title: Delayed recovery of spontaneous circulation following cessation of cardiopulmonary resuscitation in an older patient: a case report.
abstract: BACKGROUND
  This report describes the apparent 'resurrection' of a patient in an emergency department setting. Befittingly named the 'Lazarus phenomenon', the recovery of spontaneous circulation after cessation of cardiopulmonary resuscitation is an extremely rare occurrence that was first described in 1982 and has been mentioned only 38 times in the medical literature. Our patient's case is remarkable in that it helps illustrate many of the mechanisms of this rare phenomenon. It also serves as a reminder of our limitations in determining when to terminate cardiopulmonary resuscitation and suggests that cessation of cardiopulmonary resuscitation should be approached with more care.
  
  
  METHODS
  An 89-year-old Caucasian woman with a medical history of hypertension, atrial fibrillation, hypothyroidism, aortic insufficiency, lymphedema and hypoxia secondary to partial lung resection presented to our hospital after a witnessed fall unassociated with head trauma or loss of consciousness. On examination, our patient was saturating at 85 percent and exhibited a decreased range of motion of the upper extremities and left hip. Radiographic images revealed a left femoral neck and left distal radius fracture. Our patient was stabilized on 100 percent fraction of inspired oxygen and was awaiting transfer to an in-patient unit when, at 3:30 a.m., she went into cardiac arrest. An advanced cardiac life support protocol was initiated, at which time our patient was intubated and administered epinephrine, vasopressin and sodium bicarbonate. Our patient remained unresponsive and asystolic so cardiopulmonary resuscitation was abandoned at 3:48 a.m. After five minutes a ventricular contraction was noted at 3:51 a.m. This progressed to sinus rhythm with a pulse at 3:53 a.m. Our patient was stabilized on norepinephrine and moved to our Intensive Care Unit. At 10:55 a.m., however, our patient again arrested and, despite resuscitative efforts, was pronounced dead at 11:03 a.m.
  
  
  CONCLUSIONS
  Our patient's case clearly illustrates many of the proposed mechanisms for delayed return of spontaneous circulation including pulmonary hyper-inflation, hyperkalemia, delayed drug onset, and embolism dislodgement. Our patient represents a humbling and disturbing reminder that our medical acumen does not necessarily dictate the fate of our patients and that the decision to discontinue cardiopulmonary resuscitation should be approached with care by incorporating techniques such as end-tidal carbon dioxide, ventilator disconnect and passive monitoring.
authors.affiliation: Yale University School of Medicine, New Haven, CT, USA. Yili.Huang@yale.edu.
authors.forename: Yili
authors.initials: Y
authors.lastname: Huang
authors.forename: Sijun
authors.initials: S
authors.lastname: Kim
authors.forename: Amishi
authors.initials: A
authors.lastname: Dharia
authors.forename: Aleksander
authors.initials: A
authors.lastname: Shalshin
authors.forename: Jan
authors.initials: J
authors.lastname: Dauer