Fatal tension pneumoperitoneum with pneumothorax

Tension Pneumoperitoneum: A Rare Complication of Cardiopulmonary Resuscitation (CPR)

Tension pneumoperitoneum is a surgical emergency. Although rare, failure to diagnose and treat the condition may be lethal. Hence, being aware of this phenomenon, particularly in scenarios involving cardiopulmonary resuscitation (CPR), is important. Existing literature emphasises immediate abdominal needle decompression as the initial management followed by close monitoring and keeping a low threshold for surgical intervention as a definitive measure. We decided to write up this case report to raise awareness that a tension pneumoperitoneum can result as a complication of CPR, a well-known and widely practiced algorithm.

One More ‘T’ for the Mnemonic of the Management of Pulseless Electrical Activity: Tension Pneumoperitoneum

The approach in Advanced Cardiac Life Support provided by the American Heart Association and the European Resuscitation Council guidelines for the management of pulseless electrical activity emphasizes on the search of reversible causes. Tension pneumoperitoneum is an uncommon surgical emergency encountered in the accident and emergency department. We report a case of pulseless electrical activity secondary to tension pneumoperitoneum in an elderly woman. Restoration of spontaneous circulation was immediately achieved after needle decompression. The management of tension pneumoperitoneum is discussed.

Tension Pneumoperitoneum after Cardiopulmonary Resuscitation

A 61-year-old chronic schizophrenic patient developed sudden cardiac arrest and ventricular fibrillation. Tension pneumoperitoneum was noted after cardiopulmonary resuscitation. The patient had hypotension, lower limbs cyanosis and priapism. The tension was relieved by insertion of a large bore IV catheter through the abdominal wall. Immediately after decompression, the blood pressure improved with the lower limbs cyanosis and priapism resolved.

Airway management: induced tension pneumoperitoneum

Pneumoperitoneum is not always associated with hollow viscus perforation. Such condition is called non-surgical or spontaneous pneumoperitoneum. Intrathoracic causes remain the most frequently reported mechanism inducing this potentially life threatening complication. This clinical condition is associated with therapeutic dilemma. We report a case of a massive isolated pneumoperitoneum causing acute abdominal hypertension syndrome, in a 75 year female, which occurred after difficult airway management and mechanical ventilation. Emergent laparotomy yielded to full recovery. The recognition of such cases for whom surgical management can be avoided is primordial to avoid unnecessary laparotomy and its associated morbidity particularly in the critically ill.

[A case of spontaneous pneumoperitoneum associated with idiopathic intestinal pseudoobstruction]

Pneumoperitoneum, free intra-abdominal air, usually results from the perforation of a hollow viscous. In approximately 10% of cases, however, pneumoperitoneum is not caused by gastrointestinal perforation. These cases of "spontaneous pneumoperitoneum" generally follow more benign course and may not require surgical intervention. Examples include cardiopulmonary resuscitation (CPR), malrotation, mechanical ventilator support, gynecologic manipulation, blunt abdominal trauma, and chronic intestinal pseudoobstruction in infancy (Sieber syndrome). But, it is extremely rare of spontaneous pneumoperitoneum secondary to idiopathic intestinal pseudoobstruction in adult. We herein report a patient with chronic idiopathic intestinal pseudoobstruction who developed a pneumoperitoneum.

Bilateral tension pneumothorax and tension pneumoperitoneum secondary to tracheal tear in a patient with relapsing polychondritis

Relapsing polychondritis (RP) is a rare disease that is characterized by recurrent inflammation and destruction of cartilage and connective tissues. RP can have significant airway pathology that may require procedures to maintain airway patency and thus may have serious implications for anesthesiologists. Anesthesiologists must be prepared to deal with the possible complications that may occur during airway manipulation in patients with RP. Here, we present a case of life-threatening bilateral tension pneumothorax and tension pneumoperitoneum that developed after a tracheal tear during Montgomery T-tube insertion in a patient with tracheal stenosis due to RP. Correct diagnosis was delayed due to a misdiagnosis of airway obstruction. As a result, we emphasize that bilateral tension pneumothorax should be considered during refractory cardiac arrest in patients with increased airway pressure. A high index of suspicion and adequate management are mandatory for patients to survive these life-threatening complications.

Pneumoperitoneum: a review of nonsurgical causes

OBJECTIVE

To review causes of nonsurgical pneumoperitoneum (NSP), identify nonsurgical etiologies, and guide conservative management where appropriate.

DATA SOURCE

We conducted a computerized MEDLINE database search from 1970 to 1999 by using key words pneumoperitoneum and benign, nonsurgical, spontaneous, iatrogenic, barotrauma, pneumatosis, diaphragmatic defects, free air, mechanical ventilation, gynecologic, and pelvic. We identified 482 articles by using these keywords and reviewed all articles. Additional articles were identified and selectively reviewed by using key words laparotomy, laparoscopy, and complications.

STUDY SELECTION

We reviewed all case reports and reviews of NSP, defined as pneumoperitoneum that was successfully managed by observation and supportive care alone or that required a nondiagnostic laparotomy.

DATA SYNTHESIS

Each unique cause of nonsurgical pneumoperitoneum was recorded. When available, data on nondiagnostic exploratory laparotomies were noted. Case reports were organized by route of introduction of air into the abdominal cavity: abdominal, thoracic, gynecologic, and idiopathic.

CONCLUSIONS

Most cases of NSP occurred as a procedural complication or as a complication of medical intervention. The most common abdominal etiology of NSP was retained postoperative air (prevalence 25% to 60%). NSP occurred frequently after peritoneal dialysis catheter placement (prevalence 10% to 34%) and after gastrointestinal endoscopic procedures (prevalence 0.3% to 25%, varying by procedure). The most common thoracic causes included mechanical ventilation, cardiopulmonary resuscitation, and pneumothorax. One hundred ninety-six case reports of NSP were recorded, of which 45 involved surgical exploration without evidence of perforated viscus. The clinician should maintain a high index of suspicion for nonsurgical causes of pneumoperitoneum and should recognize that conservative management may be indicated in many cases.

Tension pneumoperitoneum caused by blunt trauma

Tension pneumoperitoneum (TPP), the accumulation of free intraabdominal air under pressure, is a rare event. TPP usually occurs from bowel surgery or bowel perforations. Less commonly, TPP occurs in the presence of pneumothoraces or during positive pressure ventilation. Trauma has rarely been a reported cause of TPP. The cases of 2 patients with TPP after blunt trauma are reported. The pathophysiology and management of TPP are discussed.

Trans-tracheal ventilation complicated by bilateral pneumothoraces and pneumoperitoneum

Following induction of general anaesthesia for emergency caesarean section the trachea could not be intubated, and ventilation was established only following two cricothyroidotomies. The baby was delivered unimpaired, and tracheostomy subsequently performed. On the intensive care unit, maternal cardiorespiratory variables were satisfactory, although surgical emphysema of the face and neck became apparent. Increasing abdominal distension was relieved by suction to a pelvic drain. Radiographs revealed bilateral pneumothoraces, pneumomediastinum and pneumoperitoneum, which were resolved by intrapleural drainage.