Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This case report is of particular interest because it has the potential to contribute meaningfully to the literature, especially in the context of rare injuries such as lightning strikes and their associated complications. Furthermore, the discussion of inhalation injury adds value to the report. Although I agree that this does not represent a direct inhalation injury, it may still be considered an inhalation-related injury. As described by Herndon, inhalation injury is not necessarily limited to direct airway exposure and may also be observed in patients with extensive cutaneous burns, including scald injuries, where pulmonary edema and interstitial fluid accumulation can develop as part of the systemic inflammatory response. The pathophysiological mechanisms underlying these findings are well established.

Several points require clarification and revision before the manuscript can be considered ready for publication:

1. Reference 5 should be moved to the end of the sentence in paragraph 68.
2. Figure 1 is useful in illustrating the clinical presentation; however, the quality of the images appears inadequate for publication. In addition, there are inconsistencies in image size and alignment. I would strongly recommend redesigning the figure as a single, well-organized composite panel. If available, a photograph of the scalp laceration should be included, resulting in a six-panel figure that would provide a more complete and visually coherent presentation of the case.
3. Was the patient permanently tracheostomy-dependent, or was decannulation successfully achieved during the follow-up period? This point should be clearly stated.
4. What was the patient's speech outcome following treatment? A more comprehensive description of the patient's functional recovery and overall clinical outcome would substantially strengthen the manuscript and increase the educational value of the case report.
5. Pleural drainage is mentioned in paragraph 207. Did the patient undergo drainage of both pleural cavities because of bilateral pleural effusions? If so, I recommend expanding the case presentation in Section 2 to provide a more detailed and chronological account of this aspect of management, thereby improving the clarity and completeness of the clinical narrative.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Introduction:
Epidemiology, pathophysiology and mechanism of airway compromise in lightning-induced burns are adequately described. The aim of this paper is established in the last paragraph appropriately.

 

Case presentation:

Comment 1:

"The second extubation likewise failed, with tachypnea and oxygen saturations in the 128
mid-80s. Bilevel positive airway pressure (BiPAP) temporarily stabilized oxygenation. 129
However, within two days, the patient became increasingly somnolent on 100% FiO₂, with 130
tidal volumes falling to 100–150 mL, necessitating a third reintubation. Given three se- 131
quential extubation failures..."
At this point the reader would expect the third extubation attempt; however, only the first 2 are described. The text then jumps to "Given three sequential extubation failures...". The authors should make the attempts' description more clear.

Comment 2:

"a decision was 134
made to proceed with elective tracheostomy. "

The authors should report the specific day of ICU stay the tracheostomy was performed, it is not entirely clear by reading the text.

 

Comment 3: 

"Bed- 149
side transthoracic echocardiogram showed global hypokinesis with an ejection fraction of 150
50%, and an initial right bundle branch block resolved spontaneously."

Did the TTE change after the acute phase? And if yes, on which day? Also, on which day did the RBBB resolve? Could the authors please provide more details on these in text?

 

 

Discussion:

The discussion successfully covers the pearls of treating a patient with light-induced burns, along with the limitations (eg lack of bronchoscopy) in this specific patient.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

My suggestions are in the file

Comments for author File: Comments.pdf

Comments on the Quality of English Language

My suggestions are in the file

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

I have some comments in the attached document and I have marked them in the text as follows:
Text marked in green is just a comment. Text marked in orange could be improved. Text marked in red needs revision.

Reference 1 is incomplete (article title is missing).
I have also suggested an additional reference to support my opinion about the patient's evolution. I believe that the patient suffered an oral, supraglottic and glottic burn, in addition to the skin burns and this explains the unpredictable evolution.
The patient's evolution is presented only in a narrative way, so I have suggested an additional graphic (a timeline) to have an overview of it.

I also think that the recommendation to exclude oral/supraglottic/glottic burns from the beginning in all lightning cases, at least, should be added to the Conclusions paragraph. Also in these cases, tracheostomy should be indicated until the upper respiratory tract burns have completely resolved.

Comments for author File: Comments.pdf

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have addressed all reviewer comments and implemented the necessary revisions. The manuscript has been significantly improved and is now suitable for publication in its current form.

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have addressed all my concerns. I have no further comments.

Reviewer 3 Report

Comments and Suggestions for Authors

Accept in present form

Reviewer 4 Report

Comments and Suggestions for Authors

I thank the authors for their appreciation of my comments. I must also appreciate the way they revised the article in accordance with the recommendations made by the undersigned.
In the light of the above, I consider that the article can be published in its current form.
I also recommend that the authors continue their scientific approach to include glotic/supraglotic burn injuries in the initial evaluation of lightning injuries.
A case study can provide a lot of information for future research topics, in my opinion.
I congratulate the authors once again for the revision made.