All patients with lightning injury should have a 12-lead ECG performed to evaluate for arrhythmias and injury patterns ( Tabje ,.19Zz3). Laboratory tests that should be conducted in most patients with moderate to severe injuries include determination of serum electrolytes, calcium, magnesium, blood urea nitrogen, creatinine, CK, CK-MB, arterial blood gas, and urine myoglobin levels; coagulation studies; a complete blood count; and urinalysis. A chest x-ray should be obtained to evaluate for aspiration, pulmonary edema, pulmonary contusion, rib fractures, and pneumothorax. Cervical spine films should be obtained in patients with suspected spinal injuries or trauma secondary to falls, and in obtunded patients in whom a history of trauma is uncertain. Computed tomography of the head should be performed in patients with an altered or deteriorating level of consciousness or evidence of a head injury. Additional studies may be indicated based on clinical findings.

The differential diagnosis of an unwitnessed victim of lightning strike is quite broad and includes trauma, metabolic disturbance, toxic exposure, and other causes of an altered mental status (IabJe.1.9Z.-.4). Lightning injuries can be suspected when the environmental setting is compatible and a victim displays physical findings unique to such injuries. For example, an unconscious rain-soaked patient with perforated tympanic membranes and Lichtenberg figures (fernlike skin markings) who is found in a field near a tractor is almost definitely a lightning victim.

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