A hot mess: Clothing-related burn injuries

Burns, by definition, are traumatic injuries. Burn patients must be assessed initially with a primary survey. In addition to thorough evaluation of the airway, breathing, and circulation, the evaluation must include removal of clothing to allow a direct view of the entirety of the patient. Such exposure is necessary not only to estimate burn size, but also to allow the disrobed items to be assessed and accounted for in determining the pathology and severity of thermal injury.

In the 1940s, an epidemic of pediatric burns was associated with cowboy outfits modeled after the attire worn by the popular entertainer, entrepreneur, and World War II aviator Gene Autry, also known as “The Singing Cowboy.”* Between 1945 and 1953, at least 100 lawsuits were filed against those individuals involved in the manufacture and sale of these suits. In 1953, The Flammable Fabrics Act was passed to regulate the manufacture and sale of highly flammable clothing and apparel. The act was amended in 1967 to include the fabric used to produce interior furnishings such as drapes, bedding, and floor coverings.

Factors that affect flammability

Clothing-related burn injuries involve three main factors: the fabric, wearer behavior, and the heat source. Ease of ignition, flammability, and potential for thermal injury obviously depend on the fiber type. Cotton and rayon generally possess the fastest burning characteristics. Rayon is classified as a semi-synthetic fiber, as it is derived from wood pulp. Synthetic fibers vary in their burning properties, but the misconception that synthetics are more flammable than natural fibers is false. In fact, cotton/polyester blends are more flammable than pure polyester fabrics. Garments made of animal hair, pure silk, and wool pose the least danger.

In addition to the type of fabric, certain fabric characteristics affect flammability. For example, a napped surface composed of loose fibers creates air space between the fibers, which makes them ignite more readily. Conversely, denser fabrics burn more slowly.

Garment design also may affect the likelihood of ignition. When an article of clothing swings away from the body, as in the case of blouses or pajamas, more air circulates around the clothing, portending a higher rate of flammability.*

Burn casualties

Are the mechanisms for preventing clothing-related civilian burn casualties adequate? After reviewing data from the National Center for Health Statistics, the Centers for Disease Control and Prevention, and injury surveillance databases, Hoebel and colleagues discovered that more than 4,300 serious clothing-related burn injuries occurred annually in the U.S. between 1997 and 2006.Nearly all injuries documented involved apparel that complied with the regulations set in The Flammable Fabrics Act. In addition to implementing more stringent flammability regulations, there appears to be an opportunity to target high-risk groups and behaviors.

To examine the occurrence of clothing-related burn injuries in the National Trauma Data Bank® (NTDB®) research dataset for 2013, medical admissions records were searched using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnoses codes. Specifically searched were records that contained one of the following external cause of injury codes (E-code): E893 (injury caused by ignition of clothing), E893.0 (injury caused by ignition of clothing from controlled fire in private dwelling), E893.1 (injury caused by ignition of clothing from controlled fire in other building or structure), E893.2 (injury caused by ignition of clothing from controlled fire not in building or structure), E893.8 (injury caused by ignition of clothing from other specified sources), or E893.9 (injury caused by ignition of clothing from unspecified source). A total of 2,970 records were found, 2,320 of which contained a discharge status, including 1,573 patients discharged to home, 283 to acute care/rehab, and 239 sent to skilled nursing facilities; 225 died (see figure below). Approximately 68.1 percent of the patients were male, on average 45.4 years of age, had an average hospital length of stay of 13.9 days, an intensive care unit length of stay of 17.2 days, an average injury severity score of 6.4, and were on the ventilator for an average of 10.2 days. Of those tested for alcohol (984), one-third (33.7 percent) were positive.

Hospital Discharge Status

Hospital discharge status

Avoid being a “hot mess”

Several flame-resistant fabrics are used in various industries, including offshore drilling, petrochemical, pharmaceutical, racing, and aviation. An example is the Nomex brand fiber from DuPont. Clothing made of this material will not win any fashion contests, but wouldn’t you rather be called a hot mess because of the appearance of your clothing than because of the burn injury it may cause?

Throughout the year, we will be highlighting these data through brief reports that will be published monthly in the Bulletin. The NTDB Annual Report 2014 is available on the ACS website as a PDF file. In addition, information about how to obtain NTDB data for more detailed study is posted on the website. If you are interested in submitting your trauma center’s data, contact Melanie L. Neal, Manager, NTDB, at mneal@facs.org.


Statistical support for this article has been provided by Chrystal Caden-Price, Data Analyst, NTDB.


*Oglesbay F. The flammable fabrics problem. Inj Prev. 1998;4(4):317-320.

Hoebel JF, Damant GH, Spivak SM, Berlin GN. Clothing-related burn casualties: An overlooked problem? Fire Technol. 2010;46(3):629-649.

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