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FIGURE 4B
Axial CT image of the upper chest on lung windows demonstrating right sided pneumothorax, chest tube, and subcutaneous emphysema.
decompression be performed to release intra abdominal pressure and improve respiratory and circulatory function.4
pneumoperitoneum was caused by mechanical ventilation barotrauma, CPR, or a combination of the two. Risk for mechanical ventilation barotrauma induced tension pneumoperitoneum increases with a peak inspiratory pressure (PIP) greater than
40 cm H2O, positive end expiratory pressure (PEEP) greater
than 6 cm H2O, and additional evidence of barotrauma such
as, pneumomediastinum, subcutaneous emphysema, and/or pneumothoraces.5 In our case, when the patient was initially intubated, the PIP was 31 cm H2O and the PEEP was 8 cm H2O. Approximately 45 minutes before the patient coded, the PIP was
66 cm H2O and the PEEP was 14 cm H2O. Both of these values
are well above the thresholds mentioned above. After the code, the PIP and PEEP steadily increased to maximum values of PIP 85 cm H2O and a of PEEP 18 cm H2O. The high PIP and PEEP values, along with the subcutaneous emphysema and pneumothorax, make ventilation barotrauma a likely cause of tension pneumoperitoneum in the case we presented. It is theorized that there was a high risk scenario for barotrauma at the time CPR was initiated, which then served to accelerate the trauma. In turn, the patient’s ventilation settings post CPR further exacerbated the problem, ultimately leading to the patient’s tension pneumoperitoneum.
REFERENCES
1. Lin BW, Thanassi W. Tension Pneumoperitoneum. J of Em Med. 2010;38:57-59.
2. Chan SY, Kirsch CM, Jensen WA, et al: Tension Pneumoperitoneum. West J Med. 1996;165:61-64
3. Reichardt JA, Casey GD, Krywko D. Gastric Rupture From Cardiopulmonary Resuscitation or Seizure Activity? A Case Report.
FIGURE 4C
Axial CT image of the upper chest on lung windows demonstrating large pneumoperitoneum resulting in abdominal distension and early centralization of abdominal organs and early mass effect on the IVC (open black arrow). Gas is present within
the falciform ligament (solid white arrow) and subcutaneous tissues.
In summary, we present a case of tension pneumoperitoneum with associated tension pneumothorax and extensive subcutaneous barotrauma; however CPR was also performed and therefore
the exact etiology cannot be determined in this case. Tension pneumoperitoneum is a rare, but potentially life threatening complication of mechanical ventilation. While ultimately a clinical diagnosis, the radiologist should have a high clinical suspicion and be able to recognize the imaging signs of this potentially reversible entity.
COMPLIANCE WITH ETHICAL STANDARDS
Ethical approval: This article does not contain any studies with human participants or animals performed by any of the authors.
CONTRIBUTING AUTHORS
■ ELIZABETH K. PROFFITT, MD is a Diagnostic Radiology Resident at Christiana Care Health System in Newark, Del.
■ SARAH MENG, DO is a Radiologist at Christiana Care Health System in Newark, Del.
4.
5.
J of Em Med. 2010;39:309-311.
Symeonidis, N, Ballas K, Pavlidis E, Psarras K, Pavlidis T, Sakantamis A. Tension Pneumoperitoneum: A Rare Complication of Upper Gastrointestinal Endoscopy. J of Society of Laparoendosopic Surgeons. 2012;16:495-497.
Henry RE, Ali N, Banks T, et al. Pneumoperitonum Associated with Mechanical Ventilation. J of Nat Med Acssoc 1986;78:539-541.
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