Always rule out hypothermia and Lazarus syndrome in critically ill patients before declaration of death
Dr KK Aggarwal and Advocate Ira Gupta
Doctors at a private Ram Shiva hospital in Kanpur declared a 55-year-old road accident victim Phool Singh dead on Sunday, but he regained senses while being shifted to the mortuary at Lala Lajpat Rai hospital for postmortem on the same day. He was immediately taken back to the hospital by his relatives, where he died while undergoing treatment several hours later on Monday. His kin have filed a complaint to the police, who are investigating the matter.
Quoting Singhs family, the police said he had sustained critical injuries in a road accident in Fatehpur on Sunday morning and was admitted to Rama Shiv hospital in Kanpur. After preliminary treatment, doctors at the hospital declared Singh dead around 4pm the same day and allegedly issued a death certificate. However, while his body was being shifted to the mortuary, his family members found him breathing and informed the doctors who later confirmed that he was alive.
One possible scenario that may explain this situation is that the patient was in extreme hypothermia, which went unrecognized, and the patient died later on. In extreme hypothermia, a person can be mistaken as clinically dead while he is not
Hypothermia in adults is defined as core temperature below 35°C. According to severity, hypothermia can be:
- Mild (core temperature 32 to 35°C)
- Moderate (core temperature 28 to 32°C)
- Severe (core temperature below 28ºC)
Stage 1 hypothermia as described by the International Commission for Mountain Emergency Medicine is mild hypothermia with normal mental status with shivering.
Stage 2 hypothermia is moderate hypothermia with impaired mental status; shivering may be or may not be present.
In stage 3 hypothermia (severe; core temperature 24 to 28°C), the person is unconscious.
Stage 4 hypothermia (severe; core temperature 13.7 to 24°C) is apparent death but resuscitation may be possible.
Stage 5 hypothermia is death due to irreversible hypothermia and it is not possible to resuscitate the person.
Let’s take a look at the basic physiologic changes that take place in hypothermia.
Cooling decreases tissue metabolism and inhibits neural activity. In mild hypothermia, shivering due to skin cooling generates heat and increases metabolism, ventilation, and cardiac output. As the body temperature falls, the cold slows down metabolism. Once the core temperature reaches 32°C, metabolism, ventilation, and cardiac output begin to decline and shivering becomes less effective in retaining heat until it finally stops as core body temperature continues to decline. For each 1°C fall in body temperature, the body metabolism slows by around 6%; at 28°C, the basal metabolic rate is about half of normal.
Neurologic function begins declining even above a core temperature of 35°C. Patients often lose consciousness; vital signs may be absent. Presence of muscle rigidity without shivering can be mistaken for rigor mortis. The absence of shivering and presence of stupor, skin flushing, muscle rigidity, hypoventilation, and circulatory failure means very cold patients often appear dead rather than hypothermic. But in this stage of severe hypothermia (core temperature <28°C or 82°F), a suspended metabolism may protect against hypoxia.
Stage 4 hypothermia must be excluded, which is the stage where it is still possible to revive the patient. Failure to recognize the condition of hypothermia may be the reason why severely hypothermic patients are sometimes pronounced dead. It may be possible to successfully revive a person if recognized in time. No patient therefore should be declared dead without measuring rectal temperature.
A similar situation can also occur in the following conditions:
- Lazarus syndrome, also known as autoresuscitation, after failed cardiopulmonary resuscitation is the spontaneous return of circulation after failed attempts at CPR due to buildup of pressure in the chest as a result of CPR. The relaxation of pressure after resuscitation efforts have ended is thought to allow the heart to expand, triggering the hearts electrical impulses and restarting the heartbeat. Other possible factors are hyperkalemia or high doses of adrenaline.
- Deep coma mistaken as clinical death
- Apathy in dealing with terminal cases and believing the paramedical staff