Lazarus Phenomenon - Delayed ROSC After CPR Termination

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Delayed ROSC may occur after cessation of CPR - the so called Lazarus phenomenon.  The incidence was around 6/1000 cases and occurred 3-8 minutes after CPR cessation.  All patients eventually died; 4 of 5 had PEA. It may be wise to allow 10 minutes before pronouncing death (or 4 days if the patient is actually named Lazarus).

Why does this matter?
One tends to lose face after pronouncing someone dead only to have them unwittingly spring back to life.  It happens.  There have been numerous case reports of this phenomenon, but no systematic estimate of its incidence.  But after a malpractice case in Finland, the EMS system in Helsinki protocolized a 10 minute observation period after cessation of CPR beginning in 2010. This Finnish registry sheds new light on the subject.  Even though all patients in this registry that had delayed ROSC subsequently died within a day, this can be very traumatic for family. It is important to be aware of this rare event.

Lazarus = ultimate ROSC: "Lord, by this time he stinketh: for he hath been dead four days." John 11:39
I like the word "stinketh" - we should use it more.  This was a cohort of arrest patients over a 6 year period from a prospective registry in Finland.  There were 1376 cases of cardiac arrest in which CPR was attempted; 840 were terminated in the field. There were 5 cases of delayed ROSC after CPR was terminated in the field (6/1000 incidence), occurring 3-8 minutes after CPR cessation.  3 died within another few minutes on scene; 2 died within 90 minutes and 26 hours later in hospital, respectively.  Four out of five had PEA; one had asystole. 3 of the 4 patients with PEA had a cardiac echo to confirm no cardiac movement.  No pseudo-Lazarus events were identified (i.e. inappropriate termination of CPR).  The authors recommended unhooking from the ventilator circuit (to relieve auto-PEEP) and monitoring the patient for around 10 minutes after termination of resuscitation before pronouncing death.  Be especially careful pronouncing patients with PEA.

Source
Delayed return of spontaneous circulation (the Lazarus phenomenon) after cessation of out-of-hospital cardiopulmonary resuscitation.  Resuscitation. 2017 Sep;118:107-111. doi: 10.1016/j.resuscitation.2017.07.022. Epub 2017 Jul 24.

Peer reviewed by Thomas Davis, MD.

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