Abstract | May 5, 2023

Conservative Management of a Patient with Pneumoperitoneum following Cardiopulmonary Resuscitation

Shira Rosoph, BS

Amanda Duggan, BSN, BS, Medical Student, St. George's University/Center for Haitian Studies, Miami, FL.

Learning Objectives

  1. Discuss the mechanisms of injury that may result in pneumoperitoneum following CPR.
  2. Discuss in which cases conservative management is appropriate for pneumoperitoneum following CPR rather than surgical intervention.
  3. Be able to identify pneumoperitoneum on CT scan.

Introduction:

Pneumoperitoneum is a rare complication of cardiopulmonary resuscitation (CPR) that may occur due to rupture of abdominal viscera, diaphragmatic air leak, or gastric distention [1]. Proposed mechanisms for visceral injury during CPR include transmitted pressure through the diaphragm during chest compressions, incorrect hand placement, increased susceptibility of abdominal organs to injury due to ischemia, forceful delivery of rescue breaths, and esophageal intubation [1]. Although surgical intervention is the traditional treatment for pneumoperitoneum, conservative management is being proposed as a safe alternative for patients with pneumoperitoneum without peritonitis and may be the preferred method of treatment in patients post-cardiac arrest, who have high rates of morbidity and mortality with surgical intervention [2,3,4].

Case Presentation: Our patient is a 64-year-old male with a history of chronic obstructive pulmonary disease and depression who presented to the emergency department via ambulance for acute respiratory distress, altered mental status, nausea and vomiting. Upon endotracheal intubation, he experienced pulseless electrical activity and CPR was performed. The following day, imaging studies were obtained; chest x-ray revealed no evidence of rib fracture or pneumothorax while abdominal CT showed no signs of perforated viscus. However, the abdominal CT scan was positive for pneumoperitoneum resulting in a consultation to general surgery. They performed a physical exam which showed no signs of rebound tenderness or rigidity, however, his condition was critical as he was intubated with bilateral air entry, on multiple sedatives, a norepinephrine infusion and IV fluids. Due to the high risk of mortality in this patient, as he was status post-cardiac arrest and no positive signs of peritonitis, surgery elected to treat his pneumoperitoneum conservatively with observation and imaging.

Final/Working Diagnosis: Pneumoperitoneum, status post-cardiac arrest

Management/Outcome: A follow-up abdominal CT was ordered one day later and it showed that the pneumoperitoneum was reducing in size and there was no extravasation of contrast medium, supporting the decision to undergo conservative management rather than surgical intervention. 


References 

  1. Ram P, Menezes RG, Sirinvaravong N, et al. Breaking your heart—A review on CPR-related injuries. The American Journal of Emergency Medicine. 2018;36(5):838-842. doi:10.1016/j.ajem.2017.12.063

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  1. Udelsman B, Lee K, Qadan M, et al. Management of Pneumoperitoneum. Annals of Surgery. 2019;274(1):146-154. doi:10.1097/sla.0000000000003492
  2. Milanchi S. Approach to Pneumoperitoneum After Cardiopulmonary Resuscitation. The Journal of Trauma: Injury, Infection, and Critical Care. 2006;61(6):1552-1553. doi:10.1097/01.ta.0000235972.29439.5d
  3. Hargarten KM, Aprahamian C, Mateer J. Pneumoperitoneum as a complication of cardiopulmonary resuscitation. The American Journal of Emergency Medicine. 1988;6(4):358-361. doi:10.1016/0735-6757(88)90157-x



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