An interpretation of medical report of the death of former Prime Minister Shri Lal Bahadur Shastri

The death of former Prime Minister Shri Lal Bahadur Shastri, who passed away in Tashkent, then the Soviet Union on January 11, 1966 has always been surrounded by mystery and there are several conspiracy theories about his death.

Now 52 years after his death, the medical report of his death was revealed by the Govt. in reply to an RTI filed on 24.12.2017. The RTI had asked for information on the true cause/s of the death of the prime minister and asked for a certified copy of the postmortem conducted in the USSR/India. This information was provided in a reply dated 19.1.2018. The report is available at:(http://www.republicworld.com/india-news/general-news/government-of-india-reveals-the-exact-cause-of-death-of-former-prime-minister-lal-bahadur-shastri.

As per the medical report appended with the statement made by the then Minister of External Affairs in 1966, death of Shri Lal Bahadur Shastri occurred because of an acute attack of ‘Infarctmiocardia’.

I was asked by the media to comment on this report. I also spoke to top arrhythmia experts, who said that we have never used KCl in India. But, on searching PubMed, I could find some literature on the use of KCl in cardiac arrest. May be this was the standard protocol followed by doctors in USSR at that point of time, which also correlates with scientific evidence.

Here is my interpretation (right of the box) of the medical report of the death of the former Prime Minister of India Shri Lal Bahadur Shastri.

During all the days of his stay in Tashkent, as well as on evening of January 1966, the Prime Minister of India Lal Bahadur Shastri felt well. He never complained about his health.
On the evening of 10th January 1966, the prime minister of India, Lal Bahadur Shastri as healthy and cheerful while he was attending a reception given by the chairman of the council of ministers of USSR, AN Kosygin.
According to Dr RN Chugh, the doctor-attendant on the Prime Minister, who used to be always present at his side and thus had attended the reception, after return from the reception to his residence, Lal Bahadur Shastri was in normal health and was in a good mood and spoke over the telephone with his relatives in Delhi. He went to bed at about 12:30 midnight.
On the 11th of January, at about 1.20 in the morning, Messrs, Shay, Kapur and Sharma approached the Premier’s doctor who was in the room next to him and told him that the Prime Minister is feeling unwell.	He became unwell at 1.20 am
Dr R N Chugh at once approached the Prime Minister and found that the Prime Minister was sitting on his bed, coughing and was complaining of lack of breath. He was holding his chest with his hands and looking pale. The doctor found the pulse to be very fast and blood pressure was not registered. The heart beats were hardly audible.	This is a classical presentation of acute heart attack with left ventricular failure. Ventricular arrhythmia can be a possibility.
With the help of gentlemen mentioned above the doctor put the Prime Minster in the reclining position, gave him intramuscular injection of MEPHENTINE SULPHATE one ml (15 milligram) and 1 ml of MICOREN.	At that point of time, mephenteramine was a common drug given to raise the blood pressure. Micorena was a respiratory stimulant.
Within the next 3 minutes, PRIME MINISTER LB Shastri lost consciousness, the pulse disappeared, and breathing stopped and heart rate could not be heard.	It was a cardiac arrest.
Death occurred at 1.32 am in the morning of 11th January 1966.
Doctor R. N. Chugh had already began revival treatment by the method of indirect message of the heart and artificial respiration through the mouth by means of the air tube.	CPR was attempted.
The soviet doctor V G VERMENKO who had come there immediately on a call from Dr RN Chugh also took part in the treatment by revival procedure. She found Prime Minister LB Shastri dead when she arrived. The pulse had stopped, the heart was silent, there was no breath and no corneal reflexes. The revival was continued further with the help of anti-….team of doctors which had arrived immediately on call.
Indirect massage of the heart was done, in the left cavity mixture of potassium chloride with adrenaline and glucose	Here is some literature on the use of KCl in cardiac arrest. Romain Jouffroy and Benoît Vivien. Antiarrhythmic drugs in out-of-hospital cardiac arrest: is there a place for potassium chloride? Crit Care. 2017;21 144. According to current guidelines, antiarrhythmic drugs should be administered during the metabolic phase of cardiac arrest, which is paradoxically the most unfavorable phase for their efficiency [1]. Twenty-five years ago, Beyersdorf et al. [2] observed that administration of a high-potassium solution could salvage cardiac arrest patients due to an irreversible VF in metabolic phase of cardiac arrest. Direct intravenous KCl injection was recently shown efficient to stop refractory VF in a patient under continuous ECLS: a few minutes after KCl administration, the heart recovered a hemodynamically efficient normal sinus rhythm [3]. 1.       Soar J, Nolan JP, Bottiger BW, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 3. Adult advanced life support. Resuscitation. 2015;95:100–47. doi: 10.1016/j.resuscitation.2015.07.016. [PubMed] [Cross Ref] 2.       Beyersdorf F, Kirsch M, Buckberg GD, et al. Warm glutamate/aspartate enriched blood cardioplegic solution for perioperative sudden death. J Thorac Cardiovasc Surg. 1992;104(4):1141–7.[PubMed] 3.       Jouffroy R, Lamhaut L, Philippe P, et al. A new approach for treatment of refractory ventricular fibrillation allowed by extra corporeal life support (ECLS)? Resuscitation. 2014;85(8):e118. doi: 10.1016/j.resuscitation.2013.12.038. [PubMed] [Cross Ref] Metabolic phase is defined as greater than 10 minutes of pulselessness. It is primarily based upon post-resuscitative measures, including hypothermia therapy. If not quickly converted into a perfusing rhythm, patients in this phase generally do not survive. Refractory cardiac arrest is defined as the absence of return of spontaneous circulation (ROSC) after 30 min of cardiopulmonary resuscitation (CPR). Jouffroy R, Lamhaut L, Philippe P, An K, Carli P, Vivien B. A new approach for treatment of refractory ventricular fibrillation allowed by extra corporeal life support (ECLS)? Resuscitation. 2014;85(8):e118. A 50-year-old male with refractory ventricular fibrillation (VF) out-of-hospital cardiac arrest (OHCA) was treated at home by a mobile intensive care unit team. Since ROSC was not achieved after 30 min of prehospital resuscitation despite 20 external shocks and 900 mg IV amiodarone, the patient was admitted to an ICU for implementation of ECLS (Cardiohelp Maquet©), which was started with an initial rate of 4 l min−1 (4000 rev min−1), resulting in a mean arterial blood pressure of 65 mmHg. However, VF persisted despite five additional shocks.  Since adequate tissue perfusion was ensured by ECLS, potassium chloride 3 g was injected intravenously in order to stop the VF. Less than 1 min later, the patient presented with a stable sinus cardiac rhythm, and progressively recovered spontaneously efficient circulatory function. Coronary angiography revealed an occlusion of the right coronary artery, which was treated by angioplasty and endovascular stent implementation. ECLS was removed on day 2 and the patient weaned from mechanical ventilation on day 6, and discharged on day 11 with a cerebral performance category (CPC) score of 2. The use of potassium to treat persistent VF has been described during cardiothoracic surgery6 and in a pig model of cardiac arrest,7 but to the best of our knowledge, our case is the first to describe potassium administration to stop refractory VF, while effective tissue perfusion was ensured using ECLS. Further studies are required to evaluate the efficiency of this treatment for patients in refractory VF treated with ECLS. 1.         Le Guen, M., Nicolas-Robin, A., Carreira, S. et al. Extracorporeal life support following out-of-hospital refractory cardiac arrest. Crit Care. 2011; 15: R29. 2.         Cave, D.M., Gazmuri, R.J., Otto, C.W. et al. Part 7: CPR techniques and devices: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122: S720–S728. 3.         Neumar, R.W., Otto, C.W., Link, M.S. et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122: S729–S767. 4.         Van Alem, A.P., Post, J., and Koster, R.W. VF recurrence: characteristics and patient outcome in out-of-hospital cardiac arrest. Resuscitation. 2003; 5: 181–188. 5.         Liu, Y., Zhang, S.L., Duan, W.X. et al. The myocardial protective effects of a moderate-potassium blood cardioplegia in pediatric cardiac surgery: a randomized controlled trial. Ann Thorac Surg. 2012;94: 1295–1301. 6.         Watanabe, G., Yashiki, N., Tomita, S., and Yamaguchi, S. Potassium-induced cardiac resetting technique for persistent ventricular tachycardia and fibrillation after aortic declamping. Ann Thorac Surg. 2011; 91: 619–620. 7.         Lee, H.Y., Lee, B.K., Jeung, K.W. et al. Potassium induced cardiac standstill during conventional cardiopulmonary resuscitation in a pig model of prolonged ventricular fibrillation cardiac arrest: a feasibility study. Resuscitation. 2013; 84: 378–383.
Artificial respiration by means of the machines with the help of intubation tube was also attempted. However, those measures yielded no results.
The following professors also took part in the entire treatment UA ARIPOV YK GORDAN ON PAVLON AR RAKHIMJANOY MS THRSUM-KHOJAEVA ZE UMMIDOVA
19.1.18 Praveen Kumar PMO	Sd/-
RRTI /5510/2017/PMR	Rohit Chaudhury

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA