Chapter 138: Lightning and Electrical Injuries

• Even low-voltage electrical injuries can be fatal and often show no external burns.

• Higher-energy electrical injury can cause massive muscle damage and release of myoglobin.

• Sufficient fluid should be administered to maintain a urine flow of 1–1.5 mL/kg/h, 2 mL/kg/h until the urine is myglobin-free.

• Lip and oral commissure burns are initially bloodless and nearly painless, but as the eschar separates in 1–2 weeks, severe bleeding can occur as the labial artery is uncovered.

• Resuscitation of the apparently dead is the rule with lightning injuries.

Electrical injuries are not common but can be frightening, devastating, and life changing. They may result in massive tissue destruction, changes in growth patterns, and neurologic injury, including chronic pain syndromes and permanent cognitive deficits, affecting the child's ability to learn and become a productive adult. Children at most risk are exploring toddlers (12–30 months), who suck on extension cords or stick things into electrical outlets, and adventuresome adolescents. The majority of victims are male. Adolescents often use the outdoors fearlessly as a proving ground, incurring injuries from climbing utility poles and trees and trespassing into transformer substations, resulting in high-voltage injuries.¹

In developing countries, there are large numbers of deaths in the home, both because families tend to consider household current to be “safe” and because there is little prehospital care available.^2–4

The old teaching on electrical injuries involves consideration of voltage, amperage, tissue resistance, duration, current type, and pathway. These terms are still used in the literature, and we will briefly consider them.

• Voltage is a measurement of the electrical “pressure” in a system. Injuries are divided into low (<1000 V) and high (>1000 V) voltage. High voltage tends to produce greater tissue destruction.

• Amperage is a measure of the rate of flow of electrons. There is a direct relationship between current and heat generated in the material through which current flows given a constant resistance.

• Resistance is a measure of the difficulty of electron flow through a given substance. Resistance is measured in ohms

When electricity enters an extremity, it flows readily through all of the tissues, generating more heat in some and more coagulative damage and desiccation in others.

The body is composed of different tissues, which express a different resistance to the flow of electrical current. Thus, body parts exposed to the same intensity and duration of current may show different degrees of heat-generated tissue injury. For a given energy, more severe injuries will occur in smaller cross-sectional areas than the same energy flowing through body parts with larger cross-sectional areas such as a thigh or the trunk. Damage can be especially high at the joints where the low-resistance tissues (muscle) are minimized and higher-resistance tissues (tendons, bone and cartilage) are maximal. Damage to internal organs may be more diffuse and hard to appreciate initially because of the larger cross-sectional diameter of the torso.⁵ Regardless of overall tissue resistancedifferences, physical factors, which affect skin resistance can be useful in explaining clinical or forensic findings in electrical injury. Skin is the primary resistor to electric current flowing into the body. Its resistance is affected by thickness, age, moisture, and cleanliness. In general, thickly calloused skin will have higher resistance and tends to sustain greater thermal damage at the site of contact but impedes the flow of energy internally. Resistance is tremendously lessened if the skin is wet with sweat or rainwater. Wet skin may show little or no local thermal damage but allows the majority of the energy to flow internally to the heart or other vital structures. This explains why a “bath-tub” injury may show no external signs of injury while causing cardiac arrest.⁵

Increased duration tends to result in increased damage until such time as the tissue is coagulated, charred, or mummified.⁵

Current type may be either alternating or direct. Alternating current (AC) is much more dangerous than direct current (DC) at the same voltage.⁶ Household circuits in the United States (110/220 V) operate at 60 cycles per second (cps) and 50 cps in many foreign countries, frequencies at which neuromuscular function continues indefinitely, leading to tetany. Because the flexors of the hand are stronger than the extensors, the hand gripping an AC electrical source will tend to hold onto the source in a tetanic contraction. Flexion will tend to occur at the wrist, elbow, and shoulder, seeming to pull the victim into the energy source. Tetanic muscle contraction can “freeze” the victim to the current source, prolonging the duration of contact and amount of tissue destruction. The effect of tetanic contraction is also related to the amperage applied—the margin between the household amperage (0.001–0.01 A) that causes a buzz but usually little harm, and that capable of causing respiratory arrest (0.02–0.05 A) and ventricular fibrillation (0.05–0.10 A) is narrow.⁵

With AC injuries, source and ground are more appropriate terms. It is often impossible to determine where the pathway started from looking at the burn and neither classification matters, as the emergency physician and surgeon care for the outcome, not the mechanism.⁵

Electric field strength, not listed as one of the factors, is a more useful and accurate concept in explaining and predicting injuries from technical or man-made electricity than the classical Kouwenhoven factors that have traditionally been cited in the medical literature. When 20 kV is applied to a 6-ft man, causing current to ground, an internal electrical field strength of approximately 10 kV/m is generated. When a child chews on an electric cord and suffers a lip burn, the field strength is approximately the same: 110 volts applied to 1 cm of a child's lip generates a field strength of 11 kV/m. While no one would classify the child's injury as “high” voltage, it is a high electrical field strength and produces the same tissue destruction in a small localized area much as would a “high voltage” applied to a 6-ft man (Fig. 138-1).⁵

It may be the electrical field and presence of AC in low-voltage exposure that causes a greater number of deaths due to low-voltage household accidents in developing countries compared to high-voltage exposure in working areas or on the street.^2–4

Not only can electricity cause heating, desiccation, coagulation, and immediate death of tissues due to its thermal effects, it can also cause cellular disruption without immediate death of the cell through the electrical field effect. When an electrical field is applied to a cell, the cell surface can become charged and the cell membrane can be disrupted as water molecules are forced into the bipolar lipid membrane (electroporation).^7,8 The pores that are formed allow material and water to flow nearly unhindered across the cell membrane, threatening cellular integrity. As the cell struggles to maintain its intracellular milieu, it can expend tremendous energy and resources, can swell, and eventually become exhausted and die over a more extended period of time.

Mechanisms of Injury

There are several common mechanisms of injury (Table 138-1). Contact burns are probably the most common and result from direct contact with the electrical source or grounding points. Flash burns occur when the person is close to but not part of an electrical arc or explosion. They vary from very superficial injury with little underlying damage to extensive deep burns accompanied by blunt injury from the concussive force. Arc burns may occur when energy jumps from a source to a nearby person, making them part of the circuit. These injuries typically have deep and extensive tissue damage. Flame burns can occur if clothing or flammable chemicals in the area are secondarily ignited.

Concussive injury is not uncommon with electrical injuries, especially higher voltage injuries since there is often an explosion and rapid heating of gases around the electrical source when the victim touches high-voltage cables, transformers, or circuit boxes. Significant secondary blunt injury can accompany the concussive injury if a person is thrown or falls. Fractures or dislocations may occur.

While electrical injuries are often classified under burns, higher-energy injuries may more closely resemble crush injuries caused by muscle destruction, compartment syndromes, and myoglobin production. Some victims of electrical injury may have very little external damage while sustaining serious underlying tissue damage.

Anatomic Sites of Injury

Surface burns are found in nearly all nonwater-related electrical injuries.⁹ However, there may be significant injury even in the absence of burns. The most common areas of injury are the hand, skull, and foot. Subcutaneous tissues, muscle, nerves, and blood vessels also suffer thermal damage. Skeletal muscle damage is produced by heat or electrical breakdown of cell membranes. Tissue that initially appears viable may later die because of electroporation effects, as well as ischemia caused by vascular wall damage, edema, and thrombosis, which may affect either inflow or outflow of blood to tissue.^9,10

A common injury for very young children is incurred by sucking on the ends of extension cords resulting in severe orofacial injuries. Burns are often full thickness, involving the lips and oral commissure. These burns are initially bloodless and painless. As the eschar separates in 2–3 weeks, severe bleeding can occur from damage to the labial, facial, or even carotid arteries. There can be mandibular damage, growth retardation, devitalization of teeth, and microstomia from extensive scarring.¹⁰

Current passing directly through the heart can induce ventricular tachycardia, ventricular fibrillation, or asystole. A wide variety of arrhythmias can occur, including supraventricular tachycardia, extrasystoles, right bundle branch block, and complete heart block. The most common electrocardiographic (ECG) abnormalities are sinus tachycardia and nonspecific ST-T wave changes. Most rhythm disturbances are temporary.¹¹ Myocardial infarction and ventricular perforation have been reported. Syncope, as a cardiac or neurologic manifestation, occurs in up to 33% of the children affected.¹²

Vascular injuries include thrombosis, vasculitis with necrosis of large vessels, vasospasm, and late aneurysm formation. Maximal decrease in blood flow will occur in the first 36 hours. Strong peripheral pulses do not guarantee vascular integrity.

Acute renal failure may occur from hypoxia and hypovolemia during resuscitation in combination with myoglobin released by extensively damaged muscle or hemoglobin from hemolysis.¹³ In rhabdomyolysis, myoglobin becomes concentrated along the renal tubules, a process that is enhanced by volume depletion and renal vasoconstriction mediated by the activation of the renin–angiotensin system, vasopressin, and the sympathetic nervous system. The myoglobin precipitates when it interacts with the Tamm–Horsfall protein, a process favored by acidic urine.¹⁴

Kidney damage may also occur from blunt trauma, hypotension, hypoxic ischemic injury, cardiac arrest, and hypovolemia. Oliguria, albuminuria, hemoglobinuria, and renal casts may be seen transiently.

Immediate CNS effects include loss of consciousness, seizure, agitation, amnesia, deafness, seizures, visual disturbance, and sensory complaints. Vascular and blunt injury damage may result in epidural, subdural, or intraventricular hemorrhage. Within several days, the syndrome of inappropriate antidiuretic hormone secretion (SIADH) may lead to cerebral edema and herniation. Peripheral nerve injury from vascular damage, thermal effect, or direct action of current may occur and be progressive. A variety of autonomic disturbances also occur. Late involvement of the spinal cord may produce ascending paralysis, amyotrophic lateral sclerosis, transverse myelitis, or incomplete cord transection. Cataracts can be seen in any electrical injury involving the head or neck.

Passage of current through the abdominal wall can cause Curling's ulcers in the stomach or duodenum. Other injuries described include evisceration, stomach or intestinal perforation, esophageal stricture, and electrocoagulation of the liver or pancreas.

Blunt trauma or tetanic muscle contractions can cause fractures or dislocations. Amputation of an extremity is necessary in 35–60% of survivors of high-energy injury caused by extensive underlying injuries. Infections frequently occur in gangrenous tissue. Prevalent organisms include Staphylococcus, Pseudomonas, and Clostridium.

Victims may suffer depression, flashbacks, attention deficit disorder, sleep problems, and other cognitive difficulties that can affect learning and school performance as well as social function within the family or school.

Management

Prehospital Care

Extrication is extremely dangerous until the power source is disconnected. Victims should be treated both as burn victims and as blunt trauma patients, with special attention given to spinal immobilization^. Except in known low-voltage injuries, aggressive fluid therapy is essential to sustain circulation and begin diluting myoglobin. Transport to a health care facility should not be delayed.^15,16

Several reports have shown that most deaths occurred at the scene of the accident due to cardiac arrest with asystole, arrhythmias such as tachycardia or ventricular fibrillation, or secondary to hypoxia from respiratory arrest due to compromise of the respiratory center at the brain stem or oxygenation and ventilation disorder caused by respiratory muscle tetany.^2,17–19 These patients may benefit from early cardiopulmonary resuscitation measures either by lay personnel or pre-hospital systems.

Unlike other events with multiple victims, in cases of electrical injuries, the main priority is the critical patient even when vital signs are not shown. Given the common absence of related pathologies and young age, these patients may show good prognosis, even in long resuscitation processes.¹²

Emergency Department Care

A victim of electrical injury should be approached in the same way as a victim of blunt trauma with a crush injury. The greatest threats to life include cardiac arrhythmias, renal failure from myoglobin and hemoglobin precipitants, and hyperkalemia from massive muscle breakdown in more severe injuries. A thorough search for burns, other wounds, and hidden skeletal injuries is necessary.^15,16 Lesser injuries and small burns can be treated conservatively with few or no laboratory tests or x-rays. Referral for appropriate follow-up may be all that is needed.

ECG is not indicated for children exposed to household current (120–240 V) unless there was loss of consciousness, tetany, wet skin, transthoracic current flow, or the event was unwitnessed.^11,20 Provided the ECG is normal, observation and cardiac monitoring are not usually required. Different protocols have been conducted determining the safety of the nonobservation and discharge from the emergency service.^9,12,21

For more extensive injuries, laboratory tests may include arterial blood gases, complete blood count, serum electrolytes, blood urea nitrogen, creatinine, glucose, blood type and cross-match, and urinalysis for myoglobin. Creatine kinase (CK), although commonly drawn in these patients, is not predictive of the degree of injury. Although CK-MB (muscle brain) isoenzyme elevations can be seen, they may be from damaged skeletal muscle. Radiographs of the cervical spine, chest, and pelvis may be indicated if there is any history of fall, being thrown, loss of consciousness, or pain in these areas.

Other films may be obtained as dictated by physical examination. Electrocardiograms are routinely done in more serious injuries but may not be helpful since they are not very specific, and also most ECG manifestations are transitory and do not represent the severity.^11,18 If the ECG is consistent with cardiac injury, further evaluation with echocardiographyor nuclear scanning may be necessary.^15,16

For the patient who requires fluid resuscitation and admission, the usual fluid replacement formulas utilized for burn patients often underestimate fluid requirements. Adequate fluids should be given to maintain a urine output of 1–2 mL/kg/h when pigmentation is present and less after it has cleared. Accurate measurement requires Foley catheter placement. A decreasing level of consciousness, unexplained coma, lateralizing signs, or change in mental status necessitates cranial computed tomography (CT) or magnetic resonance imaging (MRI) to rule out intracranial damage.^15,16

Extensive muscle damage may necessitate fasciotomy, particularly if the chest wall is involved. Compartment syndromes can occur if venous output is blocked by thrombosis and as tissue edema occurs. Debridement is best left to a burn surgeon and should be conservative for lip burns.^15,16

Tetanus prophylaxis should be evaluated and given as needed in the emergency department. Nasogastric intubation may be required and antacids and cimetidine are administered.^15,16 Consultations may be required, depending on the severity and type of injury. All children with oral injuries require plastic surgery and dental or orthodontic consults. Neurosurgical, ophthalmologic, and ear–nose–throat consults may also be necessary. Transfer to a burn center may be indicated.^15,16

Infection remains the most common cause of death after electrical injury. Despite aggressive debridement and decompression, digit or limb loss may be unavoidable if tissue necrosis is extensive.^15,16

Obviously, more severe patients require admission, close observation, and frequent neurovascular checks of the extremities to monitor for compartment syndromes. A multidisciplinary approach, including medical, psychiatric, and social services, is required.^15,16

Prevention

The number of injured due to electricity increases worldwide as humans expose themselves to a greater use of electrically powered devices. In developing countries, where the dangers of low-voltage electricity and household current are often misunderstood or underestimated, injury prevention must involve education and improving the safety measures in homes and rural areas.^22,23

Physicians can play an important role in prevention by educating patients and families. The following advice should be given:²⁴

• Extension cords should be in good repair and not used to replace or avoid conduit wiring.

• Unused outlets should be covered with dummy plugs.

• Electrical appliances must be kept away from sinks and bathtubs.

• Electrically operated toys should be age appropriate. Use of such toys should be supervised by adults.

Older children and adolescents can benefit from school safety programs that not only address the dangers of power lines and transformer substations, but also the risks of lower-voltage injury.

Because of educational efforts and greater awareness, lightning has slipped to the third place as a storm killer, behind floods and tornadoes in the United States^25,26 (Fig. 138-2). However, lightning remains a top killer in tropical and subtropical developing countries due to the unavailability of substantial buildings and metal vehicles, especially in rural areas.^27,28

Currently in the United States, there are less than 30 deaths reported annually for the last 3 years and injuries are estimated to be around 10 times more.²⁹ While 90% of those injured by lightning survive, a significant number may have permanent and life-changing disabilities from chronic pain or neurocognitive injury.^29,30 This is especially true for the school child who sustains an injury that affects their learning and memory skills.

Injuries are most common during high-thunderstorm months but not unheard of in the winter. More males are injured than females at nearly every age.^5,31,32 Deaths and injuries are underreported by as much as 30%.^5,28,33,34

Lightning is produced by the development of an electrical potential between a cumulonimbus cloud and the ground. Within a cloud, rising warm, humid air meets cooler air causing condensation. As ice crystals rise and fall within the cloud, charge separation occurs with primarily positive charges in the upper cloud layers and negative charges in the lower cloud layers.⁵ Around the area of the thundercloud, the negative charge in the bottom of the cloud induces the usually normally negatively charged earth to become positively charged. Eventually, static discharges occur between areas of charge separation in the cloud causing intracloud lightning, which makes up approximately 80–90% of lightning discharges. The remainder, cloud-to-ground lightning, is primarily responsible for personal injuries.

Opposite charges are also induced in structures on the ground, such as a tree, person, cow, or blade of grass. “Streamers” or upward leaders of charge rising from these structures toward the charged cloud can be sufficient to injure even when a complete lightning channel is not formed.^35–37

Mechanisms of Injury

Lightning is dangerous for three reasons: electrical effects, heat production, and concussive force. In addition, lightning may injure indirectly via forest fires, house fires, explosions, or falling objects such as trees. Only primary injury by lightning will be discussed (Fig. 138-3). The distribution of injury by commonly accepted mechanisms are³⁷:

Direct strike occurs when lightning attaches directly to the victim and occurs in 3–5% of lightning injuries. Contact potential occurs in 15–20% of lightening victims and occurs when a person is touching a fence, indoor plumbing, hard-wired telephone, game controller, or similar object attached to a conductor hit at a distance, which then transmits the lightning energy to the person. Side splash/flash occurs when a portion of the lightning energy separates from the primary conductor to injure a nearby person and account for 20–30% of injuries. Current divides itself between the two paths in inverse proportion to their resistances. Standing under or close to trees and other tall objects is a very common way in which people are splashed. Side flashes may also occur from person to person. Ground current injury occurs in 40–50% of lightning injuries and is seen when lightning strikes the ground or an object near a victim and spreads out through the ground under the person. When the victim stands with feet apart, a potential difference between the feet allows current to flow through the body to the ground (stride potential or step current). Upward streamer/leader injury account for 10–15% of lightening injuries and occurs when a streamer of charge induced by the thundercloud in a person is of sufficient magnitude to cause injury, even though a complete lightning channel is never formed. It is likely that a combination of these electrical mechanisms may occur, especially when multiple victims are involved.³⁸ Blunt injury may also occur with most of these mechanisms as the concussive wave of expanding air near the lightning strike impacts the individual or if the person is thrown by muscle contraction.³⁷

Types of Injuries

In developed countries, less than one-third of lightning survivors have external signs of burns, probably due to the usually indirect mechanism of injury. Skin damage is probably decreased by a combination of short duration of contact, lower skin resistance from rain or sweat, and flashover, where the majority of the energy flows over the outside of the body rather than through it. Deep muscle damage is rare. Victims or observers may incorrectly interpret superficial external burns as “entry” or “exit” areas, which rarely, if ever, occur with lightning.

The most common types of skin injury are listed below:

• Lichtenberg figures: These are arborescent, evanescent, spidery, erythematous streaks that are pathognomonic of lightning injury but unfortunately are rarely seen. They most commonly disappear within hours of the injury.

• Linear burns: Linear burns are partial-thickness burns usually correlating to areas of high sweat or water concentration on the body.

• Punctate burns: Cinder-like burns may occur singly or in linear or grouped patterns. They can be full- or partial-thickness burns.

• Thermal burns: Heating of metal objects or ignition of clothing can cause secondary thermal burns.

Victims in developing countries are often reported to have been “burned beyond recognition” or “charred.” It is unclear if this is due to nonfirst person reporting, differences in exposure, or to other factors.³⁹

In developed countries, cardiac arrest at the time of the injury is the only proximate cause of death from lightning, except in freak accidents such as someone falling from a cliff after being injured. It is unknown if the arrest is from CNS damage, autonomic nervous system injury, damage to conduction pathways, or a combination of these, and other factors including the portion of the cardiac cycle in which the injury occurs. In some instances, respiratory arrest may be prolonged, again from unknown specific causes. Although the heart sometimes spontaneously resumes an organized rhythm, those with prolonged respiratory arrest have a poor prognosis with secondary hypoxia and ventricular fibrillation. Congestive heart failure, cardiac contusions, and delayed rupture have also been reported. ECG changes include nonspecific ST-T wave changes, T-wave changes, axis shift, QT prolongation, and ST-segment elevation. These usually resolve gradually. Lung injuries reported include pulmonary contusion, hemorrhage, pneumothorax, pulmonary edema, and aspiration secondary to altered mental status. Arterial spasm and vasomotor instability result in cool, mottled, pulseless extremities. This usually resolves in several hours.⁵

Transient loss of consciousness, retrograde amnesia, transient paralysis, and paresthesias are common. Keraunoparalysis is flaccid paralysis accompanied by vasomotor changes, which may last several hours. In developing countries where severe burns are sometimes reported, keraunoparalysis may be the factor that prevents otherwise healthy individuals and families from escaping their housing after thatch has caught fire. Other neurologic findings may include seizures, skull fracture, intracerebral hemorrhages, elevated intracranial pressure, cerebellar ataxia, Horner's syndrome, SIADH, and peripheral nerve damage, and cerebral salt wasting syndrome.^5,40,41

Cognitive injury similar to other blunt head injury commonly occurs but may not be recognized acutely. Survivors of cardiac resuscitation may have typical anoxic injury as well. Direct or blunt injury to the spinal cord should always be ruled out, especially if symptoms do not resolve. Post-concussive-type headaches lasting weeks to months are common.⁵

Myoglobinuria is rare although there are reports of severe cases of rhabdomyolysis.⁴² Hypotension from prolonged cardiac arrest can lead to acute tubular necrosis. The kidneys may rarely be damaged by concussive force or the person being thrown.⁵

Cataracts may occur, developing either immediately or over a prolonged recovery period. Some resolve spontaneously. Fixed and dilated pupils may be seen after lightning strike from other mechanisms including retinal or optic nerve damage. Other eye injuries reported include uveitis, hyphema, vitreous hemorrhage, macular holes, retinal detachment, and optic neuritis.⁵

Tympanic membrane rupture is common but is often best treated with time rather than surgery. Other aural complications include burns to the ear, ossicular disruption, tinnitus, vertigo, and nystagmus.⁵

Gastric upset similar to post-concussive syndrome is not uncommon for weeks to months after the injury.⁵

Psychological sequelae, including anxiety, sleep disturbances, nocturnal enuresis, depression, and cognitive disability, have all been reported.⁵

Management

Prehospital Care

Lightning injury victims should be approached as blunt multiple trauma patients with attention to advanced life-support protocols and cervical spine protection. Because of the unusual findings of transient, fixed, and dilated pupils, autonomic abnormalities, keraunoparalysis, and transient asystole with prolonged apnea, standard triage procedures should be ignored. Anyone who has not suffered a cardiac arrest is highly likely to survive, is unlikely to be unstable, and may be left for later care. Victims who appear to be dead should be treated aggressively. If the history of lightning strike is unclear, protocols for altered mental status should be followed, including administering glucose and naloxone. Bystanders may be helpful in providing history.

It should be noted that, contrary to popular belief, lightning can strike twice in the same area. Rescuers and emergency personnel are at risk when working with victims near active thunderstorms and should exhibit caution if the threat of lightning strike exists at the time of their arrival.

Emergency Department Care

Treatment follows the same guidelines as for all severely injured patients. Clues that may lead to the diagnosis of lightning strike include recent thunderstorm, outdoor occurrence, clothing disintegration, typical arbores-cent burn pattern, tympanic membrane injury, and magnetization of metallic objects on the victim's body. A complete physical examination, after attention to the ABCs and cervical spine control, is indicated. A thorough search for blunt injuries is necessary. A baseline ECG is also required. Cardiac monitoring is only indicated if there was a cardiac arrest or abnormal initial ECG. Any arrhythmia should be treated by standard protocols. Fluid resuscitation should be cautious; central-monitoring lines may be helpful in more severe cases.

Laboratory tests are likely to be completely normal except in the most severely injured and are probably not cost-effective. More severely injured patients who will be admitted may benefit from baseline tests including complete blood count, renal function tests, and urinalysis for myoglobin. Arterial blood gases, creatine kinase with isoenzymes, serum troponin, and serum chemistries may be indicated for more severe patients. In some cases, urine and blood should be sent for toxicology. Radiographs are done as indicated. Cranial CT scan or MRI is indicated for all unconscious patients.

Burns should be treated by protocol. Fasciotomy is rarely indicated, as the mottled, pulseless extremities associated with lightning injury often improve over several hours. Eye and ear examinations should not be overlooked. Tetanus prophylaxis may be indicated depending on the patient's immunization status.

The vast majority of lightning survivors can be discharged from the emergency department. Exceptions, of course, include post-cardiac arrest, unstable or confused patients, or those with inadequate home supervision and close follow-up care. Appropriate consultation and documentation is necessary.

Long-term sequelae may include post-concussive syndrome, cognitive disability leading to school performance issues, chronic pain syndromes, delayed and often atypical seizures, and disturbances in balance, coordination, mood, sleep, affect, and memory. Some of these may be especially difficult to appreciate in adolescents and children.

Prevention

No place outside is safe when thunderstorms are in the area. While no one can guard against the stray “bolt from the blue,” the majority of lightning injuries are preventable if one knows and follows lightning injury prevention guidelines listed in Table 138-2.²⁵ The threefold decrease in fatalities in the United States over the last two decades is directly related to the cooperation of the media in spreading the lightning safety message which is now common in nearly every sports literature, schools, and park management publications.²⁶