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 Singh's
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 28ÂșC)
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 heart's 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
Dr KK Aggarwal
Padma
Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief
IJCP Publications
President
Heart Care Foundation of India
Immediate Past National President IMA
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