Pneumoperitoneum as a Complication of Cardiopulmonary Resuscitation

 

Pneumoperitoneum Pneumoperiton eum as a ompli omplication cation of ardiopulmonary Resuscitation KATHLEEN M. HARGARTEN, MD, CHARLES APRAHAMIAN, MD, JAMES MATEER, MD A case of pneumoperit rito oneum folo folowng cardopumonary resuscitation CPR) is reported and 11 cases in the lit lite erature are reviewed Four pati tie ents had laparotomes faling fa ling to demonstr stra ate any vscera perforation or evdence of peritontis in spte of the massive pneumoperitoneum present. Operative interve rvention im medatey after resuscitation is associated wth potentialy hgh morbd bdty ty and morta tait ity. y. Severa dagnostic toos are used includng peri rito tonea lavage and contra trast meda tests, to accuratey dagnose perforated viscus. To avod an unnecessary ceiotomy a clinca clinca tr tre eatment protoco has been deveoped for pati tie ents wth pneumoperit ito oneum secondav to CPR Such dagnostic toos as peritonea lavage and water-s r-sou oube contrast medum test are revewed and included in ths protoco. A nonsurgca approach to patient management may be reasonabe if certan rtan crit rite eria are met. Am J Emerg Med lg88;8:358-361Og88 by W8. Saunders rs Company.) .)

Complications

resulting

from cardiopulmonary

re-

suscitation suscitati on (CPR) include rib fractures, hemothorax, hemopericardium,’ laceration of the liver or spleen, bone marrow pulmonary embolis and gastric mucosal lacerations and rupture.2 Most gastric mucosal lacerations and ruptures have been diagnosed at autopsy. Pneumoperitoneum occurring after cardiopulmonary resuscitation resuscitatio n has been diagnosed infrequently, with only 11 reported cases .2-‘2 Recently, nonoperative conservative management of some patients has been suggested.12 suggested. 12 After reviewing reviewi ng these 11 cases and presenting another, anothe r, we propose a method of evaluating these patients. C SE REPORT

An 83-year-old white woman with a history of cardiac disease status after anterior septal wall myocardial infarction

From the Department of Trauma and Emergency Medicine, ical College of Wisconsin, Milwaukee, Wisconsin .

Med-

Manuscript received tember 22, 1987.

Sep-

December December

16,1986;

revision accepted

DI SCUSSI ON

Address reprint requests to Dr Hargarten: Milwaukee County Medical Complex, Medical College of Wisconsin , Department of Trauma and Emergency Medicine, 8700 W Wiscons in Ave, Milwaukee, WI 53226. Key Words

massage,

Pneumoperitoneum, gastric rupture.

0 1988 by W.B. Saunders

cardiac

Company.

07356757/88/0604-0012$5.00/O 358

and cardiopulmonary arrest 1 year earlier had an episode of chest pain while at a local bank. Within minutes she collapsed and was found by paramedics to have a weak pulse with a narrow complex tachycardia on electrocardio electrocardiogram gram (ECG). Minimal attempts at respiration were noted, so bag mask ventilation was initiated, followed by orotrache orotracheal al intubation. An intravenous (IV) line was established. She became bradycardic then asystolic, at which time CPR was begun. Within 5 minutes the patient was successfully resuscitated with epinephrine and atropine and transported to the hospital. Upon aarrival rrival at the emergency department, the patient was alert but somewhat agitated. She had a blood pressure of 120/70 mmHg; pupils were equal, round, and reactive to light; lungs were clear to auscultation. with symmetric breath sounds; cardiac exam revealed a grade 316 crescendo decrescendo murmur at the left sternal bord border er radiating to the neck. The abdomen was distended and tympanic, but not tender. Neurologically. the patient was wa s intact and able to follow complex commands. The emergency department course consisted of a I2-lead ECG showing no new changes and normal laboratory labo ratory values including a normal serum creatinine phosphok phosphokinase inase (CPK). Upright chest x-ray revealed a massive pneumoperitoneum with free air under both hemidiaphragms, and vascular congestion (Fig 1). A nasogastric tube was inserted without evidence of blood. Following gen general eral surgical consultation she was taken to the operating room for an exploratory laparotomy. Free air was evident upon entering the peritoneal cavity, but there was no evidence of peritonitis or free fluid. There was a large 9 x 5 cm ecchymotic area along the lesser curvature of the stomach. extending over the serosal surface. A small rent in the peritoneal covering of the lesser sac near the triangular ligament to the liver was seen. A mixture of saline and methylene blue was injected into the stomach, but no leak could be demonstrated. Serial ECGs and CPK determinations revealed no evidence of acute myocardial infarction. The patient did well for 2 days postoperatively but then developed severe pulmonary edema and cardiogenic shock. In spite of aggressive medical management, she died 24 hours later. At the family’s request, no postmortem exam was performed.

arrest, external

cardiac

The most common causes of pneumoperitoneum are perforated appendix, duodenal or gastric ulcer, coionic diverticulum, or perforation secondary to inflammatory bowel disease. Such patients generally present p resent with findings of peritonitis requiring exploratory laparotomy and surgical repair. Less frequent causes include positive pressure ventilation with pneumo-

 

HARGARTEN, APRAHAMIAN, AND MATEER W PNEUMOPE PNEUMOPERITONEUM RITONEUM FROM CPR

combination of excessive ventilation volume and fast ventilation flow rates has been implicated as the cause of gastric di distention. stention. This problem can be minimized by properly maintaining maintain ing an open airway and limiting volume to the point at which the chest rrises. ises. Other techniques are also reported to minimize gastric distention.23 distention. 23 The combination of gastric distention and forceful chest compression can cause mucosal tea tears rs resulting i n hemoperitoneum in or pneumoperitoneum. Our patient was fu fully lly alert and had an asymptomatic pneumoperitoneum after CPR. Her cardiac disease and postresuscit postresuscitation ation status made her an extremely high surgical risk. Although Althoug h her death may not have been directly related to surgical complications, this may have been an opportune case to consider nonoperative management. Peritoneal lavage may be a reasonable alternative to surgical exploration in a patient without signs of peritonitis but whose exam may not be reliable. It is widely accepted as a diagnostic tool for blunt abd abdominal ominal trauma. Its accuracy rate has been reported to exceed 90 in detecting injuries. injuries.24-27 24-27 Criteria for exploration26 include lavage fluid with > 100,000 eryt erythrocytes hrocytes

thorax,‘3-‘6 pneumatosi pneumatosiss cystoides intestin intestinalis,i7 alis,i7 aerophagia,” aerophagia ,” and orogenital ins insufflation. ufflation. 19*20These patients have been treated nonsurgically with frequent serial abdominal exam, ga gastrografin strografin studies, and Barium swallow. Pneumoperitoneum following CPR is an uncommon occurrence, with only 11 reported cases in the literatur literature. e. One patient was d diagnosed iagnosed at autopsy as having a perforated stomach.2 Exploratory laparotomy was performed in the remaining ten cases. Seven of these patients had positive findings on celiotomy, with six gastric and one esophageal perforation. Two

per cubic millimeter, >500 leukocytes per cubic millimeter, or 200 Karoway units amylase per 100 milliliters.26 Peritoneal lavage is not always definitive, with difficulties in technique and interpretation of results.” results .” Three of 22 patients with isolated perforated small intestine from blunt trauma were reported to have had a lavage with <lOO,OO <lOO,OOO O erythrocytes per cubic millimeter.26 Fischer Fi scher found that patients with this injury and an initially negative peritoneal lavage may develop an a n elevated leukocyte and amylase value when this thi s pro procedure cedure was repeated in 3 to 4 hours.” Contrast media tests may assist in diagnosing the presence of gastric mucosal lacerations lacer ations or rupture. Al-

patients had preoperative contrast with studies,gastric whichperforations were negative.4,7 In the remaining three cases, a celiotomy failed to demonstrate visceral perforation, in spite of the massive pneumoperitoneum.376*i2 pneumoperitoneum.376*i 2 Clinch et all2 suggested that a negative peritoneal lavage might have avoided the celiotomy that was performed in their intoxicated patient. The proposed mechanism of gastric mucosal laceration is elevation of intragast intragastric ric pressure above extragastric pressures following sudde sudden n compression of the stomach.2’ These are characteristically found in the region of the lesser curvature, which may be more prone to rupture as a result of fewer muc mucosal osal folds and less elasticity. Gastric d distention istention during CPR can eas-

though a positive is is. diagnostic diagnostic, negative results do not rule out theresult diagnos diagnosis. Three , cases of pneumoperitoneum following CPR were reported as having negative results on contrast studies of the upper gastrointestinal trointestin al (GI) tract,4*7*‘2 two of which revealed evidence of rupture or peritonitis on celiotomy. The technique used for this examination was not reported in these cases, but may have had an impact on the results of the test. Jacobson et a129 and Meyers and Jacobson 3o have repor ted the accuracy of watersoluble contrast medium examination for suspected perforated gastric and duodenal ulcers to be high when performed as follows: Preliminary roentgenograms for pneumoperitoneum are obtained; a solution of hypaque is then administere administered d through a Levin tube, and

ily occur with mouth-to-mouth resuscitatio resuscitation n or bag mask ventilation. Only a few breaths of mouthto-mouth ventilation have been shown to cause gastric distention as high as 1,900 mL in the stomach.22 The

careful fluoroscopy fluoroscopy is performed (spot films should be taken to record the site of of leakage). The investigators found this method of examination easy to accomplish even in elderly and seriously ill patients.

FIGURE 1. Upright chest x-ray reveals a massive amount of air under the diaphragnis.

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AMERICAN

JOURNAL

OF EMERGENCY

MEDICINE

Volume 6, Number 4

CONCLU LUSI ON

Twelve cases of pneumoperitoneum following CPR have been reported to date; four with negative celiotomies. Operative intervention immediately after resuscitation is associated with potentially high morbidity and mortality. To avoid an unnecessary celiotomy in a critically ill patient, we suggest the following clinical treatment protocol in patients with evidence of pneumoperitoneum (Fig 2). Patients with signs of peritonitis should have immediate laparotomy. Those with a negative abdominal exam who are alert and conscious may be closely observed in the hospital, hospital , with frequent serial abdominal exams. Those patients with altered levels of consciousnesss but no evidence of peritonitis on exam sciousnes should have a peritoneal lavage performed. If the criteria for exploration used by Engrav et a126 are met, immediate laparotomy should also be performed. Those with an equivocal or negative peritoneal lavage should be considered for water-soluble contrast stud-

CPR INDUCED

ies of the upper GI tract. If perforation is evident with installation installa tion of hypaque, laparotomy is indicated. If results of the contrast study are negative, observation with serial abdominal exams and a repeat peritoneal lavage 4 to 6 hours after the injury may be performed. If the lavage fluid still shows no significant leukocytes, erythrocytes, or amylase, the patient could safely be followed clinically with serial abdominal exams. Further research the frequency of this complication of CPR delineating is needed. Our data, collected on 12 patients w with ith pneumoperitoneum, revealed four patients with wit h no evidence of peritonitis and no obvious perforation on celiotomy. A nonsurgical approach to the management of these pati patients ents is suggested. REFERENCES 1. Agdal N, Jorgensen JG. Penetrating laceration of the pericardium and myocardium and myocardial rupture following closed-chest cardiac massage. Acta Med Stand 1973;194:477-479 2. Silberberg B, Rachmaninoff N. Complications following external cardiac massage. Surg Synec Obstet 1964;119:610 3. Atcheson SG, Peterson GV, Fred HL. Ill effects of cardiac

PNEUblOPEBlTONEUM

4.

neg. ‘exam

peritdnitis 1 laparotomy

5.

I

I

altered mental status

,

,

,

,

,

6.

ale t t

I

7.

v

i peritoneal lavage

observe 8. 9. 10.

I

laparokmy

1

11.

1

12.

contrast stu ies

po”eiz

13.

\I/

aparo t omy

repeat peritoneal lavage 4-6 hrs. post

14.

15.

16.

lapar FIGURE 2. Clinical treatment induced pneumoperitoneum. 360

6tomy

protocol

for evaluati evaluation on

JJ

observe

of CPR-

uly 1988

resuscitation: Report of two unusual cases. Chest 1975;67:61.5-616 Darke SG. Case of complete gastric rupture complicating resuscitation. Br Med J 1975;3:414-415 Demos NJ, Poticha SM. Gastric rupture occurring during external cardiac resuscitation. Surgery 1964;55:364-366 1964;55:364-366 Gordon HL. Walkup JL. Scrotal pneumotocele as an unusual sign of pneumoperitoneum: Report of a case and review of the literature. J Urol 1970;104:441-442 Linch D, McDonald A, McNichol L. Tension pneumoperitoneum complicating cardiac resuscitation. Intensive Intensive Care Med 1979;5:93-94 Matikainen M. Rupture of the stomach: A rare complication Matikainen of resuscitation. Acta Chir Stand 1978;144:61-62 McClure JN, Skardasis GM, Brown JM. Cardiac arrest in the McClure operating area. Am Surg 1972;38:241-246 Soderstrom CA, DuPriest RW Jr, Cowley RA. Pitfalls of peritoneal lavage in blunt abdominal trauma. Surg Gynecol Gynecol Obstet 1980;151:513-518 Solowiejczyk M, Wapnick S, Koren E, et al. Rupture of the stomach following mouth to mouth respiration. Postgrad Med J 1974;50:76 %772 Clinch SL, Thompson JS, Edney JA. Pneumoperitoneum after cardiopulmonary resuscitation: A therapeutic dilemma. J Trauma 1983;23:428430 1983;23:428430 Krauss M, Mann Manny y Jona. Pneumoperitoneum associated with pneumothorax: A surgical dilemma in the post-traumatic patient. J Trauma 1976;17:238-240 Aranda JV, Stern LD. Pneumothora Pneumothorax x with pneumoperitoneum in a newborn infant. Am J Dis Child 1972;123:163166 Leininger BJ, Barber WL, Langston HT. Tension pneumoperitoneum and pneumothorax in the newborn. Am J Thorat Surg 1970;9:359-363 Glauser FL, Bartlett RH. Pneumoperitoneum in association

with pneumothorax pneumothorax.. Chest 1974;66:536-540 1974;66:536-540 17. Wolloch Y, Dintsman M, Weiss A. Pneumatosis cystoides intestinalis of adulthood. Arch Surg 1972;105:723-726 1972;105:723-726 18. Papp JP, Sullivan BH. Spontaneous pneumoperitoneum without peritonitis. Cleve Clin Q 1965;32:14%155 1965;32:14%155

 

HARGARTEN, APRAHAMIAN, AND MATEER

PNEUM~PERITONEUM FROM CPR

19. Gantt CB, Daniel Daniel WW , Hallenbeck GA. Nonsurgical pneumoperitoneum. Am J Surg 1977;134:411-414 20. Freeman RK. Pneumoperitoneum from oral-genital insuffl insufflaation. Obstet Gynecol 1970;36:162-164 21. Mortiz Mort iz AR. AR . The Pa Pathology thology of Trauma, ed 2. Philadelphia, Lea & Febiger, 1954;226228 22. Safar P. Ventilatory efficacy of mouth-to-mouth artificial respiration. JAMA 1958;167:335 23. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA

26. Engrav LH, LH , Benjamin Cl, Strate RG, R G, et al. Diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma 1975;15:854-859 27. Gill W, Champion HR, Long WB, WB , et al. Abdominal lavage in blunt trauma. Br J Surg 1975;62:121-124 1975;6 2:121-124 28. Fischer RP. Diagnostic peritoneal lavage lavage for blunt trauma: A thirteen year experience with 2,262 patients. Presented at 4th Annual Trauma Symposium, Am Trauma Sot, May 1976. Medical College of Ohio, Toledo 29. Jacobson G, Berne CJ, Meyers HI, et al. The examination examination of

1986;255:2905-2984 24. Ahmad W, Polk HC Jr. Blunt abdominal trauma. Arch Surg 1976;111:489-492 25. DuPriest RW Jr, Rodriguez A, Khaneja SC, e ett al. Open diagnostic peritoneal lavage in blunt trauma victims. Surg Gynecol Obstet 1979;148:89O-894

patients with suspected perforated ulcer using a watersoluble contrast medium. Am J Roentgen01 1961;86:3749 30. Meyers HI, Jacobson G. Use of water-soluble contrast medium in suspected perforated peptic ulcer. ul cer. Radio1 Clin North Am 1964;2:55-69

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