C43-46 Mounting Pressure: A Rare Case of Iatrogenic Tension Pneumoperitoneum

Abstract Pneumoperitoneum is typically associated with gastrointestinal perforation from peptic ulcers, diverticulitis, or bowel obstruction. Esophageal intubation is a recognized but rare cause of pneumoperitoneum, often due to inadvertent insufflation of the gastrointestinal tract, which can result in significantly raised intra-abdominal pressure, and in severe cases, gastric perforation A 56-year-old male with a history of substance use was found unresponsive in his car due to suspected methamphetamine and fentanyl overdose. Due to lack of improvement in his respiratory status despite repeated naloxone doses, he was intubated by EMS with assistance of video laryngoscopy. Confirmation of endotracheal tube was done by auscultation; end-tidal carbon dioxide check was reported to give inaccurate readings. Upon arrival at the ED, he had a markedly distended abdomen and poor ventilatory compliance. Chest x-ray showed the ET overlying the right bronchus. A subsequent CT scan of the chest and abdomen revealed esophageal placement of the ET tube and massive pneumoperitoneum with significant mass effect, including right heart and inferior vena cava compression and diaphragmatic elevation. The ET tube was immediately replaced in the correct position. The patient underwent emergency laparoscopic decompression and gastric perforation repair This case highlights a rare but life-threatening complication of esophageal intubation. High clinical suspicion, prompt imaging, and surgical intervention are crucial to prevent cardiovascular collapse from intra-abdominal tension physiology. Esophageal intubation may not always be apparent, particularly when capnography is unreliable, and reliance on auscultation alone can be misleading. It is important to remain vigilant when a patient’s physiology does not match expected post-intubation findings, such as abdominal distention or unexpected ventilatory resistance. This case highlights the need for a standardized, multi-modality verification checklist before initiating ventilation in intubated patients, especially in the field. This abstract is funded by: None