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Short report
IMAGES IN EMERGENCY MEDICINE
Tension pneumoperitoneum IMAGE CASE HISTORY An elderly female with peritoneal carcinomatosis of ovarian origin was resuscitated following a pulseless electrical activity (PEA) cardiac arrest. Prehospital intubation attempts were unsuccessful and the patient received bag-valve-mask ventilation. En route, paramedics reported increasing difficulty ventilating and the patient’s abdomen became distended, tense and tympanitic. After emergency department arrival, a postintubation radiograph of the chest was obtained (figure 1). Tension pneumoperitoneum was diagnosed and abdominal decompression with a supraumbilical needle was performed. Despite initial improvement of vital signs, recurrent hypotension ensued, and the patient expired.
IMAGE DISCUSSION 1
Tension pneumoperitoneum is a rare complication of CPR. It is theorised that perforated viscera with omental fat may create a one-way valve, allowing air to exit the bowel and not re-enter.2 Accumulation of tense air within the peritoneal cavity may cause respiratory compromise and haemodyanmic collapse. Extra luminal free air may not be evacuated by gastric tube placement. Associated with high mortalities, survivors have been documented following needle decompression.3 Risk factors for tension penumoperitoneum include positive pressure ventilation or other insulflation-dependent procedures (eg, colonoscopy, endoscopy, cystoscopy or air enema).2 At times, simulating a deep sulcus sign and pneumothorax, radiological findings may include intraperitoneal free air, diaphragmatic elevation, downward and medial displacement of the liver (‘the saddle bag sign’), centralization of abdominal organs and collapsed loops of bowel.2 David T Williams, Pej Manoochehri, Hyung T Kim Department of Emergency Medicine, Keck School of Medicine of The University of Southern California, LAC+USC Medical Center, Los Angeles, California, USA Correspondence to Dr David T Williams, Department of Emergency Medicine, Keck School of Medicine of The University of Southern California, LAC+USC Medical Center, 1200 North State Street, Suite #GH1011, Los Angeles, CA 90033, USA; [email protected]
Lad TS, et al. Emerg Med J 2014;31:942–943. doi:10.1136/emermed-2013-202442
Figure 1 A portable supine radiograph of the chest illustrates significant medial displacement of the liver, ‘the saddle bag sign’ (white arrows) and upward displacement of the diaphragm bilaterally (black arrows) consistent with tension pneumoperitoneum. Contributors DTW and PM: Patient care, article research, authorship and editing. HTK: Article research, authorship and editing. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Williams DT, Manoochehri P, Kim HT. Emerg Med J 2014;31:943. Accepted 9 January 2014 Published Online First 29 January 2014 Emerg Med J 2014;31:943. doi:10.1136/emermed-2013-203469
REFERENCES 1 2
3
Reichardt J, Casey G, Krywko D. Gastric rupture from cardiopulmonary resuscitation or seizure activity. J Emerg Med 2010;39:309–11. Yakobi-Shivili R, Cheng D. Tension Pneumoperitoneum—a compication of colonoscopy: recognition and treatment in the emergency department. J Emerg Med 2002;22:419–20. Devine JF, McCarter TG Jr. Tension pneumoperitoneum. NEJM 2001;344:1985.
943
Downloaded from http://emj.bmj.com/ on April 11, 2015 - Published by group.bmj.com
Tension pneumoperitoneum David T Williams, Pej Manoochehri and Hyung T Kim Emerg Med J 2014 31: 943 originally published online January 29, 2014
doi: 10.1136/emermed-2013-203469 Updated information and services can be found at: http://emj.bmj.com/content/31/11/943
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Articles on similar topics can be found in the following collections Clinical diagnostic tests (989) Radiology (939) Radiology (diagnostics) (846) Surgical diagnostic tests (125) Ethics (368) Patients (190) Resuscitation (560)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Short report
IMAGES IN EMERGENCY MEDICINE
Tension pneumoperitoneum IMAGE CASE HISTORY An elderly female with peritoneal carcinomatosis of ovarian origin was resuscitated following a pulseless electrical activity (PEA) cardiac arrest. Prehospital intubation attempts were unsuccessful and the patient received bag-valve-mask ventilation. En route, paramedics reported increasing difficulty ventilating and the patient’s abdomen became distended, tense and tympanitic. After emergency department arrival, a postintubation radiograph of the chest was obtained (figure 1). Tension pneumoperitoneum was diagnosed and abdominal decompression with a supraumbilical needle was performed. Despite initial improvement of vital signs, recurrent hypotension ensued, and the patient expired.
IMAGE DISCUSSION 1
Tension pneumoperitoneum is a rare complication of CPR. It is theorised that perforated viscera with omental fat may create a one-way valve, allowing air to exit the bowel and not re-enter.2 Accumulation of tense air within the peritoneal cavity may cause respiratory compromise and haemodyanmic collapse. Extra luminal free air may not be evacuated by gastric tube placement. Associated with high mortalities, survivors have been documented following needle decompression.3 Risk factors for tension penumoperitoneum include positive pressure ventilation or other insulflation-dependent procedures (eg, colonoscopy, endoscopy, cystoscopy or air enema).2 At times, simulating a deep sulcus sign and pneumothorax, radiological findings may include intraperitoneal free air, diaphragmatic elevation, downward and medial displacement of the liver (‘the saddle bag sign’), centralization of abdominal organs and collapsed loops of bowel.2 David T Williams, Pej Manoochehri, Hyung T Kim Department of Emergency Medicine, Keck School of Medicine of The University of Southern California, LAC+USC Medical Center, Los Angeles, California, USA Correspondence to Dr David T Williams, Department of Emergency Medicine, Keck School of Medicine of The University of Southern California, LAC+USC Medical Center, 1200 North State Street, Suite #GH1011, Los Angeles, CA 90033, USA; [email protected]
Lad TS, et al. Emerg Med J 2014;31:942–943. doi:10.1136/emermed-2013-202442
Figure 1 A portable supine radiograph of the chest illustrates significant medial displacement of the liver, ‘the saddle bag sign’ (white arrows) and upward displacement of the diaphragm bilaterally (black arrows) consistent with tension pneumoperitoneum. Contributors DTW and PM: Patient care, article research, authorship and editing. HTK: Article research, authorship and editing. Competing interests None. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Williams DT, Manoochehri P, Kim HT. Emerg Med J 2014;31:943. Accepted 9 January 2014 Published Online First 29 January 2014 Emerg Med J 2014;31:943. doi:10.1136/emermed-2013-203469
REFERENCES 1 2
3
Reichardt J, Casey G, Krywko D. Gastric rupture from cardiopulmonary resuscitation or seizure activity. J Emerg Med 2010;39:309–11. Yakobi-Shivili R, Cheng D. Tension Pneumoperitoneum—a compication of colonoscopy: recognition and treatment in the emergency department. J Emerg Med 2002;22:419–20. Devine JF, McCarter TG Jr. Tension pneumoperitoneum. NEJM 2001;344:1985.
943
Downloaded from http://emj.bmj.com/ on April 11, 2015 - Published by group.bmj.com
Tension pneumoperitoneum David T Williams, Pej Manoochehri and Hyung T Kim Emerg Med J 2014 31: 943 originally published online January 29, 2014
doi: 10.1136/emermed-2013-203469 Updated information and services can be found at: http://emj.bmj.com/content/31/11/943
These include:
References Email alerting service
Topic Collections
This article cites 3 articles, 0 of which you can access for free at: http://emj.bmj.com/content/31/11/943#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Clinical diagnostic tests (989) Radiology (939) Radiology (diagnostics) (846) Surgical diagnostic tests (125) Ethics (368) Patients (190) Resuscitation (560)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
