Lightning injuries.

To the Editor: Whitcomb et al (1) discussed lightning injuries in a recent case report and review in the Southern Medical Journal. My colleagues and I published an article on the same topic in the International Journal of Clinical Practice in 2001. (2) In our comprehensive review article, we presented 22 hospitalized cases treated during a 23-year period. The incidence was 3 per 1,000 bums, which ranked lightning as the fourth-leading cause of bums after electrical injury. The mean age of the victims was 32.9 years (age range, 12 65 yr), with male predominance (60%). Fortunately, there were no deaths in our study, and the mean duration of hospitalization was short (17.3 d; range, 1-62 d) compared with other causes of burns (mean duration of hospitalization 31.3 d in electrical injuries, 27.2 d in flame injuries, mad 24.1 d in chemical injuries). The burned body surface ranged from 5 to 20% (average, 14%), and our approach after stabilizing the patient was early debridement, which was performed in 69% of patients. As Whitcomb et al (1) mentioned in their article, the commonest early stage complaints were confusion (73%), temporary amnesia (23%), and cystitis (19%). During long-term follow-up, the most common morbidity was chronic pain syndrome, but patients had anxiety, sleep disorder, fear of storms, mid amnesia as well. When 1 first read the Whitcomb el al (1) article, my expectation was to see our relatively high number of lightning patients cited in this literature. My other expectation was to find their institutional experience with the overall incidence rate in addition to the case presentation.

I disagree with Whitcomb et al's (1) conclusion that lightning injuries may be managed on an outpatient basis, even if the patient has no initial complications of the lightning strike, has normal findings on physical and laboratory examinations, and remains asymptomatic. We have an institutional policy in Turkey that all lightning injuries should be hospitalized for at least 1 day, regardless of the victim's appearance, and the patient may be discharged alter comprehensive medical examinations, diagnostic tests, and multidisciplinary consultations are performed. This may be adding more cost to the bill, but we think that on behalf of the victim, to stay on the safe side, it is more important than a couple hundred dollars. Any undiagnosed early or late morbidity will add more psychological and physical cost to the patient.

Atilla Soran, MD

National Surgical Adjuvant Breast and Bowel Project

University of Pittsburgh Cancer Institute

Pittsburgh, PA

References

(1.) Whitcomb D, Martinez JA, Daberkow D. Lightning injuries. South Med J 2002;95: 1331-1334.

(2.) Aslar AK, Soran A, Yildiz Y, et al, Epidemiology, morbidity, mortality and treatment of lightning injuries in a Turkish bums unit. Int J Clin Pract 2001;55:502-504.

In Reply: My colleagues and I appreciate Dr. Soran's letter and his comments about our article. (1) We welcome the opportunity to address his suggestion that all lightning strike victims be admitted to the hospital. In doing so, we point out that few case series addressing lightning strikes have been published in the medical literature. Our research yielded three case series reports, which involved small numbers of patients accumulated over extended periods of time. Muehlberger et al (2) reviewed 12 patients during a 12-year period. Alar et al (3) discussed 22 patients treated during the course of 23 years. Gluncic et al (4) described 18 patients studied in a 15-year period who sustained ear injuries as a result of lightning strikes. Three other reports described multiple victims of a single lightning strike: 17 victims, (5) 10 victims,(6) and 8 victims. (7)

As Dr. Soran notes, Aslar et al (3) suggested that all lightning strike victims be admitted to the hospital. Interestingly, of the remaining five case series, only Epperly mad Stewart (6) addressed admission criteria. In their article, they recommended that lightning strike victims be admired to the hospital if they require resuscitation in the field or in the emergency department, if they are comatose, if they have symptoms suggestive of myocardial ischemia, if they develop paralysis, if they demonstrate electrocardiographic changes, if they have neurologic abnormalities, or if they demonstrate autonomic instability.

Regarding delayed complications as a result of lightning strikes, Muehlberger et al (2) followed 10 of their 12 patients for an average period of 6.7 years (range, 1 mo-12.3 yr). They found that none of the 10 patients had any delayed or long-term complications. On the basis of their clinical findings and review of the literature, they concluded that the long-term outcome of lightning injuries was more favorable than generally reported.

Thus, we remain of the opinion that victims of lightning strike should undergo a detailed history and physical examination with appropriate laboratory studies. Clearly, treatment should be instituted as needed. Patients with noncritical injuries should be observed in the emergency department for several hours. If, after several hours of observation, the patient remains asymptomatic and has normal laboratory studies, the patient may be discharged to home with appropriate follow-up.

Jorge A. Martinez, MD, JD

Department of Emergency Medical Services 

Medical Center of Louisiana 

New Orleans, LA

References

(1.) Whitcomb D, Martinez JA, Daberkow D. Lightning injuries. South Med J 2002;95: 1331-1334.

(2.) Muehlberger T, Vogt PM, Munster AM. The long-term consequences of lightning injuries. Burns 2001;27:829-833.

(3.) Aslar AK, Soran A, Yildiz Y, et al. Epidemiology, morbidity, mortality and treatment of lightning injuries in a Turkish burns unit. Int J Clin Pract 2001;55:502-504.

(4.) Glancic I, Roje Z, Gluncic V, et al. Ear injuries caused by lightning: Report of 18 cases. J Laryngol Otol 2001;115:4-8.

(5.) Fahmy FS, Brinsden MD, Smith J, et al. Lightning: The multisystem group injuries. J Trauma 1999;46:937-940.

(6.) Epperly TD, Stewart JR. The physical effects of lightning injury. J Fam Pract 1989;29: 267-272.

(7.) Graber J, Ummenhofer W, Herion H. Lightning accident with eight victims: Case report and brief review of the literature. J Trauma 1996:40:288-290.