Skip to main content

Table 4 Proposed autoresuscitation mechanisms and recommendations based on case reports to reduce the likelihood of it occurring

From: Autoresuscitation (Lazarus phenomenon) after termination of cardiopulmonary resuscitation - a scoping review

factorProposed MechanismActions that might reduce the Likelihood of Autoresuscitation occurring
Poor controlled ventilation techniques
1) Air trapping in the lungs causing hyperinflationCaused by high tidal volume or rapid ventilation rates with insufficient time for exhalation. Releasing the positive intra-thoracic pressure will enable venous return to resume and restore the circulation [24, 38, 59, 64, 65, 74,75,76,77,78,79, 86, 98, 100,101,102]. Effect more pronounced in hypovolaemia [37, 64] and pre-existing obstructive airways disease, especially if not managed correctly [9, 59, 103].Avoid excessive ventilation (rate, tidal volume, or both)
Exclude hyperinflation as a reversible cause of Pulseless Electrical Activity (PEA) by stopping ventilation and disconnecting the bag
2) High intrathoracic pressureDelays injected CPR drugs from reaching the heart and allows drugs to accumulate peripherally. Stopping positive airway pressure allows drugs to reach the heart resulting in beneficial effects [65, 80, 86].
3) HyperventilationDeleterious effects on coronary perfusion pressure (CPP) [104].
Delayed drug effectsIn profound acidosis or impaired drugs delivery via peripheral or intraosseous lines [77,78,79]. 
CPP as low as 15 mmHg can produce Return of Spontaneous Circulation after asystoleIntrinsic vasomotor function of capacitance and resistance blood vessels may maintain CPP so that even when resuscitation has ceased, CPP may be high enough to restart the heart [105].Careful consideration before terminating resuscitation if vasopressor infusions and/or mechanical ventilation are used
Return of myocardial function following Termination of Resuscitation (TOR)Myocardial reperfusion due to spontaneous dislodging of endovascular plaque from a coronary artery [7, 10, 38]. Might also possibly allow spontaneous defibrillation in refractory VF [8, 23, 60]. 
Premature TORFailure to appreciate that transient asystole can occur immediately after defibrillation [23].Resuscitation should never be abandoned immediately after defibrillation.
Resuscitation terminated prematurely before therapeutic measures could have adequate effect.Careful consideration before terminating resuscitation especially if vasopressor infusions and/or mechanical ventilation are used.
Untreated reversible causes e.g. acid-base balance; electrolyte imbalance; hypothermia [68].Check for and correct all reversible causes of CA before considering TOR.
TOR in the presence of a potentially treatable cardiac rhythm (refractory VF, PEA, broad complexes, bradycardia) and not asystole.Caution about which cardiac rhythms are acceptable for terminating resuscitation as in 30% of autoresuscitation cases, TOR had occurred in the presence of some cardiac electrical activity (i.e. not asystole)
TOR too soon after resuscitation startedCareful consideration of how long CPR has been employed before TOR
ProceduralUnobserved minimal vital signs (e.g. pseudo-PEA) due to clinician oversight [38, 81].
Misdiagnosis of death, perhaps due to failure to fully examine patient prior to declaring death.
A 10 min observation period with ECG is generally more appropriate than 5 min following TOR [2, 7,8,9,10,11, 14, 26, 60,61,62,63,64, 66, 76, 79, 81, 94, 95, 106, 107]. After the decision has been made to terminate resuscitation, chest compressions should not be restarted
The possibility of autoresuscitation should not affect the decision about when to terminate resuscitation
Resuscitation may exacerbate acute internal bleeding leading to hypovolaemic arrestWhen resuscitation is stopped, the cardiovascular system stabilises [36].Observe the patient after TOR for 10 min.