Lazarus Syndrome

What is Lazarus Syndrome?

Lazarus Syndrome  is a condition named after Lazarus who, in the New Testament of The Bible, was raised by Jesus from the dead. The disorder, also known as autoresuscitation after failed cardiopulmonary resuscitation comes about due to the spontaneous return of blood circulation after several failed resuscitation attempts.

The syndrome is very rare and has only been noted 38 times in medical literature since 1982.

 

Causes

The occurrence of Lazarus syndrome is pretty rare and the cause unknown. One of the hypothesis outlines the cause to be as a result of pressure build-up and increase during cardiopulmonary resuscitation (CPR).

The relaxation of the pressure afterwards soon after repeated efforts of resuscitation is thought to trigger the heart’s electrical impulses therebyrestarting the heartbeat. Other possible causes of this phenomenon is high dosage of epinephrine or hyperkalaemia.

Mechanisms

In Lazarus phenomenon, there is delay in the return of spontaneous circulation after ending a CPR. While cases of this phenomenon have occurred, it appears that there has been underreporting of some of the cases. Nonetheless, this phenomenon is a reality but what’s bothering is that there seems to be no scientific explanation as to what happens.

It has also been established that delayed return of spontaneous circulation occurs in about 10 minutes something that suggests patients to be monitored for about 10 minutes after ending a cardio pulmonary resuscitation in order to confirm death. That said, here are suggested mechanisms in which this phenomenon occurs:

Positive end expiratory pressure: There can occur dynamic hyperinflation of lungs during CPR. This hyperinflation may be caused by rapid manual ventilation that don’t allow for adequate time for a patient to exhale. This may, in turn, result in gas being trapped in the lungs something that increases the end-expiratory pressure also called auto-PEEP.

The increasing end expiratory pressure or auto-PEEP leads to delay in venous return, lowered cardiac input, or even cardiac arrest especially in patients having obstructive disease.

Auto-PEEP or end-expiratory pressure is a possible cause for pulseless electrical activity or PEA. Therefore, it is recommended that rapid ventilation at time of doing CPR should be avoided. Patients need to be given sufficient time for venous return to occur. Dynamic hyperinflation may happen in various situations where there is rapid manual ventilation.

Although auto-PEEP arising from hyperinflation may be a plausible cause for delayed ROSC with some suggestive evidence in patients having obstructive airways, on the other hand, it may not be used alone to explain all cases of this phenomenon.

Delayed drug action

It has been suggested that delay in the action of drugs that are administered at time of CPR may contribute to delayed ROSC. Drugs injected via peripheral vein may not be adequately delivered centrally because of impaired venous return.

So, when venous return heightens after the dynamic hyperinflation has been stopped, then the delivery of the drug may result in return of circulation.

The problem with this theory is that it may not be possible to prove or disprove the occurrence of the phenomenon as a result of delayed action of drugs. Again, in some cases, drugs are administered using a central line. Nonetheless, it is still a reasonable explanation.

Myocardial stunning

When there is prolonged myocardial dysfunction after myocardial ischaemia, it may take several hours for normal function to return.

A number of patients who have been reported to have experienced delayed ROSC are said to have had myocardial infarction and others had hypovolaemia, both of which could have led to transient myocardial ischaemia as well as stunning.

Hyperkalaemia

In presence of hyperkalaemia, there has been some cases of delayed ROSC, however, this condition alone may not be able to explain why delayed ROSC happens after ending a CPR procedure. Hyperkalaemia refers to elevated levels of potassium in body.

This is linked with auto-resuscitation. With high potassium levels in body, they interfere with the function of heart. When a doctor prescribes glucose, calcium, insulin, or sodium bicarbonate, these reduce the level of potassium and therefore, the heart resumes beating.

Transient asystole: In more than half of the patients with Lazarus phenomenon or delayed ROSC, asystole after a countershock happening due to prolonged VF is something common. Asystole or PEA occurring after a countershock may be transient prior to perfusable rhythm restoring circulation.

Cases

• On 31^st December 1996, Daphne Banks took an overdose of certain drug while her home in Huntingdon, England. She was rushed to Hinchingbrooke hospital but was declared dead the following day. 34 hours after her death announcement, she was found snoring at the mortuary.
• A 27-year-old man from the UK collapsed soon after overdosing on cocaine and heroin. Paramedics gave him an injection that strengthened him to walk to the ambulance.
• While in transit, he went into cardiac arrest. The doctors quickly started resuscitating him but after 25 minutes he was verbally declare gone. A minute later after resuscitation ended, a nurse noticed a rhythm in the heart monitor that triggered resuscitation again. The patient fully recovered.
• A 66-year-old man was suspected to suffer from abdominal aneurysm. During his treatment he fell into cardiac arrest and doctors responded by giving him chest compressions that lasted for 17 minutes. The patient was declared dead after vital signs failed to show.
• Ten minutes later, the medical team noticed a pulse. The abdominal aneurysm was treated and the patient recovered and was discharged with no physical or neurological complications. ²
• According to a 2002 journal article written by Forensic Science International, a 65-year-old partially deaf Japanese male was found unconscious. The medical team channeled their efforts to resuscitating and defibrillating the patient, but to no success.
• He was declared dead after failed attempts of resuscitation. However, a police guard found the patient roaming through the mortuary 20 minutes later. The patient survived for 4 more days.
• In May 2007, a 61-year-old female from Delaware, United States went into cardiac arrest while at Beebe Medical Center in L
• ewes. She was given synchronized shocks and multiple medicines to save her, but she never regained her pulse. Later on, she was found in the morgue alive and breathing. She even sued the hospital for negligence and for damages arising from neurological and physical problems stemming from the ordeal. ¹
• Anthony Yahle , 37, from Ohio, USA experienced breathing difficulties while at his home on August 5^th 2013. Upon arrival at the hospital, first responders shocked him several times until they were able to record a heartbeat.
• On the afternoon, he was pronounced dead after coding 45 minutes at the hospital bed. Minutes later, his son noted a heartbeat on the monitor that was attached to his father and resuscitation efforts ensued and the patient was revived.
• A 78-year-old man from Lexington, Mississippi, United States was at home when his nurse called for a doctor to examine him. On arrival, the coroner declared Mr. Walter Williams as dead at 9 p.m. the same day. The “deceased” was later discovered roaming the funeral home. This phenomenon was highly attributed to the defibrillator attached to his chest which seemed to work efficiently until fifteen days later when the old man passed away.
• A 45-year-old Colombian woman was declared dead after ascertaining that all her vital organs were inactive. She was taken to the mortuary from where a funeral worker noticed the woman moving and alerted her co-worker to call the hospital from where she had been pronounced dead.
• A man aged 65 with a Malaysian origin was declared dead by doctors from Seberang Jaya Hospital in Penang but came alive two-and-a-half hours later after the announcement. Unfortunately the man died three weeks later.

Treatment

The occurrence of Lazarus syndrome is unpredictable and the cause unknown. The condition still remains a mystery to most doctors and physicists and as such has no cure. In case occurrences similar to those highlighted in the above cases show, resuscitation efforts may come in handy when trying to restart the heart.

Lazarus Syndrome vs. Bamforth-Lazarus Syndrome

Lazarus syndrome shouldn’t be confused with Bamforth-Lazarus syndrome, which is a congenital hypothyroidism that is characterized by thyroid digenesis. Unlike the former condition, Bamforth-Lazarus can be managed and treated if discovered at early stages.

Thyroid hormone replacement therapy is best suited for those with Bamforth-Lazarus syndrome and should be started as soon as you are diagnosed with the condition. The dosage of synthetic thyroxine should be prescribed accurately with respect to weight, age, and any other relevant medical condition.

Regular follow-ups are necessary to investigate any fluctuations in TSH levels. Phototherapy is often effective for patients born with hyperbilirubinemia.

Surgical operations on the choanal atresia (Surgery procedure to reopen the nasal passage) and cleft palate (plastic surgery) should be further discussed in a specialized health center. Speech therapy may also come in handy.

Implications

The Lazarus phenomenon raises more questions than answers. Doctors and physicists have to deal with ethical issues that determine when a person should be announced dead, when resuscitations efforts should begin or end, and when autopsies and postmortem should take place.

Medical literature recommends for a keen observation of the patient’s vital organs for about five to ten minutes after resuscitation to ascertain death.

Reference List

1. Woman Declared Dead, Still Breathing in Morgue. Retrieved from http://www.foxnews.com/story/2008/10/07/woman-declared-dead-still-breathing-in-morgue.html
2. Survival After Failed Intraoperative Resuscitation. Retrieved from http://journals.lww.com/anesthesia-analgesia/Citation/2001/03000/Survival_After_Failed_Intraoperative.27.aspx
3. Lazarus phenomenon. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2121643/
4. The Lazarus Phenomenon, Explained: Why Sometimes, the Deceased Are Not Dead, Yet. Retrieved from http://www.smithsonianmag.com/science-nature/lazarus-phenomenon-explained-why-sometimes-deceased-are-not-dead-yet-180958613/