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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

factor

Proposed Mechanism

Actions that might reduce the Likelihood of Autoresuscitation occurring

Poor controlled ventilation techniques

1) Air trapping in the lungs causing hyperinflation

Caused 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 pressure

Delays 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) Hyperventilation

Deleterious effects on coronary perfusion pressure (CPP) [104].

Delayed drug effects

In 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 asystole

Intrinsic 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 TOR

Failure 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 started

Careful consideration of how long CPR has been employed before TOR

Procedural

Unobserved 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 arrest

When resuscitation is stopped, the cardiovascular system stabilises [36].

Observe the patient after TOR for 10 min.