Act@ Anaesthesiol Scand 1991: 35: 235-237

Pneumoperitoneum - a rare complication of cardiopulmonary resuscitation T. J. HARTOKO, H. E. DEMEY, P. E. ROGIERS, H. L. DECOSTER, J. M. NAGLER and L. L. BOSSAERT Departments of Intensive Care, University Hospital Antwerp, Edegem, and Middelheim Hospital, Antwerp, Belgium

Pneumoperitoneum following cardiopulmonary resuscitation (CPR) results from a thoracic air leak (pneuniothorax, 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 recoverrd completely.

Received 27

Jub, accepted for

publication 31 August 1990

Kcy w o r k : Cardiopulmonary resuscitation; peritonitis; pneumoperitoneum.

Cardiopulmonary resuscitation could be described as “a necessary evil”: sometimes life-threatening complications may result from it, especially if CPR is not performed strictly according to accepted guidelines, or by lay-people. An uncommon complication is the occurrence of pneumoperitoneum. A limited number of cases of pneumoperitoneum have been reported in the literature (1-7). Gastric perforation leading to pneumoperitoneum was recognized in 1/14 patients autopsied after prolonged CPR (8). Another autopsy study reported an incidence of gastric perforation of 1/705 (9). In most reported patients, perforation of the lesser curvature was the underlying pathology (1, 4, 7). In several other cases, laparotomy or autopsy revealed ,pneumoperitoneum without recognizable gastro-intestinal perforation (2, 3, 5, 6 ) . A combination of pneumothorax and/or pneumomediastinum with pneumoperitoneum is also possible. It is assumed that in this case the primary air leak originates in the thorax and secondarily migrates to the abdomen through the foramen of Winslow or other diaphragmatic apertures. CASE REPORTS Cur no. I

A 44-year-old woman, with a prior history of cystic multinodular eulhyroid goiter, complained of dyspnea, which gradually deterioraqed to dysphagia and dysphonia. O n the day of admission, her dFpnea unexpectedly intensified and she collapsed. After the arrival of a mobile coronary care unit, she was intubated by an experienced physician. While visualizing the larynx, the attending physician noted extensive soft-tissue edema. External cardiac massage and basic lifesubport were performed for about 10 min, after which a stable cardiovascular status was obtained and consciousness gradually im-

proved. O n hospital admission, physical examination showed extensive soft tissue edema of the face and neck, while cardiac, pulmonary and abdominal assessment was unexceptional. Routine chemical and hematological blood analyses were all within normal limits. Admission chest X-ray revealed a shift of the trachea to the right due to the multinodular goiter and, surprisingly, large amounts of free air beneath both hemidiaphragms; rib fractures were absent (Fig. I ) . CT-scan revealed a small right-sided pneumothorax, pneumomediastinum, extensive soft tissue emphysema of the neck and retroperitonea1 space, and pneumoperitoneum. Corticosteroids were given to combat the laryngeal edema (rpinephrine had been administered during the CPR). Extubation was possible after 8 hours. There were no signs of peritonitis, but continued gastric suction was applied for 7 days. Control X-ray exaniination of chest and abdomen 72 h later revealed marked improvement of the pneumoperitoneum. Unfortunately, the patient refused further diagnostic investigations as to the cause of the air leak, probably because of the benign evolution of the pneumoperitoneum. Case no. 2 A 71-year-old female with a history of acute myocardial infarction and cardiac arrhythmias was first given basic life-support by her son for sudden collapse; advanced cardiac life-support was performed after the arrival of a medical team. She was admitted to the intensive care unit deeply comatose but hemodynamically stable. Artificial ventilation was necessary for 48 h; weaning from the ventilator was possible when the patient recovered from her coma with complete normalization of cerebral functions. At this moment subdiaphragniatic air was seen for the first time on the chest X-ray, together with a right lower and middle lobe atelectasis. the free air disappeared after 24 h. Abdominal examination remained normal. Further investigations were declined by the patient. She recovered completely and was discharged home 3 weeks later. Care no. 3

A 67-year-old female was admitted with ptosis of the left upper eyr lid and progressive dysphagia. ‘This evolved to dyspnea, trismus and left-sided torticollis. A diagnosis of tetanus was made after the sudtlcn appearance of trismus and opisthotonus, leading to cardio-respiralory arrest. Before muscular paralysis was induced with pancuronium bromide to facilitate intubation, the patient was forcefully ventilated

'1'. J . H.4K'I'OKO El' AL.

Fig. 1. Chrst X-ray of patient no. I showing frrr air under both li(.niidial,tiragms.

by liccr niicsk agaiiist the marked trismus. Shr had to IIC resusritatrd liir ;I prriod of 5 min. A control cheat X-ray showed a complete right-sitlcd pncuniotliorax and extciisive air collections under both lirmidia~~lir;cgms. 'l'hr lung expanded after 36 h of chest tube drain;igv3whilc thr abdominal frcr air disapprarrd without further trvattiirnt. No signs of prritonral irritation wrrr noted. Gastroscopy, prrli)rnird 4 days after the cardiorespiratory arrcst was complrtrly ncirnial. .I'hr paticnt madr a full rrcovcry from the trtaiius alicr 55 d;tys of iiiccli;inical vriitilation.

DISCUSSION Thr most common immediatr complications of CPR are rib and sternal fractures, chest wall hematomas, cardiac. contusions, lacerations of the liver, diaphragm and spleen, and pneumothorax (7, 10). Several authors have reported pneumoperitoneum (1-7, 9) or a combination of pneumothorax with pneumoperitoneuni ( 1 I ) following CPR. IIilTerent mechanisms are believed to explain the occurrence of CPR-associated pneumoperitoneum. hlouth-to-mouth resuscitation can provoke gastric distension, as air is blown not only into the airways hut also into the esophagus and stomach. Chest wit11

compression during external cardiac massage, C'Specially when hand placement is incorrect [i.e. lower one third of the sternum), increases external pressure on the stomach and its inlying gas bubble, possibly leading to gastric rupture, most comnionly reportrd at the small curvature ( 1 , 4, 7 ) . Another possibility is a small esophageal tear with escape of gastric gas or insufflated breaths into thc mediastinum and/or peritoneum. The three reported patients did not dcvelop symptoms of peritonitis; their condition improved and thr) were therefore treated conservatively. Because two patients refused further diagnostic investigations, we were unable to demonstrate the exact cause of the pneumoperitoneum in these patients. As the CT-scan revealrd a small right-sided pneumothorax, soft-tissue eniphysema of the neck and retroperitoneal space and pnrumo-peritoneum in the first paticnt, and a complete. right-sided pneumothorax necessitating chest tutx. drainage in the third patient, it is conceivable that a lung alveolus had burst during CPR. 'The external cardiac massage and ventilation might have caused air to enter the right pleural cavity and peritoneal cavil). Gastroscopy in the third patient was completely normal. The second patient presented with atelectasis; i t is possible that a small, perhaps ventral, pneumothorax was therefore obscured on the bedside chest X-ray. Some patients with CPR-induced pneumoperitoncurn d o not develop peritonitis. The three reported patients presented with pulmonary pathology, infrrring a thoracic origin of their pneumoperitoneum. On the other hand, a primary abdominal origin with perforation of a hollow viscus will most likely lead t o peritoneal irritation. In a recent clinical treatment protocol it was proposed to manage patients with CPRinduced pneumoperitoneum conservatively as long a s there was no evidence of peritoneal inflammation o r visceral laceration, because a laparotomy might be detrimental in the post-CPR situation (6). This is corroborated by the patients presented here. O n the other hand, clinical deterioration should lead to immediate and complete diagnostic examination, inclucling peritoneal lavage, abdominal X-rays, CT-scan and even diagnostic laparotomy to uncover and treat thr source of peritonitis (6). CONCLUSION Pneumoperitoneum may develop after CPR. Its trcatment depends on the individual clinical situation. 11' signs of peritoneal inflammation are present, surgical exploration is necessary, even when ancillary examinations remain negative, whereas, i t the patient remains in a stable condition, a conservative approach is wiir-

PNEUMOPERITONEUM

ranted. The patient should be closely followed, with frequent re-evaluations for signs of developing peritonitis.

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as a complication of cardiopulmonary resuscitation. Am J Emerg Med 1988: 6: 358-361. 7. Mills SA, Paulson D, Scott SM, Sethi G. Tension pneumoperitoneum and gastric rupture following cardiopulmonary resuscitation. Ann Emerg Med 1983: 12: 94-95. 8. Silberberg B, Rachmaninoff N. Complications following external cardiac massage. Surg Gynecol Obsfet 1964: 103: 6 1 I . 9. Krischer J, Fine E, Davis J, Nagel E. Complications of cardiar resuscitation. Chest 1987: 92: 287-291. 10. Jeresaty RM, Godar TJ, Liss JP. External cardiac resuscitation in a community hospital: a three-year experience. Arch Infern Med 1969: 124: 588-592. 11. Krausz M, Manny J. Pneumoperitoneum associated with pneumothorax: a surgical dilemma in the post-traumatic patient. J Trauma 1977: 17: 238-240. Adress:

H. E . Demy, M D Dept. of Intensive Care University Hospital Antwerp-U.I.A. Wilrijkstraat 10 B2520 Edegem Belgium