Tension pneumoperitoneum and gastric rupture following cardiopulmonary resuscitation

OUP accepted manuscript

Spontaneous pneumoperitoneum in a patient with a tracheostomy tube following cardiopulmonary resuscitation is exceedingly rare, with little experimental nor observational data to guide evidence-based management. We present the case of a 75-year-old woman with a tracheostomy tube who developed pneumoperitoneum following CPR. The patient experienced pulseless electrical activity arrest requiring nine rounds of chest compressions to return to spontaneous circulation. Computerized tomography demonstrated pneumothoraces, subcutaneous emphysema and extensive intraperitoneal, extraperitoneal and retroperitoneal free air without evidence of visceral perforation. The patient’s abdomen was distended without tenderness, guarding or rebound. She had a white blood cell count mildly elevated from her baseline levels. The management plan of serial abdominal exams without operative intervention was chosen given the absence of clinical and laboratory signs of peritonitis. This case highlights the importance of developing a standardized management algorithm for patients with pneumoperitoneum in the setting of tracheostomy tubes without evidence of perforation.

Case report: Tension pneumoperitoneum after diagnostic colonoscopy in an 11 y/o boy with Crohns disease

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Benign Pneumoperitoneum can rarely follow colonoscopy.

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Even benign Pneumoperitoneum can lead to tension pneumoperitoneum.

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Tension pneumoperitoneum is a critically dangerous adverse event.

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Risk of perforation and microperforation increases in chronically inflamed intestine.

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Apparently, even microperforations can lead to tension pneumoperitoneum.

Introduction

Endoscopy is an established diagnostic and therapeutic tool in paediatric gastroenterology and a save method with rare complications.

Presentation of case

We present the case of an 11-year-old Caucasian boy with a long history of inflammatory bowel disease. Three years prior an ileostomy was created and is still in position. After diagnostic panendoscopy (colonoscopy, gastroscopy, endoscopy of small intestine via ileostomy) the patient showed progressive abdominal distension and pain. After diagnosis of tension pneumoperitoneum by radiological proof of massive intraabdominal air and altered vital signs, we initiated emergency laparotomy. Surgical intervention ruled out a free gastrointestinal perforation as well as peritonitis. There was a gaseous insufflation of the mesenteric tissue of the sigmoid and upper rectum most likely according to microperforations to the mesentery. Due to the pre-existing ileostomy, we took no further surgical action. The abdomen was lavaged and drains inserted. Upon further conservative treatment with intravenous antibiotics, the patient showed quick recovery and was discharged on postoperative day 6.

Discussion

With an incidence of 0.01%, perforation after diagnostic colonoscopy in children is very uncommon. The zone most frequently affected is the sigmoid colon due to direct penetration or indirect force due to flexure, or insufflation. Even without macroscopic perforation, the development of a tension pneumoperitoneum seems to be possible.

Conclusion

Even though Colonoscopy in children is a safe tool, the treating physician must never underestimate the risks of such an intervention. Especially chronically altered intestine as in long-time persisting chronic inflammatory bowel disease demand special care and intensive observation of the patient after intervention.

Stomach perforation post cardiopulmonary resuscitation-A case report

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Stomach perforation after cardiopulmonary resuscitation is rare.

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CPR performed by non-medical personnel is the main cause.

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Training of medical and non-medical persons in CPR is to be encouraged.

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Correct management of airway during CPR is important.

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High degree of vigilance is required in patients presenting after CPR.

Introduction

Stomach perforation after cardiopulmonary resuscitation is a rare finding. This is mainly caused by incorrect management of the airway during CPR performed by non-medical personnel.

Presentation of case

We report a case of 72 year old female who sustained a stomach perforation during prolonged CPR in an out of hospital arrest situation. This was diagnosed on a computed tomography scan of the abdomen requiring midline laparotomy and a primary repair of the stomach.

Discussion

The training of medical and non-medical persons in cardiopulmonary resuscitation is to be encouraged. However it should be emphasized that any technique which breaches the normal integrity of the body can itself lead to life-threatening complications.

Conclusion

A high degree of vigilance is required in patients presenting after a cardiac arrest and CPR.

Tension Pneumoperitoneum Caused by Obstipation

Emergency physicians are often required to evaluate and treat undifferentiated patients suffering acute hemodynamic compromise (AHC). It is helpful to apply a structured approach based on a differential diagnosis including all causes of AHC that can be identified and treated during a primary assessment. Tension pneumoperitoneum (TP) is an uncommon condition with the potential to be rapidly fatal. It is amenable to prompt diagnosis and stabilization in the emergency department. We present a case of a 16-year-old boy with TP to demonstrate how TP should be incorporated into a differential diagnosis when evaluating an undifferentiated patient with AHC.

Gastric Rupture following Nasopharyngeal Catheter Oxygen Delivery—A Report of Two Cases

Iatrogenic gastric distension and subsequent rupture following nasal or nasopharyngeal catheter oxygen delivery is a rare but life-threatening condition that requires urgent laparotomy. We report two cases recently encountered at our institution. Both patients exhibited symptoms of abdominal pain and distension following oxygen delivery involving a nasopharyngeal catheter during procedural sedation. Oxygen flow rates were 4 l/minute in both cases. The diagnosis was made by urgent imaging. Both patients survived following laparotomy and repair of gastric rupture. Seventeen cases have been reported previously in the literature. We recommend avoidance of nasal or nasopharyngeal catheters and the use of alternative oxygen delivery methods such as nasal prongs and face masks.

Gastric perforation after cardiopulmonary resuscitation: review of the literature

The risk of complications of cardiopulmonary resuscitation (CPR) does not outweigh the benefit of a successful restoration of a spontaneous circulation. Despite the frequent occurrence of gastric distension (caused by air entering the stomach because of too forceful and/or too quick rescue breathing), there are few reports of massive gastric distension causing gastric rupture and pneumoperitoneum after CPR. We reviewed all 67 case reports of gastric perforation that have been reported after CPR. Although uncommon, this review stresses the need to consider this potentially lethal complication after initial successful resuscitation.

Frequent and rare complications of resuscitation attempts

INTRODUCTION

Resuscitation attempts require invasive iatrogenic manipulations on the patient. On the one hand, these measures are essential for survival, but on the other hand can damage the patient and thus contain a significant violation risk of both medical and forensic relevance for the patient and the physician. We differentiate between frequent and rare resuscitation-related injuries. Factors of influence are duration and intensity of the resuscitation attempts, sex and age of the patient as well as an anticoagulant medication.

MATERIALS AND METHODS

Review of current literature and report on autopsy cases from our institute (approximately 1,000 autopsies per year).

RESULTS

Frequent findings are lesions of tracheal structures and bony chest fractures. Rare injuries are lesions of pleura, pericardium, myocardium and other internal organs as well as vessels, intubation-related damages of neural and cartilaginous structures in the larynx and perforations of abdominal organs such as liver, stomach and spleen.

CONCLUSION

We differentiate between frequent and rare complications. The risk of iatrogenic CPR-related trauma is even present with adequate execution of CPR measures and should not question the employment of proven medical techniques.

Pneumoperitoneum Due to Gastric Perforation After Cardiopulmonary Resuscitation: Case Report

Background Pneumoperitoneum after cardiopulmonary resuscitation may be due to mediastinal air tracking into the peritoneal cavity via the diaphragmatic hiatus or to gastric perforation.

Case Report A 79-year-old woman received Advanced Cardiac Life Support measures in the intensive care unit. Chest compressions and endotracheal intubation were performed; a stable cardiac rhythm and perfusion were restored. A chest radiograph after resuscitation revealed pneumoperitoneum without pneumomediastinum. The patient underwent laparotomy; a 6-cm perforation of the posterior gastric wall along the lesser curve was detected and repaired.

Conclusion Gastric perforation after cardiopulmonary resuscitation should be suspected when chest radiographs obtained after resuscitation show pneumo-peritoneum without pneumomediastinum. Prompt laparotomy allows detection of gastric perforations and decreases the morbidity associated with rupture of a hollow organ. The incidence of gastric perforation after cardiopulmonary resuscitation may be decreased with early endotracheal intubation, avoidance of esophageal intubation, and expeditious placement of an orogastric tube.

Gastric Rupture After Cardiopulmonary Resuscitation in a Burn Patient

Burn injury, especially severe facial burn injury, poses a unique challenge for emergency health care personnel in administering cardiopulmonary resuscitation. Because of the perioral and oral edema with severe facial burns, intubation may be difficult, and bag-valve mask or mouth-to-mouth resuscitation may be prolonged. As a result of the difficulty in establishing a patent airway, various complications can arise. One of these includes gastric perforation which, although rare in the setting of difficult intubation or prolonged oral ventilation, may be possible. To our knowledge, acute gastric perforation after prolonged cardiopulmonary resuscitation in burn injured patients has not previously been reported thus the incidence is unknown. We report here a case of gastric perforation after a difficult tracheal intubation in a patient with extensive burns of the head and neck and 63% TBSA burn.

Gastric rupture and massive pneumoperitoneum after bystander cardiopulmonary resuscitation

Gastric perforation is a rare complication of cardiopulmonary resuscitation. The majority of reported cases have been associated with difficult airway management or esophageal intubation. There has been only one previous case report in which this complication could be attributed solely to mouth-to-mouth ventilation. We present a case of simple bystander cardiopulmonary resuscitation that resulted in gastric perforation.

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.

Gastric rupture with tension pneumoperitoneum: a complication of difficult endotracheal intubation

Gastric rupture is a rare complication of difficult airway management. In cases of vigorous mouth-to-mouth ventilation, bag-valve-mask ventilation, or esophageal intubation, gastric rupture and massive intraperitoneal free air may cause tension pneumoperitoneum. Hemodynamic instability necessitates immediate intervention, including needle decompression of the peritoneum followed by surgical exploration. We recently encountered two cases of gastric rupture with tension pneumoperitoneum that occurred after difficult endotracheal intubation. This report describes the presentation, treatment, and prevention of this entity.

Tension pneumoperitoneum after heart-lung transplantation

Tension pneumoperitoneum is a medical emergency. We report 2 cases in which tension pneumoperitoneum occurred after heart-lung transplantation and was related to positive-pressure ventilation and a transdiaphragmatic passage of omentum used to wrap the airway anastomosis. Management in these patients was targeted toward decompression of intraperitoneal air with percutaneous needle or tube placement without exploratory laparotomy, and tube thoracostomy for the concomitant pneumothorax.

Pneumoperitoneum--a rare complication of cardiopulmonary resuscitation

Pneumoperitoneum following cardiopulmonary resuscitation (CPR) results from a thoracic air leak (pneumothorax, pneumomediastinum) with escape of the air through diaphragmatic apertures (mostly foramen of Winslow) or primary perforation of the gastrointestinal tract (stomach or esophagus). We report three cases of pneumoperitoneum complicating CPR. As there was no clinical evidence of peritonitis, and the patients remained stable, a conservative approach was followed without surgical exploration. All patients recovered completely.

Gastric rupture following cardiopulmonary resuscitation

Three cases are reported in which gastric rupture occurred during cardiopulmonary resuscitation. Precipitating factors are considered and discussed with reference to the literature. This condition has been considered to be rare. Its occurrence greatly adds to the morbidity and mortality of the underlying disease. Possible precautions to limit its occurrence are discussed.

CPR-induced trauma: comparison of three manual methods in an experimental model

Cardiopulmonary resuscitation (CPR) often results in traumatic injury to the patient. Differences in CPR-induced trauma among various forms of manual, external CPR, however, are unknown. We compared CPR-induced trauma among manual standard (STD) CPR at 60 compressions per minute; high-impulse compression (HIC) CPR at 120 compressions per minute; and interposed abdominal compression (IAC) CPR at 60 compressions per minute. A large (24 +/- 3 kg) mongrel canine model was used. Ten animals were assigned to each type of CPR. Each received 17 minutes of CPR, applied to produce the best possible coronary perfusion pressure without obviously damaging the dog. Defibrillation was attempted at 20 minutes. Necropsy was performed at the time of death or after sacrifice at 24 hours. Careful postmortem examination of the thorax, lungs, heart, abdomen, and great vessels was performed. A semiquantitative trauma score of 0 to 5 was assigned to each area with a possible maximal score of 25. There was no difference in trauma scores among STD (6.4 +/- 1.5), HIC (9.4 +/- 1.4), and IAC (8.1 +/- 1.3) methods. No significant correlation was found between the method of CPR and the different types of trauma. Specifically, IAC did not produce an increase in liver lacerations nor did HIC produce a significant increase in thoracic or pulmonary injuries. Six of 20 initially resuscitated animals expired during the 24-hour follow-up period due to CPR-induced injuries. Four of these six had extensive pulmonary trauma, including pulmonary hemorrhage or edema. Liver lacerations were the second most lethal injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Gastric rupture during cardiopulmonary resuscitation

Gastric rupture following ventilation during cardiopulmonary resuscitation is a rare occurrence. We report two cases of documented gastric rupture plus two additional cases in which the clinical diagnosis of pneumoperitoneum was made and gastric rupture was assumed to be the mechanism. Review of the literature reveals the lesser curvature of the stomach to be the common site of rupture. This complication emphasizes the necessities of correct positioning of the jaw with mouth-to-mouth ventilation and careful assessment of air entry and chest movement following endotracheal intubation.