Emergency medical service personnel and bystander safety must be the first priority, since lightning can and does frequently strike twice in the same place. The standard airway, breathing, circulation, disability, and exposure protocols with advanced life support (ALS) protocols are required. Reverse triage (care for the apparently dead first) is appropriate in the case of multiple victims, because (a) most victims who are not in cardiopulmonary arrest survive without the need for ALS and (b) victims in cardiac arrest may survive if ventilated until cardiac and respiratory activity resumes. 15 Thus, concentrating limited ALS resources on apparently dead victims in a multicasualty lightning-strike event is appropriate. Due to the unusual neurologic manifestations of lightning injuries, patients with fixed and dilated pupils may survive and live a normal life. Patients who are blue, with mottled extremities, in whom it may be difficult to find a pulse or a blood pressure, may recover without sequelae. Aggressive fluid resuscitation is rarely required. Victims of a lightning strike should be transported in full spinal immobilization, due to the possibility of traumatic injuries.
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