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REVIEW ARTICLE

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Exploding power: a statewide review of lithium battery related burns

Jason Diab MBBS MIPH MSurg,1,2,4,5 Justine O’Hara FRACS MBBS (Hons) BSC,2,4 Andrea Issler-Fisher MD,2,4 Erik La Hei MBBS FRACS,1,4 Robert Gates MBBS FRACS,1,3 John Vandervord MBBS FRACS,1,3 Andrew JA Holland MBBS PhD FRACS,1,4 Peter K Maitz AM MD FRACS2,4

1

The Children’s Hospital at Westmead
Westmead, New South Wales,
AUSTRALIA

2

Concord Repatriation General Hospital
Concord, New South Wales,
AUSTRALIA

3

Royal North Shore Hospital
St Leonards, New South Wales, AUSTRALIA

4

The University of Sydney
Camperdown, New South Wales, AUSTRALIA

5

School of Medicine
University of Notre Dame
Sydney, New South Wales,
AUSTRALIA

OPEN ACCESS
Correspondence
Name: Dr Jason Diab
Address: Concord Hospital
Hospital Road
Concord, New South Wales
AUSTRALIA
Email: [email protected]
Phone: +61 (0)2 984 5000

Article information
Citation
: Diab J, O’Hara J, Fisher A-I, Hei EL, Gates R, Vandervord J, Holland AJA, Maitz PK. Exploding power: a statewide review of lithium battery related burns. Australas J Plast Surg. 2021;4(2):44–52.
DOI: https://doi.org/10.34239/ajops.v4n2.247
Manuscript received: 1 August 2020
Manuscript revised: 2 November 2020, 27 December 2020, 12 January 2021
Manuscript accepted: 24 January 2021
Published: 30 September 2021
Copyright © 2021. Authors retain their copyright in the article. This is an open access article distributed under the Creative Commons Attribution Licence 4.0 which permits unrestricted use, distribution and reproduction in any medium, provided the original work is properly cited.
Section: Burns


Abstract

Introduction: With the increase of lithium battery devices, including electronic cigarettes and battery power banks, there has been a steady rise in burn injuries secondary to device malfunction. These devices may cause chemical or flame burns. Our aim was to identify and classify epidemiological trends of explosions from lithium battery devices across the state of New South Wales (NSW), Australia.

Methods: A review of the NSW Burn Injury Service (SBIS) database from January 2005–December 2019, together with medical records from the burns units at the Children’s Hospital at Westmead (CHW), the Concord Repatriation General Hospital (CRGH) and the Royal North Shore Hospital (RNSH) was conducted. All patients who suffered a burn secondary from a lithium battery device were included and data was extracted on mechanism of injury, severity of injury and management. This study was approved by the ethics committees of CHW, RNSH and CRGH [2020/PID00179].

Results: Of the 24 patients identified, six were paediatric and 18 were adults. The majority were male (7:1) with a mean age of 29.0 (± 16.6 years). The mean total body surface area burnt was 2.5 per cent   (± 0.9) [range 0.1–21.0%]. The majority occurred after 2014 and involved spontaneous explosions. Their injuries ranged from partial to full thickness burns with flame being the most common type (n=15). Three quarters of the cases (n=18) occurred in a home setting.

Conclusions: Lithium battery device explosions can result in a mix of burn depth injuries from flame, contact and electrical, or chemical burns. Consumers need to be made more aware of the potential risks associated with use of lithium battery powered devices.

Keywords: lithium, explosions, patient safety, electronic nicotine delivery systems, New South Wales


Introduction

Lithium ion batteries are highly powered and efficient sources of energy used to power many devices from mobile phones, power tools and vehicles.1 Lithium is the third lightest element with the lowest reduction potential of any element: this allows high gravimetric, volumetric capacity and power density providing a higher charger capacity per ion.2 Lithium batteries are composed of four main components: an anode, cathode, separator and electrolyte. The electrolyte in a lithium-ion battery is intrinsically flammable resulting in an exothermic chemical reaction.3 Commercially, there are variations in lithium ion batteries based on cell design, chemistry and size. Short circuiting is a common concern among many batteries that can lead to dramatic changes in the electrochemical structure of the battery resulting in local heat generation and transfer.4 This ‘thermal runaway’ phenomenon is an exothermic event that leads to elevated temperatures up to 80 °C which cracks the electrode material and surrounding structures impeding detection of temperature differences and leading to risk of fire and explosion.5,6 There are safety measures in place for some devices such as pressure burst discs, shutdown separators, and one-shot fuses.7

In recent years lithium batteries have gained attention for their potential in harvesting energy in grid systems but also for the risk of serious burn injuries in children and adults from portable electronic devices and e-cigarettes. The popularity of e-cigarettes has risen since 2007 with changes to tobacco regulation, attitudes and market factors across countries.8–10 There have been worldwide reports about the occurrences of explosions related to these devices leading to fires and explosions in phones, electronic scooters, vehicles and airplanes.11–14 Anecdotally, we noted a surprising number of burn cases in both children and adults related to lithium battery explosions that prompted an audit of these specific types.

The aim of this study was to describe the epidemiology, mechanism of injury and clinical outcomes of lithium battery related burns across three major tertiary centres in New South Wales (NSW), Australia. The secondary objective was to analyse and explore the preventative measures and policies.

Methods

The NSW Statewide Burn Injury Service (SBIS) has three major units that treat burns including two adult services—Concord Repatriation General Hospital (CRGH) and Royal North Shore Hospital (RNSH)—and one paediatric service, the Children’s Hospital at Westmead (CHW). Each year, over 2000 patients combined are treated in these units for burn related injuries. A 15-year retrospective review of the NSW SBIS database was conducted from January 2005–December 2019 including patients of all ages with burns caused related to lithium battery devices such as phone batteries, chargeable devices or e-cigarettes. This study was approved by the ethics committees of CHW, RNSH and CRGH [2020/PID00179].

Data were collected from the SBIS database including information on: sex, time and location of injury, total burn surface area (TBSA), operative intervention, length of stay and surgical complications. A statistical analysis using IBM SPSS Statistics version 26.0 (SSP Inc, 233 S Waker Drive, 11th floor, Chicago, Illinois 60606-6307, USA) was computed for continuous variables assessing the relationship between linear data and correlation based on a level of significance (p value=0.05). The continuous variables were expressed as mean, standard deviation (SD), percentages and range. The differences between proportions were analysed using Pearson’s chi-squared test for the device of injury and type of burn from categorical data.

Analysis

Patient profile

Twenty-four patients presented with burns related to lithium batteries with a 7:1 male predominance. Patients age was normally distributed ranging from 1 to 58 years with a mean age of 29.0 (± SD 16.6) years. The mean TBSA burnt was 2.5 per cent (± SD 0.9; range 0.1–21%). Nearly all patients sustained minor burns (less than 10.0% TBSA), however, TBSA was positively skewed with an outlier of 21.0 per cent sustained from a battery charging device explosion that caused a house fire. The majority of cases were flame burns (n=15), followed by chemical burns (n=4), contact burns (n=3) and electrical burns (n=2). There were six (25%) paediatric patients and the remaining 18 cases were adults. Three quarters of the cases (n=18) occurred in the home setting. The majority of cases occurred after the year 2014.

Injury profile

The most common source of injury originated from phone batteries (n=11), portable charging batteries (n=10) and e-cigarette devices (n=3). The administration of cool running water for a minimum of 20 minutes as first aid was identified in 14 cases (58%). The most common site affected was the lower limb (n=9) notably the thigh (Figure 1), followed by the upper limbs and multiple regions respectively (n=6). The majority of injuries occurred in summer (n=11). Most patients presented to an outpatient clinic (n=21). Ten patients sustained full thickness injuries, followed by mid dermal injuries (n=8) and the remaining superficial injuries (n=6) (Table 1). Phone battery devices and charging devices resulted in a spectrum of superficial, mid dermal and full thickness injuries (Figure 2). E-cigarette devices all resulted in full thickness injuries. There was a statistically significant association between the device of injury and degree of burn (p = 0.04).

Fig 1. A 37-year-old man who sustained full thickness injury to the left thigh from an e-cigarette explosion (case 16)

Fig 2. A comparison of battery devices to the degree of burn
Table 1: Demographic and clinical patient data of lithium battery related burns
Case Sex Age (yrs) Time Device Burn type First Aid TBSA % Site of injury Depth of burn Operation Complications
Paediatric
1 M 1 Jan 2009
Phone Chemical Adequate 0.7 Face Superficial Dressings 0
2 M 1 Nov 2010 Phone Electrical Adequate 0.6 Hand Deep Dressings 0
3 F 3 Dec 2018 Battery Chemical Inadequate 0.2 Hand Mid dermal Dressings 0
4 M 4 Jan 2019 Phone Flame Adequate 5.0 Trunk, hand Deep Skin graft 0
5 M 12 Sep 2008 Battery Electrical Adequate 0.8 Hand Superficial Dressings 0
6 M 12 May 2018 Phone Flame Adequate 0.5 Thigh Superficial Dressings 0
Adult
7 M 19 Sep 2015
Battery Flame Inadequate 0.2 Hand, foot Mid dermal Dressings 0
8 F 22 Feb 2016 Phone Chemical Inadequate 0.1 Leg Superficial Dressings 0
9 F 29 Oct 2014 Phone Contact Inadequate 0.5 Hand Superficial Dressings 0
10 M 29 May 2016 Phone Flame Adequate 2.0 Leg Deep Dressings 0
11 M 31 Sep 2014 Phone Flame Inadequate 0.5 Arm, hands Mid dermal Dressings 0
12 M 31 Feb 2018 Battery Flame Adequate 2.0 Arms, thigh Mid dermal Dressings 0
13 M 34 Jun 2018
E-cigarette Flame Adequate 2.0 Thigh Deep Dressings 0
14 M 35 Jan 2012 Battery device Contact Inadequate 1.0 Thigh Deep Skin graft 0
15 M 36 Jul 2016 Phone Contact Inadequate 1.0 Thigh Deep Skin graft 0
16 M 37 Oct 2016 E-cigarette Flame Adequate 9.0 Thigh Deep Skin graft Wound infection, (length of stay 15 days)
17 M 37 Nov 2016 Phone Flame Inadequate 0.2 Face Superficial Dressings 0
18 M 37 Jun 2018 Battery device Flame Adequate 0.1 Hand Mid dermal Dressings 0
19 M 38 Mar 2017
E-cigarette Flame Adequate 6.0 Hand, thigh, genital Deep Xenograft dressing 0 (length of stay 7 days)
20 M 39 Dec 2017 E-cigarette Flame Adequate 0.6 Arm, thigh Deep Skin graft 0
21 M 46 Sep 2005 Phone Flame Inadequate 3.0 Face Mid dermal Dressings 0
22 M 46 Jun 2008 Battery device Chemical Adequate 3.0 Thigh Mid dermal Dressings 0
23 M 58 Apr 2014 Phone Flame Inadequate 21.0 Thigh, hands, feet Deep Xenograft dressing Wound infection, (length of stay 24 days)
24 M 58 Jan 2019 E-cigarette Flame Adequate 0.3 Trunk, hands Mid dermal Dressings 0
TBSA=total burn surface area

Management

The majority of these cases (n=17) were managed conservatively with manual debridement and dressings. The remaining seven cases required operative intervention involving either split thickness skin graft (n=5) or xenograft dressings (n=2). There was one outlier case (case 23) with 21.0 per cent TBSA who required multiple operations and suffered burn wound infection. Most cases (n=21) were managed in the outpatient clinic setting, however, the three full thickness injuries that were operated on had a length of stay ranging from seven to 21 days. The three full thickness injuries included spontaneous explosive flame burns from an e-cigarette device, phone battery and chargeable device respectively. Table 2 provides a summary of the patient characteristics and type of devices associated with the burn injury.

Table 2: Summary of demographic and clinical variables for lithium battery burns
Demography
Age (years)
Mean (SD) 29.0 (±- 16.6)
Range 1 - 58
Sex
Male 21
Female 3
Groups
Paediatric 6
Adult 18
Clinical variables
Total burn surface area
Mean (SD) 2.5% (± 0.9)
Range 0.1–21%
Device (p=0.04)
Phone batteries 11
Portable charging batteries 10
E-cigarettes 3
First aid adequacy
Yes 14
No 10
Site of injury
Face 3
Upper limb 6
Lower limb 9
Multiple regions 6
Depth of burn (p=0.04)
Superficial 10
Mid dermal 8
Full thickness 6
Management
Conservative 17
Operative 7
Postoperative complications
Wound infection 3
                   

Discussion

This first Australian case series of burn injuries related to lithium batteries highlights the variation in presentation with a strong male predominance and complexity of managing burns from a health professional and public health advocacy perspective. The trends in incidents relating to lithium batteries are growing at a significant rate globally with variations in the presentation of burn types related to device use and popularity at the time.15 The types of explosive injuries have the potential for a mixture of flame, chemical, electrical and contact burns resulting in different types of injuries to soft and/or hard tissues.

Paediatric

The paediatric age group had a total of six cases including flame, chemical and electrical burns with an equal number related to a phone or battery device exploding. These presentations highlight the importance of history and examination in guiding optimal management. Jones and colleagues 2019 case series on e-cigarette burns recommended initial management with mineral oil as water is contraindicated for lithium due to a risk of exothermic injury to tissues.16 For the initial assessment of a burn in an emergency department or clinic this seems valid, however, all of the paediatric injuries occurred at home where running water, as adequate first aid in the immediate setting, has priority. Detailed history from parents reported spontaneous explosions with no awareness that a device was heating up prior to an event. The danger is even greater if an actual blast explosion occurs as airways can be compromised with the release of toxic substances such as carbon monoxide, carbon dioxide and hydrogen fluoride which pose serious health threats in confined environments.17

Adult

E-cigarettes

Commonly known as vaping, e-cigarettes use lithium batteries to convert liquid nicotine into perfumed vapour. A literature review on adolescences smoking e-cigarettes found that they are more likely to be male, of older age, have a higher amount of pocket money, smoke regularly and heavily and have peers who smoke.18,19 Our adult age group had a total of 18 cases with a mix of burn types including flame, chemical, electrical and contact burns with more males affected than females. Interestingly, our series did not reflect the many reported global cases of explosion injuries from e-cigarettes resulting in serious soft and hard tissue injuries of the face, limbs and neck.20–25 Our experience noted an increase in findings of e-cigarette related burns from 2016 onwards reflective of the growing popularity of these devices and consistent with an increase of e-cigarette use reported from 2016 to 2019 in Australia.26 Data from the Burns Registry of Australia and New Zealand (BRANZ) in New Zealand reflects similar trends to our experience with notable incidences of malfunctioning phone devices, portable charging devices and e-cigarettes relating to fires reported from 2014 onwards.27

Ramirez and colleagues' 2017 series of 30 patients who had injuries from e-cigarettes reported a male predominance of mean age 30 years with thighs, hands and genitalia commonly affected (mean TBSA of 4.0%) and nine patients requiring surgery.28 Our three e-cigarette explosions involved spontaneous combustion in the pocket that resulted in full thickness injuries to the lower and upper limbs (TBSA 0.6 – 9.0%), where two of three patients required debridement and split thickness skin grafting. These spontaneous explosions raise questions about manufacturing standards and the safety of devices. None of the patients in our series were carrying metallic objects in the same pocket as the e-cigarette when the explosion occurred, as has been reported elsewhere.29,30

Seitz and colleagues' 2018 systematic review of 164 cases showed that most patients were male (9:1) between the age of 20–29 years with the majority (65%) of e-cigarettes exploding in pockets leading to thigh and genital burns, compared to exploding in the face or hand. The burns were typically deep partial burns (35%) or a combination of deep partial or full thickness burns (20%) with 48 patients (29%) required skin grafting with a median hospital stay of five days.31 To ensure prevention of ‘thermal runway’ and safe designs, Brown and Cheng recommend that manufacturers use circuits that protect against overcharging, integrate cut-offs for thermal power, and use internal overpressure relief mechanisms.32

Phone devices and chargeable devices

Case reports have documented spontaneous explosions of phone devices with and without the use of charging stations and without warning about overheating.33–35 In the media, there have been safety reports from mobile phone manufacturers leading to recalls of devices due to short-circuiting.36 These devices, similar to e-cigarettes, have potential to cause a combination of chemical, flame and contact burns with potential to cause significant disability and the need for ongoing rehabilitation. Their proximity to thighs and hands while in use risks serious morbidity owing to the potential for soft and hard tissue damage caused by these types of explosions.

There appears to be more literature on e-cigarette devices exploding than phone devices, however, our series showed a wide variety of injuries from phone devices in children and adults prior to 2014 when e-cigarette popularity increased significantly. Manufacturers have created internal devices to detect and monitor electrochemical changes that may lead to explosions including: thermal stability separators that detect variations in temperature, solid electrolytes which are less combustible and flame retardants such as polymer binders in the device framework to reduce fires in solid state materials.37

Recommendations

We recommend stronger transparency for public education and access regarding safe use including clearly labelled lithium batteries with key standards for safe operation such as maximum charging rate, cell voltage and correct charging with safe disposal.38,39

Globally, the standards for battery operating equipment and testing fall under different jurisdictions with no international consensus on industry design and performance-based test methodologies.40 There are gaps between the industry, research, fire departments, consumers, stakeholders and burns units where collaboration and sharing of information about these incidents could help to facilitate improvements, integration and harmony across sectors. As a result of these potential dangers, The International Civil Aviation Organization has prohibited airplane passengers and crew from carrying e-cigarettes and other battery-powered portable electronic smoking devices in checked baggage, and from recharging the devices in aircraft cabins.41 Health professionals must therefore advocate for consumers for safety warnings of potential explosions and inform the Australian Competition and Consumer Commission (ACCC) when injuries occur.42

Limitations

The limitations of this study reflect the retrospective nature of the data collection process. Since the rise of e-cigarettes in 2007, and particularly after 2014, we have noted more cases presenting to burns units but this may not have been captured in the data at the time. The small sample size, collected over a period of 15 years, reflects the limited research that has been undertaken in Australia and New Zealand on the number and impact of lithium battery related burns. With a small sample size, descriptive statistics highlight interesting points and statistical association between depth burn and devices. This research is one of the largest series specifically on lithium battery devices that will add value to the growing literature and incidents reported on related fires and how to better educate consumers and health professionals.

A further limitation with the collection of data was the lack of objective measurement tools for burn depth assessment such as laser Doppler imaging and therefore may be subject to inter-observer bias. Burn depth is most often assessed clinically and there are some variations in treatment across units.

This statewide case series highlights the impact these injuries have on both paediatric and adult patients with potential for soft and hard tissue injury. Health professionals should be informed about trends associated with the use of lithium-ion powered battery devices.

Conclusion

Lithium battery related burn injuries pose a modern challenge for burns professionals and health practitioners and a serious risk to children and adults of soft and hard tissue injuries from a combination of flame, chemical, electrical and contact burns. The nature of the injury and the severity of depth related to these everyday devices beckons regulation on the manufacturing and improved dissemination of safety information.

Acknowledgements

We would like to extend our acknowledgement to the burns team members at all three units who provided ongoing support for this research. We wish to thank Anne Darton and the SBIS Data Registry of the NSW Agency for Clinical Innovation for their assistance with data acquisition.

Patient consent

Patients/guardians have given informed consent to the publication of images and/or data.

Disclosure

The authors have no conflicts of interest to disclose.

Financial declaration

The authors received no financial support for the research, authorship, and/or publication of this article.

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