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Background: Firework injuries to the hand can be devastating due to the explosive and ballistic nature of these devices. The aim of this study was to describe the injury and treatment characteristics of patients requiring surgery for firework-related hand injuries and to investigate which factors are associated with an increased utilization of health care resources. Methods: A retrospective chart review of patients undergoing surgery for firework-related hand injuries at two American College of Surgeons level I trauma centers between 2005 and 2016 was performed. Twenty cases were identified. These patients were evaluated for demographics, injury characteristics, number and types of surgical interventions, length of stay, and utilization of health care resources. Bivariate analyses were performed to investigate which factors were associated with increased consumption of health care resources. Results: Injuries ranged from digital nerve injuries to traumatic amputation. Patients underwent a median of 3 surgical operations. More than half the patients underwent flap or skin graft coverage of a soft tissue defect. The median length of hospital stay was 7 days. Factors found to be associated with an increased utilization of surgical and hospital resources included a first web space injury, thumb fracture, and traumatic amputation of any digit. Conclusions: The morbidity inflicted by firework injuries to individual patients is substantial. Patients with severe injuries undergo a median of three surgical operations and have a long duration of initial hospital stay. Knowing which factors are associated with an increased utilization of resources can help prognosticate these preventable injuries.

IMPORTANCETumescent local anesthesia (TLA, whereby anesthesia is achieved by injection of a highly diluted solution of local anesthesia into skin and subcutaneous tissues) is a technique for delivering anesthesia for superficial surgical procedures. TLA obviates the need for general anesthesia or intravenous sedation in most cases. Pain control and TLA-related complications are key factors in determining the success of TLA.OBJECTIVETo conduct a systematic review of the English medical literature’s data regarding pain control and TLA-related complications in TLA surgical cases to determine its efficacy and safetyEVIDENCE REVIEWThe review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Searches of both the MEDLINE and EMBASE databases were performed. Articles using 10-point quantitative scales were included in the pain analysis. Complications were tabulated from cohort studies, case series, and case reports. A total of 184 articles cotaining reports of 71,483 surgical procedures met inclusion criteria, including 43 with pain outcomes and 141 reporting complications.FINDINGSLiposuction procedures were associated with relatively low degree of both intraoperative pain (10-point visual analog scale 1.1 ± 2.1) and post-operative pain (0.53 ± 0.44) and the fewest complications (1.2%). The highest intra-operative and post-operative pain was reported in facial/cleft-lip surgery (3.7 and 3.99, respectively), while mastectomy was associated with highest post-operative complication risk (20.8%). There were 8 reported cases of death unlikely related to TLA: pulmonary embolus (4 cases), complications related to concurrent general anesthesia (2 cases), hemorrhage, and visceral perforation. There were 5 reported cases of death related to TLA (lidocaine/bupivacaine toxicity in 4 cases and one case of fluid overload) during its development when optimal dose and volume parameters were being established. There have been no TLA-associated deaths reported in the 33,429 cases published since 2003.CONCLUSIONS AND RELEVANCEThis systematic review demonstrates TLA to be a safe and effective anesthetic approach. Its low-cost and rapid patient recovery warrant further studies of cost-reduction and patient satisfaction. Expanded education of TLA techniques in surgical and anesthesia training programs may be considered to broaden patient access to this anesthetic modality for cutaneous and subcutaneous surgical procedures.Key PointsQuestionIs TLA an effective and safe local anesthetic technique for pain management during surgical procedures?FindingsIn this review of 157 publications, TLA was a safe and effective anesthetic approach. The least pain and fewest complications were in liposuction procedures. The highest postoperative complication risk was with mastectomy. Though five TLA-related deaths were reported in early liposuction cases, there have been no deaths in the 33,429 TLA cases published since 2003.MeaningTLA is an effective and safe anesthetic technique which enables cutaneous and subcutaneous surgery to be performed in office-based settings with high safety and low cost.