top of page

Lazarus Syndrome: Tales from the Funeral Home

Can you escape or avoid death?? This rare, but likely under reported phenomenon is named after Lazarus of Bethany, and it comes up in the news headlines and EMS magazines on occasion. You see, Lazarus was the subject of a prominent miracle of Jesus -- he was restored to life four days after death. The name Lazarus (as it relates to restoration of life) is used in science and is even scattered in popular culture. The Lazarus taxon can even be applied to organisms that reappear in the fossil record after a period of apparent extinction.

As it applies to our environment - the syndrome can be described as autoresuscitation OR a delayed return of spontaneous circulation (ROSC) after cessation of CPR. The question now stands -- how does this happen? There may be more plausible explanations, but the one that is most widely accepted is related to auto-PEEP (dynamic hyperinflation). During a code, our adrenaline takes over and gets transferred to aggressive BVM/ventilation maneuvers, which in turn raises the intrathoracic pressures in the chest cavity -- impeding venous return back to the heart. Some would argue that the phenomena could also be linked to drug delays in action - our pharmacological interventions "catching up".

Regardless of the why - consider:

+ Watching the patient for 60 seconds of apnea prior to terminating the resuscitation.

+ Monitor the patient for several minutes before scene departure (as you console family).

+ Monitor ETCO2 on all resuscitations.

+ Don't rush to death declarations.

+ Allow auto-PEEP/air trapping to resolve, if applicable.

+ You aren't dead until the functions of all of your organ systems irreversibly fail.

Dozens of Lazarus Syndrome cases have been documented in the literature, and most, but not all, have been derived from medical etiologies (AMI/lung diseases, overdoses, hyperkalemia). Generally speaking, most patients were in asystole or PEA and had ROSC occur within 10 minutes. Many times, patients who "auto resuscitate" may have varying degrees of anoxic brain injury - but a staggering number of cases are documented that shows favorable neurological outcomes upon hospital discharge.... these discharges can come with some hefty financial settlements for the patient and their families.

In related ethical news, there appears to be a gross mismatch between published case studies of Lazarus Syndrome and observed incidence on the ground, and this is likely related to concerns regarding the professional and legal consequences associated with a premature declaration of death. There are also many incidents of Lazarus Syndrome reported in the media which do not appear in the academic literature, possibly due to privacy laws that require consent from patients or families prior to publishing a case study in scientific literature.

The finding that approximately one-third of people survive autoresuscitation and go on to make a good recovery has important implications for resuscitation practices and protocols surrounding the decision to terminate resuscitation and declare death. The take home message is clear -- Ventilation should be gentle and appropriate to avoid intrathoracic pressure and hyperinflation of the lungs. Termination of resuscitation should be followed by up to ten minutes of patient observation.

As previously stated, auto-resuscitation is an extremely rare phenomenon...BUT it has grave implications regarding the definition of “death” and when all resuscitative efforts should cease. Further research needs to be done to clarify the underlying etiology.

Looks like death determination may be a little harder than we first thought!!

April 10, 2023

Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP

Pass with PASS, LLC.

17 views0 comments

Recent Posts

See All


bottom of page