them particularly susceptible to the “thermal runaway.” Therefore, we recognized the need to expand the regulation and control of the quality of these devices. Prevention of these burns will require continuing education for the community on the use of E-cig. products and its potential hazardous implications.

New efforts should be made to educate the community and healthcare providers regarding the potential hazardous implication of carrying these batteries. Also, there is insufficient data to support or deny the long-term health effects of using e-cigarettes.

Burn injuries caused by e-cigarette explosions: A systematic review of published cases

INTRODUCTION

E-cigarettes have the potential to cause burns from batteries that explode. Although e-cigarette explosion burns have been reported by the media (e.g. local online news, blogs), there is a need for a comprehensive review of published medical case reports regarding these injuries.

METHODS

CINAHL and PubMed were systematically searched using common terms regarding e-cigarettes (electronic cigarette, e-cigarette, vape, vaping, electronic nicotine delivery systems) in every combination with the term ‘explosion’. Peer-reviewed articles were included if they: were written in English, described case reports of burn injuries caused by e-cigarette explosions, and were published in any year. Cases were categorized by demographics, location of the e-cigarette explosion, burned body areas, types of burns, total body surface area of burns, the need for skin grafting, and the length of hospital stay.

RESULTS

Thirty-one articles were included in the review and described 164 cases. Most patients (90%) were male and between 20 to 29 years old. In the majority of cases (65%), e-cigarettes exploded in pockets, compared to exploding in the face or hand. Common burned areas included the thigh, hand, genitals, and face. Burn severity was typically second-degree burns (35%) or a combination of second-degree and third-degree burns (20%). In all, 48 patients required skin grafting, with 19 reporting a median hospital stay of 5 days.

CONCLUSIONS

This review has several implications, including the need for regulation of batteries, education regarding battery safety, and leveraging images of the severity of e-cigarette explosion burns to discourage the use of e-cigarettes.

Electronic Cigarettes: Exposure and Use Among Pediatric Populations

As an emerging inhalational exposure, electronic cigarettes (e-cigarettes) have rapidly gained public awareness with increasing use among adolescents and adults, leading to increased primary use by adolescents and increased secondhand exposure to emissions in infants, children, and adolescents. Although the long-term health risks for primary use and secondhand emission exposure are unknown, limited data from animal studies suggest that there is the potential for long-term lung injury and altered neurocognitive development in children with exposure to nicotine-containing aerosols. In this pediatric-focused review, we discuss the history of e-cigarettes, the demographics of adolescent users, effects on health, and current legislative efforts to protect infants, children, and adolescents from exposure.