Is increased positive end-expiratory pressure the culprit? Autoresuscitation in a 44-year-old man after prolonged cardiopulmonary resuscitation: a case report

Review article: Back to life from being declared dead in the Resus Bay: An integrative review of the phenomenon of autoresuscitation and learning for ED

This is a literature review of ED autoresuscitation. The impetus for this review was a case which revealed a lack of understanding about Lazarus syndrome among ED staff. The primary objective was to see the proportion of cases who survived neurologically intact to discharge and the time frame when this occurred after death had been declared. A secondary outcome was to see whether these studies mention whether bedside echo was performed prior to deciding whether to terminate resuscitation. A systematic search of five databases was undertaken with keywords, 'autoresuscitation', 'cardiac arrest' and 'emergency department'. Articles published in the English language were selected for inclusion. No time frame was selected because of the low number of articles. A total of 240 articles were identified, that yielded 26 cases that were relevant and could be synthesised to create a discussion on the current clinical guidelines around resuscitation. Our analysis demonstrates that of the 11 survivors who were discharged neurologically intact, the average age was 42.9 years; otherwise, the average was 62.6 years. The majority (23/26) 88% auto-resuscitated within 10 min after being pronounced dead. Only five patients are mentioned as having had a bedside echo prior to deciding to cease efforts. Under-reporting of autoresuscitation is suspected because of fears of blame. Passive monitoring for 10 min after resuscitation is ceased, is recommended. There is need for more data on this phenomenon to help inform further research on the topic.

Lazarus Phenomenon or the Return from the Afterlife-What We Know about Auto Resuscitation

Autoresuscitation is a phenomenon of the heart during which it can resume its spontaneous activity and generate circulation. It was described for the first time by K. Linko in 1982 as a recovery after discontinued cardiopulmonary resuscitation (CPR). J.G. Bray named the recovery from death the Lazarus phenomenon in 1993. It is based on a biblical story of Jesus' resurrection of Lazarus four days after confirmation of his death. Up to the end of 2022, 76 cases (coming from 27 countries) of spontaneous recovery after death were reported; among them, 10 occurred in children. The youngest patient was 9 months old, and the oldest was 97 years old. The longest resuscitation lasted 90 min, but the shortest was 6 min. Cardiac arrest occurred in and out of the hospital. The majority of the patients suffered from many diseases. In most cases of the Lazarus phenomenon, the observed rhythms at cardiac arrest were non-shockable (Asystole, PEA). Survival time after death ranged from minutes to hours, days, and even months. Six patients with the Lazarus phenomenon reached full recovery without neurological impairment. Some of the causes leading to autoresuscitation presented here are hyperventilation and alkalosis, auto-PEEP, delayed drug action, hypothermia, intoxication, metabolic disorders (hyperkalemia), and unobserved minimal vital signs. To avoid Lazarus Syndrome, it is recommended that the patient be monitored for 10 min after discontinuing CPR. Knowledge about this phenomenon should be disseminated in the medical community in order to improve the reporting of such cases. The probability of autoresuscitation among older people is possible.

Autoresuscitation (Lazarus phenomenon) after termination of cardiopulmonary resuscitation - a scoping review

BACKGROUND

Autoresuscitation describes the return of spontaneous circulation after termination of resuscitation (TOR) following cardiac arrest (CA). We aimed to identify phenomena that may lead to autoresuscitation and to provide guidance to reduce the likelihood of it occurring.

MATERIALS AND METHODS

We conducted a literature search (Google Scholar, MEDLINE, PubMed) and a scoping review according to PRISMA-ScR guidelines of autoresuscitation cases where patients undergoing CPR recovered circulation spontaneously after TOR with the following criteria: 1) CA from any cause; 2) CPR for any length of time; 3) A point was reached when it was felt that the patient had died; 4) Staff declared the patient dead and stood back. No further interventions took place; 5) Later, vital signs were observed. 6) Vital signs were sustained for more than a few seconds, such that staff had to resume active care.

RESULTS

Sixty-five patients with ROSC after TOR were identified in 53 articles (1982-2018), 18 (28%) made a full recovery.

CONCLUSIONS

Almost a third made a full recovery after autoresuscitation. The following reasons for and recommendations to avoid autoresuscitation can be proposed: 1) In asystole with no reversible causes, resuscitation efforts should be continued for at least 20 min; 2) CPR should not be abandoned immediately after unsuccessful defibrillation, as transient asystole can occur after defibrillation; 3) Excessive ventilation during CPR may cause hyperinflation and should be avoided; 4) In refractory CA, resuscitation should not be terminated in the presence of any potentially-treatable cardiac rhythm; 5) After TOR, the casualty should be observed continuously and ECG monitored for at least 10 min.