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Author: Bill Christian, MS-III
Ross University School of Medicine
AAEM/RSA Social Media Committee
A 27-year-old male is brought into the emergency department (ED) in asystole after collapsing while allegedly using intravenous drugs. At the scene, emergency medical services (EMS) gave him naloxone, after which he regained pulses. However, on arrival to the ED, the patient’s respiratory rate decreases, and he subsequently goes into cardiac arrest. He is pronounced dead after attempting resuscitation for twenty-five minutes in which he remained asystolic with no respiratory effort. One minute later, the patient has return of spontaneous circulation (ROSC), is intubated, and transferred to the ICU. He eventually makes a full recovery with no neurological deficit. This is an actual case of Lazarus syndrome, also known as auto-resuscitation after failed cardiopulmonary resuscitation.
The cases of Lazarus syndrome described in the literature are varied. The characteristics can range widely by patient age, medical conditions, and total duration of cardiopulmonary resuscitation (CPR). ROSC occurs within ten minutes for most cases, as was the case for a 66-year-old man who “died” intraoperatively for a suspected abdominal aorta aneurysm leak.[2,3] It remains unclear as to the pathophysiology, but there are hypotheses. One proposed mechanism is rapid manual ventilation leading to hyperinflation and gas trapping, which delays venous return thus causing low cardiac output. Other suggestions are hyperkalemia (rendering cardiac muscle retractile), myocardial stunning (which can occur following myocardial ischemia), or transient asystole (following countercheck of prolonged ventricular fibrillation).
After escaping death, how is a patient’s quality of life? According to one review, 35% of these patients had good neurological function and were discharged, while the rest eventually died. If we think about patients with Lazarus Syndrome having a “bad” heart, what about a “bad” brain? Can those with brain death be brought back to life with some sort of meaningful quality of life? There’s anecdotal evidence claiming some cases of neurological recovery after brain death. However, there are no reported cases of patients recovering neurological function after a diagnosis of brain death according to the American Academy of Neurologists’ standards. In addition, one must be aware of brain death mimickers. For example, there is a case report of a bupropion overdose resulting in loss of brainstem reflexes and electroencephalography burst suppression, rather than true brain death.
Preventing brain death after cardiac arrest is key. One must be aware of the neuroprotective strategies on post-cardiac arrest patients. Targeted temperature management describes strict temperature control following cardiac arrest and has been shown to provide benefit in survival and neuroprotection. However, when it comes to a specific temperature, there has not been consensus on a superior targeted temperature; benefit is derived from a target temperature ranging from hypothermic to normothermic, namely between 32°C and 36°C.[7,8] Methods for decreasing temperature include cold intravenous saline, cooling vests, cooling machines, sedation, and paralysis.
So it is possible for someone to come back from the dead? One must be reminded that Lazarus syndrome is extremely rare at a rate of 5.95 per 1000 people. Regarding the recovery from brain death, unfortunately, there has been no known cases of true full recovery. Keep your eyes alert even after a patient dies! Will you be fortunate enough to see a “Lazarus" and “raise” him or her from the dead?
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