The Lazarus phenomenon – paramedic friend or foe
The initial excitement has long passed, your own excited, racing heart replaced by the weariness and aching back that comes from over thirty minutes of vigorous cardiopulmonary resuscitation. That fatigue has been underscored by the fact that today just isn’t to be your day. With a last glance at the cardiac monitor, the decreasingly occasional agonal complexes tells you what you have known for a while now.
You’ve lost this one and it’s time to stop.
You shake your head surreptitiously and gently reach over to stop the fire-fighters hands from continuing to pump the unfortunate patient’s chest. Standing, you take a few seconds to flex your punished knees before making your way across to the waiting family. You’ve been constantly back and forth with them all the way and know that they’re expecting bad news by now. Predictably though the grief still hits them hard. No more helpful words come to mind so you step back to give them a moment’s piece.
As you begin to pack up your equipment, bagging up the inevitable rubbish you have strewn around, your partner points suddenly at the cardiac monitor screen. With little more than curiosity you turn your head to follow the direction of his point before freeing, your mouth agape.
There is a rhythm on the monitor, still attached to the patient.
Sinus rhythm in fact. A slight fluttering in his neck catches your eye as well prompting you to thrust your fingers in search of a carotid pulse.
There is a pulse there also.
What the heck? How has this happened? How could it be possible for a patient to be clearly without any signs of life, stay that way throughout your best resuscitation, then, just as you break the bad news to the survivors, as you’ve done so many other times, an apparent miracle occurs. Not exactly a wanted miracle as it turns out. And it’s not from anything you did. Rather, it appears, from you doing precisely nothing.
It doesn’t happen very often. Though not rare, many may never encounter it. So what caused it?
Nobody knows precisely why this happens. One thing in common is that it follows cardiac arrest resuscitation efforts and not just resurrection of an apparently lifeless patient when found. There may in fact be multiple reasons for it to happen that all are scooped up into the same presentation. Hyperinflation of the lungs is one favoured supposition, particularly where there is reason such event might occur (lung trauma, restrictive airways disease). It could be caused by poor delivery of peripheral IV drugs that finally take effect later or perhaps by alteration of blood pH and its effect on administered drugs. Other more difficult to prove explanations include transient bradyarrhythmia/asystole, stunned myocardium during ACS or even electrolyte disturbance 1,2,3,4,5,6,7.
Whatever the cause, the occurrence shouldn’t be the cause of great excitement. Some patients may reach hospital still alive but few actually walk out and return to their lives. More likely it will prove only a temporary stay of fatality. Some may return to lifeless within minutes. In the meantime, if the patient does come back to life, there is little else but to manage them to the best of your ability as if they are salvageable.
Since you don’t want to have patients resurrect themselves after you’ve broken the bad news, how can this be avoided? Assuming you’ve gone through the mechanics of an effective resuscitation and you have become sure of the patient’s demise, consider weaning yourself from your efforts. Stop administering intravenous drugs first. Let them circulate with the compressions and metabolise over the next few minutes. Then cease the ventilation and let any trapped air out of the chest. Do that of course much earlier if there is suspicion of asthma or COPD in there. And of course ventilate patients appropriately for those conditions. After a couple more minutes, it’s time to stop the compressions as well.
Finally, the last and most important part. Provided you have the opportunity, give it a few more minutes before you break the bad news. If there is to be a Lazarus miracle, it will happen within ten or so minutes, fifteen at the most. After that, a clear verification of death can be completed.
Jeff Kenneally www.prehemt.com
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