C52-05 Spontaneous Pneumoperitoneum in a Patient Following Cardiopulmonary Resuscitation and Emergent Endotracheal Intubation

Abstract Introduction Pneumoperitoneum typically results from hollow viscus perforation and requires emergent surgical consultation. However, in critically ill or mechanically ventilated patients, it may arise from extra-abdominal sources. Here we present a rare case of tension pneumothorax and pneumoperitoneum following cardiopulmonary resuscitation (CPR) and endotracheal intubation in a patient with severe COPD. Case Presentation A 78-year-old female with a history of a thoracic aortic aneurysm, atrial flutter on apixaban, heart failure with preserved ejection fraction, and severe chronic obstructive pulmonary disease (COPD) (FEV₁ 0.5 L, 22% predicted), presented to the emergency department with respiratory distress requiring non-invasive ventilation. She was admitted to the intensive care unit (ICU) and treated for a COPD exacerbation. She improved and was transferred to the medical floor, where she additionally underwent a thoracentesis for a chronic pleural effusion. Later in her hospital course, she developed acute respiratory distress with a consequent cardiac arrest. The patient underwent CPR with emergent endotracheal intubation. After return of spontaneous circulation was achieved, difficulty with ventilation was noted. A rapid chest radiograph revealed a right-sided tension pneumothorax, which improved with emergent chest thoracostomy. The same radiograph incidentally demonstrated subdiaphragmatic free air concerning for a perforated hollow viscus. Surgery was emergently consulted. Patient examination demonstrated hemodynamic stability with a distended but soft abdomen with a persistent air leak from the right-sided chest tube. Computed tomography (CT) of the abdomen and pelvis with oral contrast revealed extensive pneumoperitoneum and retroperitoneal air without contrast extravasation, bowel wall thickening, or free fluid. A Chest CT also demonstrated bilateral pneumothoraces and pneumomediastinum. The patient’s lactate was normal. Given the patient’s stable hemodynamics, absence of peritoneal signs, and normal lactate, it was concluded that the pneumoperitoneum was likely attributed to air dissecting through a defect between the thoracic and abdominal cavities. The patient was managed conservatively in the ICU, and eventually, the pneumothoraces, pneumomediastinum, and pneumoperitoneum resolved. Discussion This case highlights a rare extra-abdominal cause of pneumoperitoneum following CPR and endotracheal intubation with resulting barotrauma in a patient with severe COPD. The differentiation between surgical and nonsurgical pneumoperitoneum is critical to guide management and avoid an unnecessary exploratory laparotomy in a critically ill patient. Mechanisms include alveolar rupture with air dissection along fascial planes through the mediastinum into the peritoneal cavity. Careful clinical correlation and imaging are essential for management decisions. This abstract is funded by: None