2. Singapore General Hospital, College road, Singapore 169608, Block 2 level 2, Singapore.
A 62-year-old male with a history of complete heart block with pacemaker pacing was found unresponsive after a fall whilst inpatient. He sustained severe head injury and was transferred to the Intensive Care Unit. Five minutes after arrival, patient developed ventricular fibrillation. Cardiopulmonary resuscitation commenced. Patient was intubated and his respiratory function supported on ventilator. The predominant cardiac rhythm was ventricular fibrillation. There was a transient (30 seconds) return of pulse 30 minute into the resuscitation. This ventricular tachycardia rapidly degenerated into ventricular fibrillation and then idioventricular rhythm with un-captured pacemaker spikes. Other features of circulatory arrest including absent heart sounds, pulse, blood pressure, and the cessation of breathing. Resuscitation was terminated after another 10 minutes. In total, 15 doses of intravenous adrenaline 1mg; IV lidocaine 75mg; 15 cycles of 360J monophasic defibrillation were delivered during the 40-minute resuscitation. Ventilation was continued until the pacemaker could be deactivated. This idioventricular rhythm with un-captured pacemaker spikes lasted 5 minutes after the termination of unsuccessful resuscitation. The return of spontaneous circulation subsequently occurred with an intrinsic ventricular rhythm of rate of 55-75 beats per minute. Pacemaker spikes were seen, without mechanical capture. Strong regular carotid pulse, previously undetected during ventricular fibrillation, was detected. Noninvasive blood pressure readings and other parameters were listed in table 1. CPR was not restarted and circulation ceased after 34 minutes. After further 124 minutes until the pacemaker was deactivated, patient was certified dead.
Conclusion: Autoresuscitation has implications on the certification of death and the decision to cease resuscitation. Our report illustrates the difficulties in diagnosing cardiovascular death in a patient with 40 minutes of circulatory standstill despite advanced cardiac life support as cardiac function was regained 5 minutes after abandonment of resuscitation. Longer period of time may be required for the cessation of cardiorespiratory function to have occurred in patients with pacemakers before the death can be pronounced.
Keywords: Lazarus syndrome, death certification, auto-resuscitation