Virginia Research Day 2025

Medical Resident Research Case Reports

14 Lazarus Phenomenon: Delayed Return of Spontaneous Circulation After Termination of Cardiopulmonary Resuscitation in a Patient With an In-Hospital Cardiopulmonary Arrest

Mirna Martinez, DO; Allison Nanez, MS3; Kimberly Bird, MD; Sulaiman Tijani, MD Corresponding author:mirna.martinez@lpnt.net

Sovah Health Internal Medicine Residency Program

A middle-aged man presented to the emergency department after being found unresponsive at home in a kneeling position with unknown downtime. Based on collateral information and history of previous suicide attempt, his presentation was thought to be a suicide. A urine drug screen was positive for tricyclics and cocaine. Patient had been recently prescribed a 90-day supply of Benztropine. Benztropine has potent anticholinergic toxicity in an overdose and in this patient likely caused muscle weakness and coma. In the emergency department, this patient was found to have severe hyperkalemia with a potassium of 8.2, acidosis with a pH of 7.10, a lactic acid of 10.1, and severe rhabdomyolysis with a CPK of 7001. He was intubated in the emergency department. Multiple electrocardiograms demonstrated ventricular tachycardia. Poison control recommended serial monitoring with electrocardiograms, temporizing measures for hyperkalemia, lidocaine drip, and bicarbonate drip which were performed. Shortly after his admission to the ICU, patient suffered a PEA

arrest, and ACLS protocol was followed. After 40 minutes, cardiopulmonary resuscitation (CPR) efforts were terminated. Since the patient’s case was going to be reviewed by the medical examiner in the setting of suicide attempt, the patient remained intubated with ventilator turned off. After the code was called and the team had left, the nurse reassessed the patient who was found to have a pulse. His medical care was resumed. Despite multiple rounds of temporizing measures, his hospitalization was complicated by refractory hyperkalemia with a maximum potassium of 8.6, worsening rhabdomyolysis with a maximum CPK of 133,098, and persistent acidosis. He required maximal pressor support for hypotension. After several ongoing discussions with family, they elected comfort measures only and the patient expired two days after his PEA arrest. During the code blue debriefing meeting, there was a discussion that the patient was being over-ventilated. The patient experienced “autoresuscitation”- delayed ROSC

after termination of resuscitation in cardiac arrest, also known as the Lazarus Phenomenon. The exact mechanisms of delayed ROSC are unclear. It is possible that in this patient, the administration of a significant tidal volume with excessive frequency led to an increase in intrathoracic pressure. This caused delayed venous return including an interruption of optimal pharmacokinetics of the ACLS medications. During cardiopulmonary resuscitation, once an advanced airway is established, 1 breath is given every 6 seconds (10 breaths/min) with continuous chest compressions. Clinicians should recognize that the chances of autoresuscitation are increased in prolonged resuscitation efforts greater than 30 minutes. This case illustrates the importance of avoiding hyperventilation during cardiopulmonary resuscitation and a standardized observation period following the cessation of in-hospital cardiopulmonary resuscitation.

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