Down the Wrong Pipe: Tension Pneumoperitoneum from Esophageal Intubation

Area of Science:

• Emergency Medicine
• Critical Care
• Surgical Pathology

Background:

• Tension pneumoperitoneum (TPP) is a rare, life-threatening condition characterized by excessive peritoneal air, mimicking abdominal compartment syndrome.
• TPP causes hemodynamic instability due to intra-abdominal vasculature compression.
• Common causes include viscus perforation post-endoscopy or gastric perforation during resuscitation.

Purpose of the Study:

• To highlight TPP as a critical differential diagnosis in patients with hemodynamic instability and abdominal distension post-intubation.
• To emphasize the importance of abdominal needle decompression as a life-saving intervention for TPP.
• To underscore the necessity of verifying endotracheal tube placement to prevent iatrogenic gastric perforation.

Main Methods:

• Case report of a 58-year-old female presenting with unresponsiveness, intubation, and subsequent hemodynamic collapse.
• Diagnostic imaging revealed significant free air, indicative of tension pneumoperitoneum.
• Management included emergent abdominal needle decompression and exploratory laparotomy.

Main Results:

• The patient developed tension pneumoperitoneum likely secondary to esophageal intubation and positive pressure ventilation, causing gastric perforation.
• Despite rapid intervention, the patient expired.
• This case illustrates the rapid progression and fatal potential of TPP.

Conclusions:

• Emergency physicians must consider TPP in patients with recent, unverified intubation presenting with abdominal distension and hemodynamic compromise.
• Abdominal needle decompression is a vital skill for emergency physicians managing TPP.
• Confirmation of endotracheal tube placement is essential to prevent iatrogenic complications like gastric perforation.