- Email: [email protected]
The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature
JBUR 5156 No. of Pages 6
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Case report
The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature A. Arnaout a, *, H. Khashaba b , T. Dobbs a , F. Dewi b , S. Pope-Jones a , A. Sack b , C. Estela b, D. Nguyen a a Plastic and Reconstructive Surgery, Welsh Centre for Burns and Plastic Surgery (WCBP), Morriston Hospital, Swansea, SA6 6NL, UK b Department of Burns and Plastics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
article info
abstract
Article history:
Introduction: Since the introduction of e-cigarettes to the UK market in 2007 their popularity
Accepted 5 January 2017
amongst young adults has significantly increased. These lithium-ion powered devices
Available online xxx
remain unregulated by the Standards Agency and as a result burns centres across the world have seen an increasing number of patients presenting with significant burns, resulting from
Keywords: Electronic cigarettes E-cigarette Explosion Burn Lithium-ion Lithium battery
poor quality batteries that appear to be liable to explode when over-heated, over-charged or incorrectly stored. Methods: Retrospective and perspective review of all e-cigarette related burns presenting to the Southwest Burns Network; South Wales Burns Centre (Morriston Hospital) or to Bristol burns centre (Southmead Hospital) between Oct 15–July 16, followed by a review of available literature performed and eligible papers identified using PRISMA 2009 Checklist. Results: South Wales Burns Centre (Morriston Hospital) (N=5), Bristol burns centre (Southmead Hospital) (N=7). 92% of injuries were seen in male patients with a mean age of 34.58 (12.7). The mean TSBA sustained 2.54% of mixed depth, most common anatomical area is the thigh 83% (n=10) with a mean 23.1(5) days to heal with conservative management. The literature search yielded 3 case series (Colaianni et al., 2016; Kumetz et al., 2016; Nicoll et al., 2016) [8,9,12] and 4 case reports (Jablow and Sexton, 2015; Harrison and Hicklin, 2016; Walsh et al., 2016; Shastry and Langdorf, 2016) [6,7,10,11]. We compare our findings with the published studies. Conclusion: The import and sale of e-cigarettes remains unrestricted. This increases the risk of devices being available in the UK market that do not meet the British Standard Specification, potentially increasing their risk of causing fire and exploding. Consumers should be made aware of this risk, and advised of adequate charging and storage procedures.
* Corresponding author. E-mail addresses: [email protected], [email protected] (A. Arnaout), [email protected] (H. Khashaba), [email protected] (T. Dobbs), [email protected] (F. Dewi), [email protected] (S. Pope-Jones), [email protected] (A. Sack), [email protected] (C. Estela), [email protected] (D. Nguyen). http://dx.doi.org/10.1016/j.burns.2017.01.008 0305-4179/© 2017 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: A. Arnaout, et al., The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.008
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In case lithium ion compounds leak following a breach in the battery, first aid with mineral oil use is advocated to avoid a further chemical reaction. © 2017 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Electronic cigarettes remain fairly new, they were invented in 2003 in China, and introduced into the UK market in 2007 [1]. Most consist of three different components; a cartridge containing a liquid solution with varying amounts of nicotine, flavouring and other chemicals, a heating device (vaporizer) and a power source (usually a battery). E-cigarettes are designed to simulate the act of smoking but with less of the toxic chemicals produced by burning tobacco [2]. As they deliver nicotine without burning tobacco e-cigarettes appear as if they may be a safer, less toxic alternative to conventional cigarettes. However the health consequences of how the absorption of nicotine and other compounds found in the e-cigarette vapour such as formaldehyde and acetaldehyde may be potentially toxic or carcinogenic is unclear. In the battle to lower smoking rates the e-cigarette has been promoted as a ‘healthier way to smoke’ and a method to help people to stop smoking. However evidence thus far to show a link with smoking cessation is lacking [3,4]. There were an estimated 1.3 million e-cigarette users in 2014 and this is likely to continue to increase [5]. We have witnessed an increasing number of burns as a result of spontaneous explosions of the e-cigarettes battery across South Wales and South West of England. We present one of the largest published case series of burns from e-cigarette batteries, reviewing those already published and discussing the potential worldwide public health impact this has.
2.
Methods
A retrospective and perspective review of all e-cigarette related burns that presented to either the South Wales Burns Centre (Morriston Hospital) or to Bristol burns centre (Southmead Hospital) between October 2015 and July 2016. Retrospective patients were identified using the local the international Burn Injury Database (iBID) using terms “electronic cigarette” and “e-cigarette.” A review of literature was performed using OvidSp 1 Medline , the US National library of Medicine resources, and Google Scholar using keywords; “electronic cigarettes or ecigarettes and burns”; “electronic cigarettes or e-cigarettes and explosions” Eligible papers were identified using PRISMA 2009 Checklist. The search yielded has two case series [8,9] and three case reports [6,7,11] published in the United States of America and a recent case series [12] and case report [10] published in the United Kingdom (UK) in 2016 (Table 1).
3.
Case reports
3.1.
Case 1
A 22-year-old man placed his e-cigarette on its charger where it then shot across the room and exploded, igniting the carpet. In attempting to extinguish the fire he sustained TSBA 1% superficial partial thickness burns to both hand and the sole of right foot (Figs. 1 & 2). 1 Treatment was conservative with Jelonet based dressings, and a course of antibiotics to cover the foot burns; total time to complete healing 36 days.
3.2.
Case 2
A 22-year-old man was carrying his e-cigarette in his right trouser pocket whilst at work in a factory. It suddenly exploded and he sustained a TSBA 1% mixed depth burn to his right medial thigh and scrotum (Figs. 5 & 6), and superficial partial thickness burns to his left hand whilst trying to extinguish the flames (Fig. 3). 1 Treated conservatively initially with Jelonet based dress1 ings, followed by Simple Mepilex dressings; total time to complete healing 25 days.
3.3.
Case 3
49 year-old sales manager, had put a lithium-ion battery of his e-cigarette in his right-side pocket along with some coins. He felt the battery is heating up and suddenly burst into flames and his jeans caught fire. Sustaining a 7% TBSA superficial partial thickness (SPT) burns flame burns with a central deep dermal area (Figs. 4 & 5). 1 Treated conservatively with Mepilex Ag; total time to complete healing 20 days.
4.
Results
From our findings; 92% of injures seen were in male patients (n=11), 8% in female patients (n=1) with a mean age of 34.58 Population SD (12.7). The most common anatomical area to sustain a burn from our findings is thigh 83% (N=10) compared to the overall 74% (N=17), followed by hand 16% (N=2) overall 13% (N=3). The mean total surface body area sustained from our findings was 2.54% SD (2) of mixed depth, with a mean of 23.1 SD (5) days from presentation to complete healing with conservative management (Table 2).
Please cite this article in press as: A. Arnaout, et al., The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.008
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Table 1 – Summary of e-cigarette cases. Age Gender New Jersey March 2015 [5] South Carolina [3] Boston February 2016 [2]
California March 2016 [1] Manchester March 2016 [12] California March 2016 [4]
Dundee April 2016 [11] Bristol April–May 2016
Swansea October 2015– July 2016
Site
%TBSA (total)
%TBSA/depth
Management
30
M
R thigh
8%
N/A
N/A
28 41 26 18 26 23 35
M M M M M F M
Oral cavity Face Thigh Thigh & genitalia Oral cavity R hand & thigh R thigh
N/A N/A N/A N/A N/A 4 1.5
N/A N/A Mixed/full thickness Full thickness N/A Mixed/full thickness 1 SPT 0.5 DD/FT
Debridement +closure Suturing Debridement +SSG Debridement +SSG Debridement +closure Conservative 90 days to heal Conservative 56 days to heal
26
M
L chest & arm
1
Conservative management
39 30 50 42 49 31 28 29 63 24 22 30 22 25
M M M M M M M M M M F M M M
R thigh R thigh R thigh L thigh R thigh R thigh R thigh R thigh, abdomen & R hand Lthigh R hand Feet R thigh R thigh & genitalia L thigh
4 3 2.5 2 7 1 1 4 4 <0.5% 1 1 1 5.5
SPT & shrapnel-like superficial skin penetration 3.5 SPT 0.5 DD/FT 3 SPT 0 DD/FT 2 SPT 0.5 DD/FT 1.75 SPT 0.25 DD/FT 6 SPT 1 DD/FT 0.5 SPT 0.5 DD/FT 1 SPT 0 DD/FT 3 SPT 1 DD/FT 3.5 SPT 0.5 DD/FT SPT SPT Mixed depth SPT/DD Mixed depth SPT/DD Mixed depth SPT/DD/ FT
Debridement +SSG Conservative management Conservative 24 days to 95% heal Conservative 22 days to heal Conservative 20 days to 95% heal Conservative 23 days to heal Conservative 16 days to heal Conservative 20 days to heal Conservative 22 days to 95% heal Conservative 25 days to heal Conservative 36 days to heal Conservative 21 days to heal Conservative 25 days to heal Currently receiving treatment
The case series by Colaianni et al. [8] and by Kumetz et al. [9] 2016 reported a combined total of 5 separate individuals who presented with thermal burns as a results of spontaneous ecigarette explosions. Three of these patients sustained mixed thickness burns to legs, genitalia and/or hands requiring
grafting. While the two other patients sustained a blast type injury to their oral cavity as the e-cigarette exploded, resulting in fracture of several teeth intra-oral burns. A case study by Harrison and Hicklin [7] who reports a further case study with an intra-oral blast type injury from an e-cigarette explosion suggested there have been further multiple similar cases (estimated 7 further cases at time of publishing her case report) reported in news outlets.
Fig. 1 – Planter aspect right foot, superficial partial thickness burn to toe and midfoot.
Fig. 2 – Volar aspect right hand, superficial partial thickness burn to thumb and small areas of palm.
5.
Literature review
Please cite this article in press as: A. Arnaout, et al., The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.008
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1
Fig. 6 – Efest IMR, 18560 3.7V, 2600mAh lithium ion battery. Fig. 3 – Volar aspect left hand, superficial partial thickness to ring finger.
Table 2 – Summary of results.
Mean age Male Female Thigh Hand Oral Genitalia TBSA% Total time to heal
Fig. 4 – Left thigh, anterior mixed depth burn.
The BBC news outlet reported a nationwide alert warning following a spate of fires from exploding e-cigarette chargers in 2015, where one man died from extensive burns after his ecigarette charger ignited and caused his oxygen equipment to
Overall
34.58 SD (12.7) 92% (n =11) 8% (n = 1) 83% (n =10) 16% (n =2) 0% (n = 0) 8.3% (n =1) 2.54% SD (2) 23.1 SD (5)
32.04 SD (10.56) 91% (n =21) 8.7% (n =2) 74% (n =17) 13% (n =3) 8.7% (n =2) 8.7% (n =2) 2.88% SD (2.23) N/A
explode. Futhermore a block of flats was evacuated due to a fire believed to have originated from a charging e-cigarette [13]. The case series by Nicoll et al. [12] focused on the chemical component of the lithium battery, suggesting that e-cigarette explosions will likely result in a combined thermal and alkali burn, with a reported pH of 9–10, witnessed in the patients presenting to their unit. Leaked lithium compounds react vigorously with water and produce alkali lithium hydroxide, resulting in both thermal and chemical burns if irrigated [12,14,15].
6.
Fig. 5 – Left thigh, medial mixed depth burn.
Our findings
Discussion
The popularity of e-cigarettes amongst young people is increasing, with an estimated market worth of over £340 million in the UK alone [5]. This has attracted several e-cigarette start-ups and over 250 independent suppliers since the product launched in the UK according to Public Health England marketing group [5]. From the 20th of May 2016 e-cigarettes in the UK are regulated Tobacco Products Directive 2014 (TPD), which regulates the labelling and advertisement of these products, the nicotine based liquid; nicotine levels (up to 18mg/ml), size and presentation [16] The import and sale of these products from EU and non-EU countries remains unrestricted, and therefore the lithium battery and chargers remain unregulated and do not meet British Standard Specifications. Lithium ion cells instability and fire risk due to overcharging, over-heating, and crushing is well documented in its
Please cite this article in press as: A. Arnaout, et al., The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.008
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use in mobile phones and laptops over the past years [17–21]. More recently this has also been highlighted with the ‘Hoverboard’ seizure at UK ports and boarders by the National Trading Standards agency and their withdrawal from the market by the online store Amazon due to major safety risks identified with the lithium battery, charger and cut-off switch [22,23]. The mobile phone manufacturer Samsung also withdrew sales of their Galaxy Note 7 phone [15] after high profile media coverage of exploding batteries. Cases of e-cigarette explosions are due to the same previously identified risks with other electronic products using lithium-ion cells, however this has not received the same media coverage. Cases of e-cigarette explosions are due to the same previously identified risks with other electronic products using lithium-ion cells. The Bristol team has identified that the majority of patients 1 were using the same brand of e-cigarette (Efest IMR, 18560 3.7V, 2600mAh, ShenZhen Fest Technology Co., Ltd., Guangdong, China), Fig. 6, a similar brand of that reported by the Dundee Team [12]. Serious burns related to batteries of these cigarettes may be developing a trend in the 1st half of 2016. Rechargeable lithiumion batteries (LIB) have been in use for 20 years. Lithium-ion batteries have been reported to form dendritic arrangement of lithium around the graphite rod, which may result in internal overheating and flame. Lithium is a metal that highly reacts with water forming lithium hydroxide and hydrogen in an exothermic reaction. Lithium hydroxide is a strong alkali which can contribute to the burning process [24,25]. Several of the reported cases show that “the battery in pocket” precedes the incident [8,10,12]. The damp environment in the pocket may have sufficient moisture to start a chemical reaction within the lithium-ion battery and the presence of metal objects can produce short-circuit which can over heat the battery leading to an explosion [26]. We do not know the exact mechanism leading to the ignition of the battery, but we believe it could be multiple causes; faulty battery, over-heating, moist environment and/ or over charging. Our patients report flame as the initial cause of burn, the same as reported in the previous case reports. None of our patients reported continuous burning after presentation. But we acknowledge an element of alkaline burn could be an additional cause, although we did not perform a litmus paper test, yet it may be evident with the deeper central part of the burn, as reported in the majority of these cases.
e5
copious amount of running cold water if access to mineral oil is not available help reduce the burn. The authors recommend applying restriction of e-cigarette import to ensure all products sold within the UK market meets the British Standard Specifications and the National Trading Standards to prevent burns related to lithium battery explosions. We also advise further consumer guidance on charging and storage of e-cigarettes to reduce the risk sustaining burns. Following our contact with the National Trading standards their office issues the following advice to consumers. Consumers should only buy from reputable sellers, and they should ensure the product carries the “CE” mark on the packaging to indicate that it has been placed on the market after appropriate safety checks have been undertaken by reference to a recognised standard. Some devices and eliquids claim to have been tested to a quality standard by “SGS”, but as far as the Tranding Standards office is aware “SGS” does not undertake this type of testing/assurances, and therefore these e-cigarettes and e-liquids should be avoided. Consumers should use these devices sensibly, avoid damage or impact and in accordance with the provided instruction. The device should be charged according to the instructions and avoid re charging when the consumer is not present with the product. A further consideration is the potential for spontaneous explosion of e-cigarettes carried on aircraft. As of July this year, the TSA stated that e-cigarettes could be carried on planes in either in carry-on baggage or on person [27]. Our case series highlights the health implications of e-cigarettes for individuals, but it also raises the question of health and safety implications for the wider public, especially in high-risk areas such as aviation.
Conflict of interest Authors have no conflict of interest.
Ethics approval Not required.
Consent to participate/publish 7.
Conclusions
Despite the well documented risks of unregulated lithium batteries causing significant harm, the import of e-cigarettes remains unrestricted and below the set standard for British specifications. Due to risk of lithium ion compounds leakage following a breach in the battery, caution should be exercised in exposing these burns to irrigation with water and the use of mineral oil to cover these burns would be advocated, followed by early surgical cleaning and debridement to remove residual lithium contamination [12]. We believe the residual lithium on the skin maybe insignificant and would still advocate first aid with
Written consent available on request.
Funding Nil. No raw data available.
Acknowledgement Not applicable.
Please cite this article in press as: A. Arnaout, et al., The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.008
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REFERENCES
[1] Fire research report — e-cigarette fire risk and reported incidents Fire & Rescue New South Wales (FRNSW). NSW Government, A.D.I.D. [30 January 2015].. [2] Goniewicz ML, Knysak J, Gawron M, Kosmider L, Sobczak A, Kurek J, et al. Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control 2014;23(2): 133–9. [3] Lerner CA, Sundar IK, Yao H, Gerloff J, Ossip DJ, McIntosh S. Vapors produced by electronic cigarettes and e-juices with flavorings induce toxicity, oxidative stress, and inflammatory response in lung epithelial cells and in mouse lung. PLoS One 2015;10(2):e0116732. [4] Jensen RP, Luo W, Pankow JF, Strongin RM, Peyton DH. Hidden formaldehyde in e-cigarette aerosols. N Engl J Med 2015;372 (4):392–4. [5] Bauld L, Angus K, De AM. E-cigarette uptake and marketing: a report commissioned by Public Health England. . [6] Jablow LM, Sexton Ryan J. Spontaneous electronic cigarette explosion: a case report. Am J Med Case Rep 2015;3(4):93–4. [7] Harrison R, Hicklin Jr. D. Electronic cigarette explosions involving the oral cavity. J Am Dent Assoc 2016;147(November (11)):891–6. [8] Colaianni CA, Tapias LF, Cauley R, Sheridan R, Schulz JT, Goverman J. Injuries caused by explosion of electronic cigarette devices. Eplasty 2016;16:ic9. [9] Kumetz EA, Hurst ND, Cudnik RJ, Rudinsky SL. Electronic cigarette explosion injuries: a case series. Am J Emerg Med 2016;34(November (11)):2252-e1. [10] Walsh K, Sheikh Z, Johal K, Khwaja N. Rare case of accidental fire and burns caused by e-cigarette batteries. BMJ Case Rep 2016;2016. [11] Shastry S, Langdorf MI. Electronic vapor cigarette battery explosion causing shotgun-like superficial wounds and contusion. West J Emerg Med 2016;17(2):177–80. [12] Nicoll KJ, Rose AM, Khan MA, Quaba O, Lowrie AG. Thigh burns from exploding e-cigarette lithium ion batteries: first case series. Burns 2016;42(4):e42–6. [13] E-cigarette charger safety alert issued after spate of fires. Available from: http://www.bbc.co.uk/news/uk-33489427. [11 July 2015, 18 June 2016].
[14] Paulino JF, Busnardo NG, Afonso JC. Recovery of valuable elements from spent Li-batteries. J Hazard Mater 2008;150 (3):843–9. [15] Samsung. Samsung expands recall to all Galaxy Note7 devices. Available from: http://www.samsung.com/us/note7recall/. [13 October 2016, 16 October 2016]. [16] Agency, M.a.H.p.R. E-cigarettes: regulations for consumer products. Available from: https://www.gov.uk/guidance/ecigarettes-regulations-for-consumer-products—overview. [29 February 2016, 27 May 2016, 18 June 2016]. [17] Karabagli Y, Kose AA, Cetin C. Partial thickness burns caused by a spontaneously exploding mobile phone. Burns 2006;32 (7):922–4. [18] Rose A, Hassan Z, Falder S. Lithium-ion battery: the “minibomb” in your pocket, on your desk, and behind your wheels!. J Burn Care Res 2010;31(4):675. [19] Goodenough JB, Park KS. The Li-ion rechargeable battery: a perspective. J Am Chem Soc 2013;135(4):1167–76. [20] Xiong M, Tang H, Wang Y, Pan M. Ethylcellulose-coated polyolefin separators for lithium-ion batteries with improved safety performance. Carbohydr Polym 2014;101:1140–6. [21] Mankowski PJ, Kanevsky J, Bakirtzian P, Cugno S. Cellular phone collateral damage: a review of burns associated with lithium battery powered mobile devices. Burns 2016;42(4): e61–4. [22] Thousands of unsafe ‘hoverboards’ detained over past seven weeks. Available from: http://www.nationaltradingstandards. uk/news/thousands-of-unsafe-hoverboards-detained-overpast-seven-weeks/. [18 June 2016]. [23] Hoverboards are pulled from Amazon due to fears some models with cheap batteries can EXPLODE. Available from: http://www.dailymail.co.uk/news/article-3359241/ Hoverboards-pulled-Amazon-fears-models-cheap-batteriesEXPLODE.html. [18 June 2016]. [24] Bruno Scrosati JH, Sun Yang-Kook. Lithium-ion batteries. A look into the future. Energy Environ Sci 2011;(4):3287–95. [25] Xu K. Nonaqueous liquid electrolytes for lithium-based rechargeable batteries. Chem Rev 2004;104(10):4303–417. [26] Khundkar R, Malic C, Estela C. Burned by a battery-coin short circuit: old concept for a new burn. Burns 2010;36(1):pe4–5. [27] TSA. e-cigarette. Available from: https://apps.tsa.dhs.gov/ mytsa/cib_results.aspx?search=e-cigarette. [16 October 2016].
Please cite this article in press as: A. Arnaout, et al., The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.008
burns xxx (2017) xxx –xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Case report
The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature A. Arnaout a, *, H. Khashaba b , T. Dobbs a , F. Dewi b , S. Pope-Jones a , A. Sack b , C. Estela b, D. Nguyen a a Plastic and Reconstructive Surgery, Welsh Centre for Burns and Plastic Surgery (WCBP), Morriston Hospital, Swansea, SA6 6NL, UK b Department of Burns and Plastics, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
article info
abstract
Article history:
Introduction: Since the introduction of e-cigarettes to the UK market in 2007 their popularity
Accepted 5 January 2017
amongst young adults has significantly increased. These lithium-ion powered devices
Available online xxx
remain unregulated by the Standards Agency and as a result burns centres across the world have seen an increasing number of patients presenting with significant burns, resulting from
Keywords: Electronic cigarettes E-cigarette Explosion Burn Lithium-ion Lithium battery
poor quality batteries that appear to be liable to explode when over-heated, over-charged or incorrectly stored. Methods: Retrospective and perspective review of all e-cigarette related burns presenting to the Southwest Burns Network; South Wales Burns Centre (Morriston Hospital) or to Bristol burns centre (Southmead Hospital) between Oct 15–July 16, followed by a review of available literature performed and eligible papers identified using PRISMA 2009 Checklist. Results: South Wales Burns Centre (Morriston Hospital) (N=5), Bristol burns centre (Southmead Hospital) (N=7). 92% of injuries were seen in male patients with a mean age of 34.58 (12.7). The mean TSBA sustained 2.54% of mixed depth, most common anatomical area is the thigh 83% (n=10) with a mean 23.1(5) days to heal with conservative management. The literature search yielded 3 case series (Colaianni et al., 2016; Kumetz et al., 2016; Nicoll et al., 2016) [8,9,12] and 4 case reports (Jablow and Sexton, 2015; Harrison and Hicklin, 2016; Walsh et al., 2016; Shastry and Langdorf, 2016) [6,7,10,11]. We compare our findings with the published studies. Conclusion: The import and sale of e-cigarettes remains unrestricted. This increases the risk of devices being available in the UK market that do not meet the British Standard Specification, potentially increasing their risk of causing fire and exploding. Consumers should be made aware of this risk, and advised of adequate charging and storage procedures.
* Corresponding author. E-mail addresses: [email protected], [email protected] (A. Arnaout), [email protected] (H. Khashaba), [email protected] (T. Dobbs), [email protected] (F. Dewi), [email protected] (S. Pope-Jones), [email protected] (A. Sack), [email protected] (C. Estela), [email protected] (D. Nguyen). http://dx.doi.org/10.1016/j.burns.2017.01.008 0305-4179/© 2017 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: A. Arnaout, et al., The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.008
JBUR 5156 No. of Pages 6
e2
burns xxx (2017) xxx –xxx
In case lithium ion compounds leak following a breach in the battery, first aid with mineral oil use is advocated to avoid a further chemical reaction. © 2017 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Electronic cigarettes remain fairly new, they were invented in 2003 in China, and introduced into the UK market in 2007 [1]. Most consist of three different components; a cartridge containing a liquid solution with varying amounts of nicotine, flavouring and other chemicals, a heating device (vaporizer) and a power source (usually a battery). E-cigarettes are designed to simulate the act of smoking but with less of the toxic chemicals produced by burning tobacco [2]. As they deliver nicotine without burning tobacco e-cigarettes appear as if they may be a safer, less toxic alternative to conventional cigarettes. However the health consequences of how the absorption of nicotine and other compounds found in the e-cigarette vapour such as formaldehyde and acetaldehyde may be potentially toxic or carcinogenic is unclear. In the battle to lower smoking rates the e-cigarette has been promoted as a ‘healthier way to smoke’ and a method to help people to stop smoking. However evidence thus far to show a link with smoking cessation is lacking [3,4]. There were an estimated 1.3 million e-cigarette users in 2014 and this is likely to continue to increase [5]. We have witnessed an increasing number of burns as a result of spontaneous explosions of the e-cigarettes battery across South Wales and South West of England. We present one of the largest published case series of burns from e-cigarette batteries, reviewing those already published and discussing the potential worldwide public health impact this has.
2.
Methods
A retrospective and perspective review of all e-cigarette related burns that presented to either the South Wales Burns Centre (Morriston Hospital) or to Bristol burns centre (Southmead Hospital) between October 2015 and July 2016. Retrospective patients were identified using the local the international Burn Injury Database (iBID) using terms “electronic cigarette” and “e-cigarette.” A review of literature was performed using OvidSp 1 Medline , the US National library of Medicine resources, and Google Scholar using keywords; “electronic cigarettes or ecigarettes and burns”; “electronic cigarettes or e-cigarettes and explosions” Eligible papers were identified using PRISMA 2009 Checklist. The search yielded has two case series [8,9] and three case reports [6,7,11] published in the United States of America and a recent case series [12] and case report [10] published in the United Kingdom (UK) in 2016 (Table 1).
3.
Case reports
3.1.
Case 1
A 22-year-old man placed his e-cigarette on its charger where it then shot across the room and exploded, igniting the carpet. In attempting to extinguish the fire he sustained TSBA 1% superficial partial thickness burns to both hand and the sole of right foot (Figs. 1 & 2). 1 Treatment was conservative with Jelonet based dressings, and a course of antibiotics to cover the foot burns; total time to complete healing 36 days.
3.2.
Case 2
A 22-year-old man was carrying his e-cigarette in his right trouser pocket whilst at work in a factory. It suddenly exploded and he sustained a TSBA 1% mixed depth burn to his right medial thigh and scrotum (Figs. 5 & 6), and superficial partial thickness burns to his left hand whilst trying to extinguish the flames (Fig. 3). 1 Treated conservatively initially with Jelonet based dress1 ings, followed by Simple Mepilex dressings; total time to complete healing 25 days.
3.3.
Case 3
49 year-old sales manager, had put a lithium-ion battery of his e-cigarette in his right-side pocket along with some coins. He felt the battery is heating up and suddenly burst into flames and his jeans caught fire. Sustaining a 7% TBSA superficial partial thickness (SPT) burns flame burns with a central deep dermal area (Figs. 4 & 5). 1 Treated conservatively with Mepilex Ag; total time to complete healing 20 days.
4.
Results
From our findings; 92% of injures seen were in male patients (n=11), 8% in female patients (n=1) with a mean age of 34.58 Population SD (12.7). The most common anatomical area to sustain a burn from our findings is thigh 83% (N=10) compared to the overall 74% (N=17), followed by hand 16% (N=2) overall 13% (N=3). The mean total surface body area sustained from our findings was 2.54% SD (2) of mixed depth, with a mean of 23.1 SD (5) days from presentation to complete healing with conservative management (Table 2).
Please cite this article in press as: A. Arnaout, et al., The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.008
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Table 1 – Summary of e-cigarette cases. Age Gender New Jersey March 2015 [5] South Carolina [3] Boston February 2016 [2]
California March 2016 [1] Manchester March 2016 [12] California March 2016 [4]
Dundee April 2016 [11] Bristol April–May 2016
Swansea October 2015– July 2016
Site
%TBSA (total)
%TBSA/depth
Management
30
M
R thigh
8%
N/A
N/A
28 41 26 18 26 23 35
M M M M M F M
Oral cavity Face Thigh Thigh & genitalia Oral cavity R hand & thigh R thigh
N/A N/A N/A N/A N/A 4 1.5
N/A N/A Mixed/full thickness Full thickness N/A Mixed/full thickness 1 SPT 0.5 DD/FT
Debridement +closure Suturing Debridement +SSG Debridement +SSG Debridement +closure Conservative 90 days to heal Conservative 56 days to heal
26
M
L chest & arm
1
Conservative management
39 30 50 42 49 31 28 29 63 24 22 30 22 25
M M M M M M M M M M F M M M
R thigh R thigh R thigh L thigh R thigh R thigh R thigh R thigh, abdomen & R hand Lthigh R hand Feet R thigh R thigh & genitalia L thigh
4 3 2.5 2 7 1 1 4 4 <0.5% 1 1 1 5.5
SPT & shrapnel-like superficial skin penetration 3.5 SPT 0.5 DD/FT 3 SPT 0 DD/FT 2 SPT 0.5 DD/FT 1.75 SPT 0.25 DD/FT 6 SPT 1 DD/FT 0.5 SPT 0.5 DD/FT 1 SPT 0 DD/FT 3 SPT 1 DD/FT 3.5 SPT 0.5 DD/FT SPT SPT Mixed depth SPT/DD Mixed depth SPT/DD Mixed depth SPT/DD/ FT
Debridement +SSG Conservative management Conservative 24 days to 95% heal Conservative 22 days to heal Conservative 20 days to 95% heal Conservative 23 days to heal Conservative 16 days to heal Conservative 20 days to heal Conservative 22 days to 95% heal Conservative 25 days to heal Conservative 36 days to heal Conservative 21 days to heal Conservative 25 days to heal Currently receiving treatment
The case series by Colaianni et al. [8] and by Kumetz et al. [9] 2016 reported a combined total of 5 separate individuals who presented with thermal burns as a results of spontaneous ecigarette explosions. Three of these patients sustained mixed thickness burns to legs, genitalia and/or hands requiring
grafting. While the two other patients sustained a blast type injury to their oral cavity as the e-cigarette exploded, resulting in fracture of several teeth intra-oral burns. A case study by Harrison and Hicklin [7] who reports a further case study with an intra-oral blast type injury from an e-cigarette explosion suggested there have been further multiple similar cases (estimated 7 further cases at time of publishing her case report) reported in news outlets.
Fig. 1 – Planter aspect right foot, superficial partial thickness burn to toe and midfoot.
Fig. 2 – Volar aspect right hand, superficial partial thickness burn to thumb and small areas of palm.
5.
Literature review
Please cite this article in press as: A. Arnaout, et al., The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.008
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1
Fig. 6 – Efest IMR, 18560 3.7V, 2600mAh lithium ion battery. Fig. 3 – Volar aspect left hand, superficial partial thickness to ring finger.
Table 2 – Summary of results.
Mean age Male Female Thigh Hand Oral Genitalia TBSA% Total time to heal
Fig. 4 – Left thigh, anterior mixed depth burn.
The BBC news outlet reported a nationwide alert warning following a spate of fires from exploding e-cigarette chargers in 2015, where one man died from extensive burns after his ecigarette charger ignited and caused his oxygen equipment to
Overall
34.58 SD (12.7) 92% (n =11) 8% (n = 1) 83% (n =10) 16% (n =2) 0% (n = 0) 8.3% (n =1) 2.54% SD (2) 23.1 SD (5)
32.04 SD (10.56) 91% (n =21) 8.7% (n =2) 74% (n =17) 13% (n =3) 8.7% (n =2) 8.7% (n =2) 2.88% SD (2.23) N/A
explode. Futhermore a block of flats was evacuated due to a fire believed to have originated from a charging e-cigarette [13]. The case series by Nicoll et al. [12] focused on the chemical component of the lithium battery, suggesting that e-cigarette explosions will likely result in a combined thermal and alkali burn, with a reported pH of 9–10, witnessed in the patients presenting to their unit. Leaked lithium compounds react vigorously with water and produce alkali lithium hydroxide, resulting in both thermal and chemical burns if irrigated [12,14,15].
6.
Fig. 5 – Left thigh, medial mixed depth burn.
Our findings
Discussion
The popularity of e-cigarettes amongst young people is increasing, with an estimated market worth of over £340 million in the UK alone [5]. This has attracted several e-cigarette start-ups and over 250 independent suppliers since the product launched in the UK according to Public Health England marketing group [5]. From the 20th of May 2016 e-cigarettes in the UK are regulated Tobacco Products Directive 2014 (TPD), which regulates the labelling and advertisement of these products, the nicotine based liquid; nicotine levels (up to 18mg/ml), size and presentation [16] The import and sale of these products from EU and non-EU countries remains unrestricted, and therefore the lithium battery and chargers remain unregulated and do not meet British Standard Specifications. Lithium ion cells instability and fire risk due to overcharging, over-heating, and crushing is well documented in its
Please cite this article in press as: A. Arnaout, et al., The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.008
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use in mobile phones and laptops over the past years [17–21]. More recently this has also been highlighted with the ‘Hoverboard’ seizure at UK ports and boarders by the National Trading Standards agency and their withdrawal from the market by the online store Amazon due to major safety risks identified with the lithium battery, charger and cut-off switch [22,23]. The mobile phone manufacturer Samsung also withdrew sales of their Galaxy Note 7 phone [15] after high profile media coverage of exploding batteries. Cases of e-cigarette explosions are due to the same previously identified risks with other electronic products using lithium-ion cells, however this has not received the same media coverage. Cases of e-cigarette explosions are due to the same previously identified risks with other electronic products using lithium-ion cells. The Bristol team has identified that the majority of patients 1 were using the same brand of e-cigarette (Efest IMR, 18560 3.7V, 2600mAh, ShenZhen Fest Technology Co., Ltd., Guangdong, China), Fig. 6, a similar brand of that reported by the Dundee Team [12]. Serious burns related to batteries of these cigarettes may be developing a trend in the 1st half of 2016. Rechargeable lithiumion batteries (LIB) have been in use for 20 years. Lithium-ion batteries have been reported to form dendritic arrangement of lithium around the graphite rod, which may result in internal overheating and flame. Lithium is a metal that highly reacts with water forming lithium hydroxide and hydrogen in an exothermic reaction. Lithium hydroxide is a strong alkali which can contribute to the burning process [24,25]. Several of the reported cases show that “the battery in pocket” precedes the incident [8,10,12]. The damp environment in the pocket may have sufficient moisture to start a chemical reaction within the lithium-ion battery and the presence of metal objects can produce short-circuit which can over heat the battery leading to an explosion [26]. We do not know the exact mechanism leading to the ignition of the battery, but we believe it could be multiple causes; faulty battery, over-heating, moist environment and/ or over charging. Our patients report flame as the initial cause of burn, the same as reported in the previous case reports. None of our patients reported continuous burning after presentation. But we acknowledge an element of alkaline burn could be an additional cause, although we did not perform a litmus paper test, yet it may be evident with the deeper central part of the burn, as reported in the majority of these cases.
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copious amount of running cold water if access to mineral oil is not available help reduce the burn. The authors recommend applying restriction of e-cigarette import to ensure all products sold within the UK market meets the British Standard Specifications and the National Trading Standards to prevent burns related to lithium battery explosions. We also advise further consumer guidance on charging and storage of e-cigarettes to reduce the risk sustaining burns. Following our contact with the National Trading standards their office issues the following advice to consumers. Consumers should only buy from reputable sellers, and they should ensure the product carries the “CE” mark on the packaging to indicate that it has been placed on the market after appropriate safety checks have been undertaken by reference to a recognised standard. Some devices and eliquids claim to have been tested to a quality standard by “SGS”, but as far as the Tranding Standards office is aware “SGS” does not undertake this type of testing/assurances, and therefore these e-cigarettes and e-liquids should be avoided. Consumers should use these devices sensibly, avoid damage or impact and in accordance with the provided instruction. The device should be charged according to the instructions and avoid re charging when the consumer is not present with the product. A further consideration is the potential for spontaneous explosion of e-cigarettes carried on aircraft. As of July this year, the TSA stated that e-cigarettes could be carried on planes in either in carry-on baggage or on person [27]. Our case series highlights the health implications of e-cigarettes for individuals, but it also raises the question of health and safety implications for the wider public, especially in high-risk areas such as aviation.
Conflict of interest Authors have no conflict of interest.
Ethics approval Not required.
Consent to participate/publish 7.
Conclusions
Despite the well documented risks of unregulated lithium batteries causing significant harm, the import of e-cigarettes remains unrestricted and below the set standard for British specifications. Due to risk of lithium ion compounds leakage following a breach in the battery, caution should be exercised in exposing these burns to irrigation with water and the use of mineral oil to cover these burns would be advocated, followed by early surgical cleaning and debridement to remove residual lithium contamination [12]. We believe the residual lithium on the skin maybe insignificant and would still advocate first aid with
Written consent available on request.
Funding Nil. No raw data available.
Acknowledgement Not applicable.
Please cite this article in press as: A. Arnaout, et al., The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.008
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Please cite this article in press as: A. Arnaout, et al., The Southwest UK Burns Network (SWUK) experience of electronic cigarette explosions and review of literature, Burns (2017), http://dx.doi.org/10.1016/j.burns.2017.01.008