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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Monday, July 27, 2015

Auto-resuscitation: Lazarus Syndrome!


What is Lazarus Syndrome?

Lazarus syndrome/ phenomenon is a rare and probably under reported condition where delayed return of spontaneous circulation (ROSC) after cessation of cardiopulmonary resuscitation (CPR) is seen. This was first reported in 1982, so far 38 cases of delayed ROSC have been published and majority of them come from anaesthesia and critical care literature. 

In the cases reported so far, ROSC very often occurred within 10 minutes of stopping CPR. Less than half of them achieved good neurological recovery following ROSC and the rest died soon after.




What are the possible mechanisms that explain Lazarus Syndrome?

The exact mechanism of delayed ROSC is unclear and not well understood. This is possibly multifactorial:

1. Positive end expiratory pressure

Dynamic hyperinflation of the lung causing increased positive end expiratory pressure (PEEP) is one of the proposed mechanisms.

2. Delayed action of drugs

Some authors suggest delayed action of drugs administered during CPR as a mechanism for delayed ROSC. It is possible that drugs injected through a peripheral vein are inadequately delivered centrally due to impaired venous return, and when venous return improves after stopping the dynamic hyperinflation, delivery of drugs could contribute to return of circulation.

3. Myocardial stunning

Prolonged myocardial dysfunction can occur following myocardial ischaemia, taking up to several hours before normal function returns. Myocardial Infarction was present in about 1/3 of the cases reported so far which could have contributed to transient myocardial ischaemia and stunning.


What can be the implications for emergency health care providers with delayed ROSC?

Delayed ROSC can lead to serious professional and legal consequences. Questions can be raised about the quality of resus and whether it was stopped too soon. The  physicians might also be accused of negligence or incompetence and even be sued for the damages.

In such a scenario, the conduct of resuscitation can only be assessed from the documentation, so it is vital to record the events during cardiac arrest as accurately as possible. It is absolutely essential to get a consensus from the arrest team and to document the reason for termination of CPR. 



So, What makes Lazarus Syndrome important for us?

We need to realize that death is not an event, but a process. It is a process during which various organs supporting the continuation of life fail. Cessation of circulation and respiration is such an example. The physical findings to support this—absence of heartbeat and respiration—are the traditional and the most widely used criteria to certify death. Since these findings alone are not a sign of definitive death, it is quite possible to declare death in the interval between cessation of CPR and delayed ROSC.

Some recommend that the patients should be passively monitored for few minutes following unsuccessful CPR. It should also be mentioned that the patient is being closely monitored to establish death. Death should not be certified in any patient immediately after stopping CPR, and one should wait at least 5-10 minutes, if not longer, to verify and confirm death beyond doubt.  


The time honoured criteria of the stoppage of the heart beat and circulation are indicative of death only when they persist long enough for the brain to die.

KEY POINTS

  • Lazarus phenomenon is delayed ROSC after cessation of CPR.
  • Understand death: It is a process, Stop looking at it like a single event.
  • Observe the patients for 5-10 minutes the cessation of CPR before confirming death. (Get an EKG or bedside ECHO before you declare death)
  • Re-read and scrutinise the chart before signing it off. 

References: 
  1. Adhiyaman V, Adhiyaman S, Sundaram R. The Lazarus phenomenon. Journal of the Royal Society of Medicine. 2007;100(12):552-557.Bray JG. The Lazarus phenomenon revisited. Anesthesiology 1993;78: 991
  2. Linko K, Honkavaara P, Salmenpera M. Recovery after discontinued cardiopulmonary resuscitation. Lancet 1982;1: 106-7  
  3. Martens P, Vandekerckhove Y, Mullie A. Restoration of spontaneous circulation after cessation of cardiopulmonary resuscitation. Lancet 1993;341: 841 
  4. Braunwald E, Kloner RA. The stunned myocardium: prolonged, postischemic ventricular dysfunction. Circulation 1982;66: 1146-9 
  5. De Salvia A, Guardo A, Orrico M, De Leo D. A new case of Lazarus phenomenon? Forensic Sci Int2004;146: S13-5  
  6. Monticelli F, Bauer N, Meyer HJ. Lazarus phenomenon. Current resuscitation standards and questions for the expert witness (German). Rechtmedizin 2006;16: 57-63
  7. Lantos JD. The Lazarus Case: Life and Death Issues in Neonatal Intensive Care. Baltimore: Johns Hopkins University Press, 2001
  8. Conference of Medical Royal Colleges and their Faculties in the United Kingdom 1979. Diagnosis of death. BMJ 1979;1: 332. 
  9. Sweet WH. Brain death. NEJM 1978;299: 410-2  

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