a b s t r a c t

Since its introduction on the market in 2007, the number of reports on injuries caused by the ignition or explosion of electronic nicotine delivery systems (ENDS) has increased significantly.

Two male patients have been treated at our Burn center, the for ENDS-related injuries. Their batteries came into contact with metal objects stored in their pants pockets, resulting in a short circuit and finally ignition. In both patients, the combined flame and chemical burn wounds were initially irrigated with water upon arrival at the emergency department, leading to increased levels of pain. In our burn center, the wounds were extensively cleansed which led to a subsequent drop in NRS-scores. Laser Doppler Imaging showed a clear indication for sur- gery as both patients suffered a partial-thickness burn, with one patient having a patch of full-thickness burn as well. We swiftly performed an enzymatic debridement in both patients, followed by conservative wound man- agement. Although enzymatic debridement is not generally recommended in the treatment of chemical burns, we successfully made use of this treatment option.

Different authors advocate the use of mineral oils to irrigate or cover alkali burns, as contact between the chem- ical compounds and water can set off an exothermic reaction, leading to further injury. We believe that a hyper- tonic rinsing solution could be recommended as well in an emergency setting and we want to stress the importance of rapid removal of the chemical compounds in suspected chemical burns as well as swift debridement.

(C) 2020

1. Introduction

Since its introduction on the market in 2007, the popularity of elec- tronic nicotine delivery systems (ENDS) among young adults has in- creased significantly and it has even surpassed that of smoking tobacco products [1]. These devices are designed to simulate the act of smoking, though with less of the toxic chemicals produced by burning tobacco [2]. Nevertheless, evidence establishing a link with smoking cessation is still lacking [3,4].

ENDS are increasingly seen by the general public, as a less harmful alternative to Traditional methods of inhaled Tobacco use [5]. However, several recent studies have described a newly identified lung disease,

? This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

* Corresponding author at: C. Heymanslaan 10, 9000 Ghent, Belgium.

E-mail addresses: [email protected] (K.E.Y. Claes), [email protected] (T. Vyncke), [email protected] (E. De Wolf), [email protected] (H. Hoeksema), [email protected] (J. Verbelen), [email protected] (S. Monstrey).

¹ Equal contribution as first author.

linked to ENDS use: E-cigarette or Vaping product use-Associated Lung Injury (EVALI) [6-8]. The Long-term effects however, are unknown and the general public is insufficiently informed about the known ad- verse health effects including the risk of traumatic and burn injuries [5]. The power source of ENDS is generally a (rechargeable) lithium-ion battery which can be susceptible to overheating, ignition and/or explo- sion, usually as a result of thermal runaway [9]. This happens when in- creases in temperature and pressure cause the battery to rupture, and potentially ignite and/or explode [10]. In recent years, the number of re- ports worldwide on injuries due to overheating, ignition and/or explo- sion of these devices, has increased significantly. Between 2015 and 2017, there were an estimated 2035 ENDS explosion and burn injuries presenting to US hospital emergency departments (95% CI:

1107-2964) [11].

We hereby present two cases in which we used extensive conven- tional wound cleansing followed by enzymatic debridement as a treat- ment for ENDS-related deep partial- and full-thickness burns and we describe how these potentially complicated wounds should be initially managed. Approval for this project was obtained by the ethical commit- tee of our hospital, nr. 2019-1592.

https://doi.org/10.1016/j.ajem.2020.02.030

0735-6757/(C) 2020

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1. Cases
   1. Case 1

A 45-year-old male sustained a Burn injury following spontaneous ignition of his ENDS in the right pocket of his jeans. This caused a com- bined superficial partial and deep partial-thickness burn on his right upper leg, with an estimated Total body surface area (TBSA) of 9% (Fig. 1).

After the wound had been irrigated with water in a peripheral hos- pital, the patient was transferred to our burn center. On arrival, he was experiencing high levels of pain (Numeric rating scale (NRS) 10). The wound was extensively rinsed again and cleaned from debris lead- ing to a subsequent drop in NRS score. The following day, Laser Doppler Imaging (LDI, Moore Instruments, Axminster, UK) confirmed the clinical suspicion (Fig. 1): a combination of superficial partial, deep partial and full-thickness burns.

The deep partial-thickness and full-thickness burn wounds were en- zymatically debrided that same day using NexoBrid(R) (Mediwound, Yavne, Israel), performed under Epidural anesthesia. After removal of the enzymatic debriding agent, there were no evident clinical signs of full-thickness burns that clearly needed additional Skin grafting. There was no step-off, no visible fat layer nor bluish coloration of the remain- ing dermal layer.

After the procedure, the wound was covered with allografts in order to provide moist healing without the need for daily (and painful) dress- ing changes. This resulted in progressive epithelialization and complete wound healing was achieved 35 days after the injury occurred. In accor- dance with our regular protocol, pressure garments were prescribed 2 weeks after complete wound healing. In regular circumstances, these garments are worn for a period of at least 1 year. However, due to the high temperatures that summer, the patient could only endure the gar- ments for 2 months. The burn scars showed excellent healing without any hypertrophic scarring and there were no functional restrictions.

Case 2

The second case involved a 47-year-old male patient who had stored an isolated ENDS battery inside his pocket together with his keys. The battery went into thermal runaway causing a combined superficial partial-thickness, deep partial-thickness and full-thickness burn with an estimated TBSA of 9% over his left upper leg (Fig. 2). He tried to extin- guish the fire with his left hand, causing superficial burns to his fingers as well.

After rinsing with water in a peripheral hospital, the patient was transferred to our burn center for further management. This patient too suffered high levels of pain (NRS 10), which led us to conclude that there was a combined flame and chemical burn. Based on our

Fig. 1. Patient 1 - LDI scan (left) of the burn wound (right).

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Fig. 2. Patient 2 - LDI scan (left) of the burn wound (right).

previous experience, we started off by extensively rinsing the wound bed with saline and removing any debris, once leading to a drop in NRS score. The LDI scan, performed b48 h after the burn trauma, con- firmed the clinical suspicion and showed a combination of superficial partial, deep partial and full-thickness burns (Fig. 2).

Immediately thereafter, an enzymatic debridement -under epi- dural anesthesia- of the deep partial and full-thickness burns over the left upper leg, was performed using NexoBrid(R). Similarly to the previous case, there were no clinical signs of an evident full- thickness burn necessitating any additional Skin grafting. Allografts were used as a biological dressing to cover the wounds. We noted progressive epithelialization with Conservative therapy. These burn wounds however, needed 61 days to heal completely. Pressure gar- ments were prescribed 2 weeks after complete wound healing and one month later a silicone layer was added to treat the hypertrophic scarring on the posterior side of the upper leg. Despite the long Healing time, the long-term results were excellent with the gradual disappearance of the hypertrophic scarring.

1. Discussion

Injuries from overheating, ignition or explosion of ENDS are an emerging, underreported and underinvestigated topic. Thus far, no guidelines have been issued on the management of these injuries and different treatment options are still being investigated. Both the con- sumers and health care providers should be made aware of the risks and be advised about how to safely handle these devices. When these incidents do occur, appropriate measures should be taken. If a lithium- ion battery gets breached, patients are exposed to lithium cobalt oxides or lithium manganese oxides. These may leak onto the skin and be absorbed by the body, debridement is therefore primordial in an emer- gency department setting [12-14]. As suggested by different authors

[12,13], this should not be done using water, as contact between the chemical compounds and water sets off an exothermic reaction possibly leading to further injury and high levels of pain [15]. Upon arrival in the hospital, a litmus test to check for an alkali pH of the burn wound should be performed in case of a suspected exposition to alkali substances. If an alkali pH (around 9-10) is confirmed at the site of injury with a normal pH of the adjacent unaffected skin, burns should not be irrigated with water [16]. Some authors suggest cleansing with mineral oils to ensure no residual materials are present in the wound, prior to cleaning and de- bridement of elemental metals [17-19]. Other authors advocate the use of mineral oil to cover the burns [14]. Still, there are no specific guide- lines for the management of lithium-ion battery related burns. Based on our local experience and the literature, we recommend irrigation with Diphoterine(R) (Laboratoire Prevor, Valmondois, France) as a valu- able treatment option, as it is a nonaqueous, hypertonic, amphoteric, polyvalent and chelating decontamination solution [20,21]. Enzymatic debridement of burn injuries has gained increasing relevance in the last few years [22-25]. To our knowledge however, only one author has reported a case of enzymatic debridement of a burn injury caused by explosion of a lithium-ion battery of a mobile phone [26]. Nexobrid(R) is a recent non-surgical, enzymatic tool to treat burn injuries of different degrees. It is specific and selective in the removal of eschar and other dead tissues without harming the surrounding healthy tissues. These products are useful in the treatment of burns wounds of older patients and patients with health issues for whom Surgical debridement is not advised. Furthermore, the selectivity and simplicity of the enzymatic method make bedside treatment of burns possible (TBSAb10% and without comorbidities). Systematic guidelines on this specific topic are not yet available, but Hirche et al. [27] published a European consensus paper which serves as a preliminary guideline for the use of enzymatic debridement with user-oriented recommendations, in anticipation of further evidence and systematic guidelines becoming available. The

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use of this treatment option is painful and therefore suitable pain man- agement is necessary. This is why, at our center, this procedure for lower limbs are performed under epidural anesthesia.

1. Conclusion

Both patients suffered a combined flame and chemical burn after ex- plosion of their ENDS and isolated ENDS battery, respectively. A litmus test should have been carried out to confirm an alkali pH in the burn wound. If confirmed, the burn wounds should be extensively irrigated and cleaned from debris. Irrigation shouldn’t have been carried out with saline, but preferably with Diphoterine(R) or mineral oils, until no residual materials are present in the wound. Despite the fact that NexoBrid(R) is not generally recommended in the treatment of chemical burns, both patients were successfully treated with enzymatic debride- ment followed by conservative treatment with allografts and dressing changes. No clinical nor laboratory events occurred, substantiating the safety of enzymatic debridement use after combined chemical and flame burns (e.g. ENDS-related). Despite the absence of a large number of cases, we do recommend the use of bromelain-enriched proteolytic enzyme debridement in the management of burns related to ENDS igni- tions and/or explosions, definitely in patients for whom surgical de- bridement is not advised.

CRediT authorship contribution statement

Karel E.Y. Claes: Conceptualization, Formal analysis, Methodology, Project administration, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing. Tom Vyncke: Conceptualiza- tion, Formal analysis, Investigation, Methodology, Project administra- tion, Software, Writing - original draft, Writing - review & editing. Edward De Wolf: Formal analysis, Investigation, Methodology. Henk Hoeksema: Data curation, Formal analysis, Project administration. Jozef Verbelen: Data curation, Formal analysis, Project administration. Stan Monstrey: Conceptualization, Supervision, Validation.

Declaration of competing interest

None.

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