A Winter Wonderland of Emergencies

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With holidays come a unique set of potential catastrophes.

It’s the holiday season, which means it’s that time to gather around and enjoy some quality family moments.  Regardless if you enjoy the holidays, with the cold and snow come several specific wintertime emergencies. This piece will look at several of these conditions, but before we begin, let’s discuss several cases.


Case 1: A 43-year-old male, Clark, is up on a ladder hanging Christmas lights. This year he is determined to win the neighborhood light contest.  A family cousin, Eddie, calls out to him about dumping sewage into the storm drain. This crazy question elicits a quick response from Clark, who looks over and shifts his balance. The sudden movement causes a small slip, and before you know it, he’s back on the ground. His neighbor rushes over to find Clark unconscious.

Case 2: A 22-year-old female, Elsa, is lighting candles in her living room. Unfortunately, one of the candles is close to the real tree in the living room that is decorated with ornaments from the hit movie “Frozen.” Elsa rapidly tries to extinguish the fire, suffering burns to her hands and forearms.

Case 3: A 45-year-old male, Buddy, is feeling especially upbeat this holiday season. He just started dating Jovie. This Christmas, he thinks he will dress like an elf and present her with several gifts. Unfortunately, wrapping the presents is challenging for Buddy, as he is all hopped up on candy canes and maple syrup. He cuts himself with scissors, resulting in a deep laceration to the palm of his hand.


Before we go through these cases, some background in holiday-related injuries is needed. The United States Consumer Product Safety Commission (CPSC) determined there were 1,700 ED visits for holiday-related injuries to 100 hospitals over 2011-2015.[1,2]  Keep in mind that this is only for 100 hospitals. Nationwide, in November and December of 2014 and 2015, over 14,000 injuries due to holiday decorations alone were treated in U.S. EDs, with six deaths.[1,2]  The most common cause of injury is related to decorations during the holiday period, accounting for over two-thirds of injuries. Other injuries include wrapping/unwrapping gifts, stocking-related and Christmas-tree related.  The most common injuries over the 2011-2015 timeframe included lacerations, sprains, contusions/abrasions and fractures.[1,2] However, dangerous conditions including foreign object ingestion, internal organ injury, concussion, dislocation, toxic ingestion, and electrical and thermal burns also occur.

Case 1 involves a patient falling from a ladder knocked unconscious. During 2000-2003, over 17,000 patients were treated in EDs for decorating-related falls, with 62% of patients aged 20-49 years and males affected more commonly.[2,3] Falls from a ladder accounted for 43% of injuries, while other falls were from roofs, furniture and stairs.[3] Though Clark likely has a closed head injury, close to 46% of patients experience extremity injury, with fractures occurring in 34%.[3] Clark requires a focused trauma evaluation and management with primary and secondary surveys. Pay close attention to his neurological status and assess for closed head injury. Examine his extremities for any evidence of fracture. Your history and exam determine further evaluation such as imaging. For evaluation of cervical pain, the NEXUS or Canadian C-spine rules can assist.[4,5]

Sure, Christmas-tree related injuries make sense. Lifting that heavy tree is bound to increase risk of back injuries and pain, while rogue branches and needles can cause ophthalmologic injuries. The major problem we will discuss is the risk of fire with real Christmas trees. Before you call us Scrooge, we love the smell of fresh Christmas trees. However, trees beginning to turn brown with brittle needles that shower from the tree with contact means the tree is too dry and at higher risk of fire. On average 200 fires from Christmas trees occurred annually between 2010 and 2012.[1] Per year, these fires caused 10 deaths, 20 injuries and over $17 million dollars in property loss.[1] Candles are also a significant problem when it comes to fire-related issues, with 6,500 residential fires due to candles, resulting in 80 deaths and 650 injuries every year.[1]

Case 2 involves Elsa, who experienced burns to her hands and forearms. Burn injuries can range from the mild first-degree injury (sunburn) to fourth-degree (Table 1)[.6,7] The burn victim will require initial stabilization and determination of the burn depth and size (using Rule of Nines or the Lund-Browder Classification).[8,9]


For minor burns, the burn can be cleaned with mild soap and water with a topical antimicrobial, with discharge if the criteria for outpatient treatment in Table 2 are met. Blisters can be left intact for mild burns unless they cover a joint or if they preclude the placement of a dressing.[6,7] Severe burns (Table 2) should be discussed with a burn specialist and transferred. Prophylactic antibiotics are not required, but large burn wounds can be covered with a sterile dry sheet or drape. Smaller wounds can be covered with moist saline-soaked dressings.[6,7]

Table 1. Burn Types

Burn Burn Characteristics
First-Degree ·         Affects epidermis

·         Red and tender, but not blisters

·         Heals with no scarring in seven days

Second-Degree Superficial Partial Thickness ·         Epidermis plus superficial dermis

·         Blisters and painful burn

·         Capillary refill intact, dermis is perfused

·         Heals with no scarring in 14-21 days

Second-Degree Deep Partial Thickness ·         Epidermis plus deep dermis

·         Painful blisters, exposed dermis that is yellow/pale

·         Burned areas do not blanch with pressure

·         Diminished light touch and pinprick sensation

·         Normal pressure sensation

·         Heals with scarring in three to eight weeks

Third-Degree ·         Full thickness burn

·         White, leathery skin

·         No pain to palpation

·         Requires grafting

Fourth-Degree ·         Third-degree with involvement of muscle, fat and bone


Back to Elsa: on exam, her burns appear to be second-degree burns with blistering on the hands and distal forearms, and the burned areas do not blanch. The exposed dermis is also yellow, suggestive of deep partial thickness injury. She has bilateral radial and ulnar pulses. You call the nearest burn center, who asks that you cover the wounds with sterile dressings and transfer her.

Table 2. Patient Disposition and Burn Grading

Disposition Burn Characteristics
Outpatient Treatment with 24-48 hr follow up ·         Partial thickness < 10% BSA, age 10–50 yrs

·         Partial thickness < 5% BSA, age < 10 or > 50 yrs

·         Absence of major burn characteristics

Hospital Admission ·         Partial thickness 10-20% BSA, age 10-50 yrs

·         Partial thickness < 10% BSA, age < 10 or > 50 yrs

·         Burns with suspected inhalation injury

·         Patient with significant comorbidities

·         No major burn characteristics present

Burn Center Transfer ·         Partial thickness > 20% BSA, age 10-50 years old

·         Partial thickness > 10% BSA, age <10 or > 50 yrs  old

·         Full thickness burn in any patient

·         Burns involving face, eyes, ears, genitalia, joints, hands, feet

·         Burns with inhalation injury

·         High voltage electrical burn

·         Burns complicated by fracture or other trauma (burn is main cause of morbidity)

·         Chemical burns in high-risk patients


Another problem with Christmas trees and outdoor decorations includes lighting.[1,2] Electrical shocks can occur, with tissue damage occurring via electrical energy (thermal injury once it enters the tissue). Fat, bone, tendons and dry skin have high resistance, while muscle, nerves and blood vessels have lower resistance. Normal household electricity will be alternating current (AC) and low voltage (< 1000 volts).[10-12]

Though fortunately household currents are low voltage, AC arcs onto the body, causing muscle contraction that prevents full release from the source. The current can flow through body tissues, potentially causing injury. Organ systems affected include cardiovascular (dysrhythmia, necrosis), central nervous system (loss of consciousness, stroke), orthopedic (dislocation, fracture, compartment syndrome, rhabdomyolysis), ocular (cataracts), burns and gastrointestinal (GI).[10-12]  Obtain an ECG, and if normal and the patient is asymptomatic, he/she can be discharged. Patients with high voltage injury, symptoms with low voltage injury, abnormal ECG, positive troponin, loss of consciousness, persistent paresthesias or hypoxia, and severe burns require admission.[11,12]

Case 3 involves the newly in love Buddy who suffered a hand laceration while wrapping a present for his girlfriend. You might be surprised (or not), but the second most common type of injury around the holidays is associated with wrapping and unwrapping gifts.[1] Though injuries are not typically life-threatening, knives and scissors can cause significant injury, especially when utilized without close attention. Glass is often the cause of lacerations in the pediatric population, again with injuries ranging from mild superficial injuries to deep and long lacerations causing neurovascular damage.[13-15] If a patient presents with a laceration, you know what to do. Assess their neurovascular status in the affected injury, closely examine for any injury to the tendons and inquire concerning tetanus status.

Ready for two more scenarios? Our next case is a family of four hurriedly speeding along the interstate in a snowstorm. They are trying to make it to the famous Christmas Eve dinner hosted by extended family, but a snowstorm is causing some problems. On an annual basis, there are over 5.8 million vehicle crashes, with 1.2 million of those related to weather. Close to 5,000 mortalities each year are due to weather-related accidents.[16]  Interestingly, wet pavement and rainfall are associated with the majority of these accidents, 70% and 46%, respectively. About 18% occur during snow, 13% on icy pavement and 16% on snow or slush.[16] Though snow-related accidents may not occur as frequently as rain-related crashes, consider the potential mass casualty incidents that can occur. A February 2016 blizzard resulted in an accident involving 50 vehicles on Interstate 78 in Pennsylvania, with three deaths.[17]

The last case involves Kevin, who was home alone when he accidentally swallowed a holiday ornament. Holiday ornament-related injuries more commonly affect the pediatric population, most often resulting in laceration or ingestion.[1,18] One retrospective study published in 2009 evaluating ornament-related injuries found 53.9% of injuries involved ingestions, with almost all ornaments made of glass.[18] Of these instances, 28% of patients experienced an associated bleed from the mouth or GI tract. Lacerations accounted for 27.6% of injuries, with eye injuries and minor electrical injuries accounting for 5.1% and 2.5% of injuries, respectively.[18] The ingested foreign body requires imaging and discussion with the GI/ENT specialist, due to the risk of GI tract damage or airway obstruction, depending on whether the ornament was ingested or aspirated.[19-24] Airway intervention may be needed, and severe airway obstruction can require jet ventilation in the young patient. Other injuries associated with ingestion of glass in pediatric patients include mediastinitis and retropharyngeal abscess.[19-24]

Key Points:

Though Christmas and the holiday season can be fun and full of cheer, be wary of several injuries. The holidays are associated with high risk of decoration-related injuries and weather issues. Several decoration-related injuries include falls, burns, electrical injuries, lacerations and foreign body ingestion/aspiration. Keep these in mind as you sit down with some eggnog or are getting ready for your next holiday season shift.


  1. United States Consumer Product Safety Commission. ‘Tis the Season to Decorate Safely. 2016. Available at https://onsafety.cpsc.gov/blog/2016/12/05/tis-the-season-to-decorate-safely-2/.
  2. Collins K. America’s most common Christmas-related injuries, in charts. QZ.com. Available at https://qz.com/859303/americas-most-common-christmas-related-injuries-in-charts/.
  3. Centers for Disease Control and Prevention (CDC). Fall-relatedinjuriesduring the holiday season–United States, 2000-2003. MMWR Morb Mortal Wkly Rep. 2004 Dec 10;53(48):1127-9.
  4. Hoffman JR,Mower WR,Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000 Jul 13;343(2):94-9.
  5. Stiell IG,Wells GA,Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA. 2001 Oct 17;286(15):1841-8.
  6. Greenhalgh DG. Burn resuscitation. J Burn Care Res 2007; 28:555–565.
  7. American Burn Association Consensus Statements. 2013. DOI: 10.1097/BCR.0b013e31828cb249.
  8. Lund CC, Browder NC. The estimation of areas of burns.Surg Gynecol Obstet.1944;79:352–8.
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  10. Kym D, Seo DK, Hur GY, Lee JW. Epidemiology of electrical injury: Differences between low- and high-voltage electrical injuries during a 7-year study period in South Korea. Scand J Surg. 2015 Jun;104(2):108-14.
  11. Koumbourlis AC. Electrical injuries. Crit Care Med. 2002 Nov;30(11 Suppl):S424-30.
  12. Kai J, Jeschke MG, Barrow RE, Herndon DN. Electrical Injuries: A 30-Year Review. J Trauma Acute Care Surg. 1999;46(5):933-936.
  13. Bell D. Two hundred glass injuries. Arch Dis Child. 1984;59:672Y673.
  14. Armstrong AM, Molyneux E. Glass injuries to children. BMJ. 1992; 304:360Y361.
  15. Iconomou TG, Zuker RM, Michelow BJ. Management of major penetrating glass injuries to the upper extremities in children and adolescents. Microsurgery. 1993;14:91Y96.
  16. U.S. Department of Transportation: Federal Highway Administration. How Do Weather Events Impact  Roads? Available at https://ops.fhwa.dot.gov/weather/q1_roadimpact.htm.
  17. The Weather Channel. Snowy Roads in Lebanon County, Pennsylvania, Cause Multi-Vehicle Collision on I-78; At Least 3 Dead. Available at https://weather.com/news/news/lebanon-county-pennsylvania-i78-deadly-multi-car-vehicle-collision.
  18. Kimia A, Lee L, Shannon M, et al. Holiday Ornament-related Injuries in Children. Ped Emerg Care. 2009;25(12):819-22.
  19. Houghton AD. Obstruction at Christmas. Br J Clin Pract. 1991;45(4):295.
  20. Kiff ES, Hulton N. Small bowel perforation due to a Christmas cake decoration. Br Med J (Clin Res Ed). 1983;287(6409):1923Y1924.
  21. Norberg HP Jr, Reyes HM. Complications of ornamental Christmas bulb ingestion. Case report and review of the literature. Arch Surg. 1975;110(12):1494Y1497.
  22. Philip J, Bresnihan M, Chambers N. A Christmas tree in the larynx. Paediatr Anaesth. 2004;14(12):1016Y1020.
  23. Walker P, Davidson T. The Christmas star. ANZ J Surg. 2005; 75(12):1126Y1127.
  24. Allotey J, Duncan H, Williams H. Mediastinitis and retropharyngeal abscess following delayed diagnosis of glass ingestion. Emerg Med J. 2006;23(2):e12.


Brit Long, MD is an EM Attending Physician at San Antonio Uniformed Services Health Education Consortium.

Alex Koyfman, MD is a Clinical Assistant Professor of Emergency Medicine at UT Southwestern Medical Center and an Attending Physician at Parkland Memorial Hospital. He is also Editor-in-Chief for emDocs.

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