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Tension pneumoperitoneum and gastric rupture following cardiopulmonary resuscitation
CASE REPORT cardiopulmonary resuscitation; gastric rupture; tension pneumoperitoneum
Tension Pneumoperitoneum and Gastric Rupture Following Cardiopulmonary Resuscitation Inadvertent esophageal intubation during cardiopulmonary resuscitation following aortocoronary bypass grafting resulted in gastric rupture and tension pneumoperitoneum in a 65-year-old patient. Rapid hemodynamic deterioration necessitated emergency laparotomy with successful repair of the gastric rupture. The patient's recovery was uneventful, and he was doing well at six months .follow up. Awareness of this unusual complication may lead to early recognition and successful treatment. [Mills SA, Paulson D, Scott SM, Sethi G: Tension pneumoperitoneum and gastric rupture following cardiopulmonary resuscitation. Ann Emerg Med 12:94-98, February 1983.]
INTRODUCTION Complications of cardiopulmonary resuscitation are common, and include rib fractures, 1 bone marrow 1 and fat emboli, 1 gastric dilatation, 2 laceration of the liver, 2 hemopericardium, 2 and skin burns from the defibrillation electrodes. 1 Major complications, such as cardiac rupture, 3 are less frequent; however, awareness of their potential hazard may lead to timely intervention when they do occur. We report the occurrence of tension pneumoperitoneum due to gastric rupture during cardiopulmonary resuscitation. The patient had had respiratory arrest after a coronary artery bypass grafting.
Stephen A. Mills, MD* Donald Pautson, PA* Winston-Salem, North CaroLina Stewart M. Scott, MDt Gulshan Sethi, MDt AshevilLe, North Carolina From the Section of Cardiothoracic Surgery. Department of Surgery, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem;* and the Department of Cardiothoracic Surgery, Ashevitle Veterans Administration Hospital, Asheville, North Carolina. t Address for reprints: Stephen A. Mills, MD, Section of Cardiothoracic Surgery, Bowman Gray School of Medicine, 300 South Hawthorne Road, Winston-Salem, North Carolina 27103.
CASE REPORT A 65-year-old man was admitted with a history of ethanol and tobacco abuse, hypertension and severe angina that could not be controlled medically. Cardiac catheterization demonstrated an ejection fraction of 50% and significant left main coronary artery disease. The patient underwent three-vessel aortocoronary bypass grafting and had an uncomplicated intraoperative and immediate postoperative course. He was extubated 18 hours after operation. Four hours later, as he was being helped out of bed, he became tachypneic, cyanotic, and diaphoretic. He was put back in bed and endotracheal suction was performed. Arterial blood gas measurements were as follows: pH, 7.14; PO2, 54; PCO2, 66; HCO3, 21.7 mEq/L; and O2 saturation, 72%. Breath sounds were diminished bilaterally. Intubation of the trachea was attempted but was complicated by the patient's combativeness, and the esophagus was inadvertently intubated. He was ventilated several times by hand, and his abdomen immediately distended; the endotracheal tube was then repositioned correctly in the trachea. He had several episodes of hemodynamic instability and bradycardia that required external cardiac massage. Placement of a nasogastric sump tube did not decompress the distended abdomen. Ventilation became progressively more difficult and a diagnosis of tension pneumothorax was considered, but bilateral placement of chest tubes did not relieve the situation. A portable anteroposterior chest roentgenogram showed a massive pneumoperitoneum. The patient by then was moribund. He was returned to the operating room for an exploratory laparotomy. Opening the peritoneal cavity resulted in a massive decompression of
12:2 February 1983
Annals of Emergency Medicine
94/55
TENSION PNEUMOPERITONEUM Mills et al
air under tension and a dramatic improvement in the patient's hemodyn a m i c and v e n t i l a t o r y s t a t u s . H i s stomach was not distended and the nasogastric tube was in place. A small h e m a t o m a could be seen in the gastrohepatic l i g a m e n t adjacent to the lesser curve of the stomach. Mobilization of the stomach revealed an 8-cm, f u l l - t h i c k n e s s tear along the lesser curve. T h e tear was closed in two layers. T h e p a t i e n t ' s c o n v a l e s c e n c e w a s s a t i s f a c t o r y a n d h e w a s discharged in good condition. H e was doing well at six m o n t h s follow up. DISCUSSION A u t o p s y studies following unsuccessful c a r d i o p u l m o n a r y r e s u s c i t a tions have demonstrated lacerations of the gastric mucosa in 10% of cases. 4 Actual rupture of the gastric wall has been r e p o r t e d f o l l o w i n g m o u t h - t o m o u t h resuscitation and following the use of n a s a l o x y g e n or c o n t i n u o u s positive airway pressure delivered by face mask. 5-tl In our case, rapture of the gastric wall followed external cardiac massage in a patient w i t h gastric distention due to inadvertent esophageal, rather than tracheal, intubation. The majority of reported gastric ruptures have occurred along the lesser curvature near the cardia, 4 as in our case, and it has been suggested that t h e d e c r e a s e d n u m b e r of m u c o s a l folds in that area m a y l i m i t distensibility of the s t o m a c h ] In adults, a pressure of 120 to 150 m m Hg is required to cause gastric rupture, a pressure that corresponds to a v o l u m e of 4 L. 1~ However, lesser pressures m a y result in gastric rupture if the airway is obstructed or if extern a l c a r d i a c m a s s a g e is b e i n g performed, as in our case. These lesser pressures can be developed w i t h either m o u t h - t o - m o u t h r e s u s c i t a t i o n 7 or m a n u a l r e s u s c i t a t i o n w i t h bag and face m a s k . 6 T h e l a t t e r m e c h a n i s m may have been responsible for some of the gastric distention in this patient, but undoubtedly the significant insuf-
56/95
flation of air resulted from esophageal p l a c e m e n t of the endotracheal tube. T h e p n e u m o p e r i t o n e u m in our patient was associated with an adequately d e c o m p r e s s e d s t o m a c h , a n d air passing from the stomach to the peritoneal cavity was apparently held under tension by the valve-like action of the lacerated gastric tissue and gastrohepatic omentum. P n e u m o p e r i t o n e u m caused by gastric r u p t u r e m u s t be d i f f e r e n t i a t e d from that caused by barotrauma. 13-1s T h e latter is u s u a l l y found in comb i n a t i o n w i t h m e d i a s t i n a l emphysema, s u b c u t a n e o u s e m p h y s e m a , or pneumothorax. It is c o m m o n l y associated with mechanical ventilation, particularly when positive end-expiratory pressure is used. P n e u m o p e r i t o n e u m following closed-chest cardiac massage n e e d n o t r e f l e c t a p e r f o r a t e d viscus 16 and, if the patient's condition is stable enough, contrast studies m a y help determine whether the viscus is perforated. Aggressive diagnostic and therapeutic approaches are warranted, for gastric rupture is associated w i t h a high mortality. Management of massive abdominal distention associated w i t h cardiopulmonary resuscitation should start with passage of a nasogastric tube in an effort to decompress the stomach, followed by needle aspiration of the a b d o m e n should d i s t e n t i o n persist, s While several authors 4,7-11 have docu m e n t e d p n e u m o p e r i t o n e u m associated with gastric rupture in a variety of situations, they have not emphasized that the condition is often a tens i o n p n e u m o p e r i t o n e u m , and t h a t tension p n e u m o p e r i t o n e u m related to gastric rupture can be associated w i t h fulminant h e m o d y n a m i c and respiratory deterioration. Such rapid deterioration occurred in our patient. Gastric rupture leading to tension p n e u m o p e r i t o n e u m r e m a i n s an unc o m m o n but important complication of cardiopulmonary resuscitation and inappropriate esophageal intubation. Early recognition can lead to definitive and life-saving therapy.
Annals of Emergency Medicine
REFERENCES 1. Baringer JR, Salzman EW, Jones WA, et al: External cardiac massage. N Engl ] Med 265:62-65, 1961. 2. Himmelhoch SR, Dekker A, Gazzaniga AB, et al: Closed-chest cardiac resuscitation. A prospective clinical and pathological study. N Engl ] Med 270:118-122, 1964. 3. Fletcher GF: Hazardous complications of "closed-chest" cardiopulmonary resuscitation. A m Heart J 77:431-432, 1969. 4. Anthony PP, Tattersfield AE: Gastric mucosal lacerations after cardiac resuscitation. Br Heart J 31:72-75, 1969. 5. Cole DS, Burcher SK: Accidental pneumatic rupture of esophagus and stomach. Lancet 1:24-25, 1961. 6. Darke SG, Bloomfield E: Case of complete gastric rupture complicating resuscitation. Br Med J 3:414-415, 1975. 7. Valtonen EJ, Hakola N: Rupture of the normal stomach during mouth-to-mouth resuscitation. Report of a case. Acta Chir Scand 127:427-431, 1964. 8. Demos JN, Poticha SM: Gastric rupture occurring during external cardiac resuscitation. Surgery 55:364-366, 1964. 9. Fenton ESN: A danger of a nasal catheter used as a means of oxygenation postoperatively. Br J Anaesth 28:220-221, 1956. 10. Longobardi A, Ruggles DW, Burgess AM: Rupture of the normal stomach during oxygen therapy by nasal catheter. A brief report of three cases and a simple means of preventing this disaster. Ann Intern Med 55:1014-1015, 1961. 11. Waisted PM, Conklin WS: Rupture of the normal stomach after therapeutic oxygen administration. Report of three cases. N Engl J Med 264:1201-1202, 1961. 12. Revilliad L: Rupture de l'estomac. Rev Med Suisse Rorn 5:5-13, 1885. 13. Summers B: Pneumoperitoneum associated with artificial ventilation. Br Med J 1:1528-1530, 1979. 14. Gallagher TJ: Pneumoperitoneum and mechanical ventilation, (letter). JAMA 235:2814, 1976. 15. Andrew TA, Milne DD: Pneumoperitoneum associated with pneumothorax or pneumopericardium: A surgical dilemma in the injured patient. Injury 11:65-70, 1979. 16. Atcheson SG, Petersen GV, Fred HL: Ill-effects of cardiac resuscitation: Report of two unusual cases. Chest 67:615-616, 1975.
12:2 February 1983
Tension Pneumoperitoneum and Gastric Rupture Following Cardiopulmonary Resuscitation Inadvertent esophageal intubation during cardiopulmonary resuscitation following aortocoronary bypass grafting resulted in gastric rupture and tension pneumoperitoneum in a 65-year-old patient. Rapid hemodynamic deterioration necessitated emergency laparotomy with successful repair of the gastric rupture. The patient's recovery was uneventful, and he was doing well at six months .follow up. Awareness of this unusual complication may lead to early recognition and successful treatment. [Mills SA, Paulson D, Scott SM, Sethi G: Tension pneumoperitoneum and gastric rupture following cardiopulmonary resuscitation. Ann Emerg Med 12:94-98, February 1983.]
INTRODUCTION Complications of cardiopulmonary resuscitation are common, and include rib fractures, 1 bone marrow 1 and fat emboli, 1 gastric dilatation, 2 laceration of the liver, 2 hemopericardium, 2 and skin burns from the defibrillation electrodes. 1 Major complications, such as cardiac rupture, 3 are less frequent; however, awareness of their potential hazard may lead to timely intervention when they do occur. We report the occurrence of tension pneumoperitoneum due to gastric rupture during cardiopulmonary resuscitation. The patient had had respiratory arrest after a coronary artery bypass grafting.
Stephen A. Mills, MD* Donald Pautson, PA* Winston-Salem, North CaroLina Stewart M. Scott, MDt Gulshan Sethi, MDt AshevilLe, North Carolina From the Section of Cardiothoracic Surgery. Department of Surgery, Bowman Gray School of Medicine of Wake Forest University, Winston-Salem;* and the Department of Cardiothoracic Surgery, Ashevitle Veterans Administration Hospital, Asheville, North Carolina. t Address for reprints: Stephen A. Mills, MD, Section of Cardiothoracic Surgery, Bowman Gray School of Medicine, 300 South Hawthorne Road, Winston-Salem, North Carolina 27103.
CASE REPORT A 65-year-old man was admitted with a history of ethanol and tobacco abuse, hypertension and severe angina that could not be controlled medically. Cardiac catheterization demonstrated an ejection fraction of 50% and significant left main coronary artery disease. The patient underwent three-vessel aortocoronary bypass grafting and had an uncomplicated intraoperative and immediate postoperative course. He was extubated 18 hours after operation. Four hours later, as he was being helped out of bed, he became tachypneic, cyanotic, and diaphoretic. He was put back in bed and endotracheal suction was performed. Arterial blood gas measurements were as follows: pH, 7.14; PO2, 54; PCO2, 66; HCO3, 21.7 mEq/L; and O2 saturation, 72%. Breath sounds were diminished bilaterally. Intubation of the trachea was attempted but was complicated by the patient's combativeness, and the esophagus was inadvertently intubated. He was ventilated several times by hand, and his abdomen immediately distended; the endotracheal tube was then repositioned correctly in the trachea. He had several episodes of hemodynamic instability and bradycardia that required external cardiac massage. Placement of a nasogastric sump tube did not decompress the distended abdomen. Ventilation became progressively more difficult and a diagnosis of tension pneumothorax was considered, but bilateral placement of chest tubes did not relieve the situation. A portable anteroposterior chest roentgenogram showed a massive pneumoperitoneum. The patient by then was moribund. He was returned to the operating room for an exploratory laparotomy. Opening the peritoneal cavity resulted in a massive decompression of
12:2 February 1983
Annals of Emergency Medicine
94/55
TENSION PNEUMOPERITONEUM Mills et al
air under tension and a dramatic improvement in the patient's hemodyn a m i c and v e n t i l a t o r y s t a t u s . H i s stomach was not distended and the nasogastric tube was in place. A small h e m a t o m a could be seen in the gastrohepatic l i g a m e n t adjacent to the lesser curve of the stomach. Mobilization of the stomach revealed an 8-cm, f u l l - t h i c k n e s s tear along the lesser curve. T h e tear was closed in two layers. T h e p a t i e n t ' s c o n v a l e s c e n c e w a s s a t i s f a c t o r y a n d h e w a s discharged in good condition. H e was doing well at six m o n t h s follow up. DISCUSSION A u t o p s y studies following unsuccessful c a r d i o p u l m o n a r y r e s u s c i t a tions have demonstrated lacerations of the gastric mucosa in 10% of cases. 4 Actual rupture of the gastric wall has been r e p o r t e d f o l l o w i n g m o u t h - t o m o u t h resuscitation and following the use of n a s a l o x y g e n or c o n t i n u o u s positive airway pressure delivered by face mask. 5-tl In our case, rapture of the gastric wall followed external cardiac massage in a patient w i t h gastric distention due to inadvertent esophageal, rather than tracheal, intubation. The majority of reported gastric ruptures have occurred along the lesser curvature near the cardia, 4 as in our case, and it has been suggested that t h e d e c r e a s e d n u m b e r of m u c o s a l folds in that area m a y l i m i t distensibility of the s t o m a c h ] In adults, a pressure of 120 to 150 m m Hg is required to cause gastric rupture, a pressure that corresponds to a v o l u m e of 4 L. 1~ However, lesser pressures m a y result in gastric rupture if the airway is obstructed or if extern a l c a r d i a c m a s s a g e is b e i n g performed, as in our case. These lesser pressures can be developed w i t h either m o u t h - t o - m o u t h r e s u s c i t a t i o n 7 or m a n u a l r e s u s c i t a t i o n w i t h bag and face m a s k . 6 T h e l a t t e r m e c h a n i s m may have been responsible for some of the gastric distention in this patient, but undoubtedly the significant insuf-
56/95
flation of air resulted from esophageal p l a c e m e n t of the endotracheal tube. T h e p n e u m o p e r i t o n e u m in our patient was associated with an adequately d e c o m p r e s s e d s t o m a c h , a n d air passing from the stomach to the peritoneal cavity was apparently held under tension by the valve-like action of the lacerated gastric tissue and gastrohepatic omentum. P n e u m o p e r i t o n e u m caused by gastric r u p t u r e m u s t be d i f f e r e n t i a t e d from that caused by barotrauma. 13-1s T h e latter is u s u a l l y found in comb i n a t i o n w i t h m e d i a s t i n a l emphysema, s u b c u t a n e o u s e m p h y s e m a , or pneumothorax. It is c o m m o n l y associated with mechanical ventilation, particularly when positive end-expiratory pressure is used. P n e u m o p e r i t o n e u m following closed-chest cardiac massage n e e d n o t r e f l e c t a p e r f o r a t e d viscus 16 and, if the patient's condition is stable enough, contrast studies m a y help determine whether the viscus is perforated. Aggressive diagnostic and therapeutic approaches are warranted, for gastric rupture is associated w i t h a high mortality. Management of massive abdominal distention associated w i t h cardiopulmonary resuscitation should start with passage of a nasogastric tube in an effort to decompress the stomach, followed by needle aspiration of the a b d o m e n should d i s t e n t i o n persist, s While several authors 4,7-11 have docu m e n t e d p n e u m o p e r i t o n e u m associated with gastric rupture in a variety of situations, they have not emphasized that the condition is often a tens i o n p n e u m o p e r i t o n e u m , and t h a t tension p n e u m o p e r i t o n e u m related to gastric rupture can be associated w i t h fulminant h e m o d y n a m i c and respiratory deterioration. Such rapid deterioration occurred in our patient. Gastric rupture leading to tension p n e u m o p e r i t o n e u m r e m a i n s an unc o m m o n but important complication of cardiopulmonary resuscitation and inappropriate esophageal intubation. Early recognition can lead to definitive and life-saving therapy.
Annals of Emergency Medicine
REFERENCES 1. Baringer JR, Salzman EW, Jones WA, et al: External cardiac massage. N Engl ] Med 265:62-65, 1961. 2. Himmelhoch SR, Dekker A, Gazzaniga AB, et al: Closed-chest cardiac resuscitation. A prospective clinical and pathological study. N Engl ] Med 270:118-122, 1964. 3. Fletcher GF: Hazardous complications of "closed-chest" cardiopulmonary resuscitation. A m Heart J 77:431-432, 1969. 4. Anthony PP, Tattersfield AE: Gastric mucosal lacerations after cardiac resuscitation. Br Heart J 31:72-75, 1969. 5. Cole DS, Burcher SK: Accidental pneumatic rupture of esophagus and stomach. Lancet 1:24-25, 1961. 6. Darke SG, Bloomfield E: Case of complete gastric rupture complicating resuscitation. Br Med J 3:414-415, 1975. 7. Valtonen EJ, Hakola N: Rupture of the normal stomach during mouth-to-mouth resuscitation. Report of a case. Acta Chir Scand 127:427-431, 1964. 8. Demos JN, Poticha SM: Gastric rupture occurring during external cardiac resuscitation. Surgery 55:364-366, 1964. 9. Fenton ESN: A danger of a nasal catheter used as a means of oxygenation postoperatively. Br J Anaesth 28:220-221, 1956. 10. Longobardi A, Ruggles DW, Burgess AM: Rupture of the normal stomach during oxygen therapy by nasal catheter. A brief report of three cases and a simple means of preventing this disaster. Ann Intern Med 55:1014-1015, 1961. 11. Waisted PM, Conklin WS: Rupture of the normal stomach after therapeutic oxygen administration. Report of three cases. N Engl J Med 264:1201-1202, 1961. 12. Revilliad L: Rupture de l'estomac. Rev Med Suisse Rorn 5:5-13, 1885. 13. Summers B: Pneumoperitoneum associated with artificial ventilation. Br Med J 1:1528-1530, 1979. 14. Gallagher TJ: Pneumoperitoneum and mechanical ventilation, (letter). JAMA 235:2814, 1976. 15. Andrew TA, Milne DD: Pneumoperitoneum associated with pneumothorax or pneumopericardium: A surgical dilemma in the injured patient. Injury 11:65-70, 1979. 16. Atcheson SG, Petersen GV, Fred HL: Ill-effects of cardiac resuscitation: Report of two unusual cases. Chest 67:615-616, 1975.
12:2 February 1983