LAUSR

Learning Objectives: Tension pneumomediastinum (TPM) is a rare, potentially lethal complication of endotracheal intubation. We report a case of TPM secondary to intubation-related airway injury requiring emergent decompression. Methods: A 10-year-old male presented to the emergency department with acute onset headache and altered mental status. He became apneic during a CT scan and was emergently intubated by a staff physician in a single attempt. He developed PEA immediately after intubation and received CPR with ROSC after one dose of epinephrine. CT brain showed acute subdural hematoma layering over the tentorium, subarachnoid hemorrhage, and right cerebellar hemorrhage with mass effect. He was treated with standard medical therapy for intracranial hypertension in addition to an emergent bedside ventriculostomy. Initial chest x-ray showed bilateral diffuse lung infiltrates. The endotracheal tube tip was in the right main stem bronchus and was retracted. Neurogenic pulmonary edema was suspected and the patient required significant ventilatory support. The patient developed subcutaneous emphysema and pneumomediastinum over a few hours, as well as fluid and vasoactive refractory hypotension. Ventilator pressures were reduced briefly but oxygenation could not be maintained. TPM was suspected and cardiothoracic surgery was consulted. A mediastinal tube thoracostomy was performed using an anterior subxiphoid approach. An incision was made followed by digital manipulation into the anterior mediastinum with a release of air under pressure. A 16-french chest tube was placed. Vasopressors were weaned off. The patient required a chest tube for right pneumothorax after removal of the mediastinal tube. A CT scan revealed a posterolateral tracheal defect. The patient was treated conservatively and bronchoscopy 3 weeks after intubation showed a healing tear. He was then extubated. Results: Subcutaneous emphysema, pneumomediastinum and pneumothorax have been associated with tracheobronchial injury as well as barotrauma during positive pressure ventilation. TPM should be suspected if there is cardiovascular compromise, even in the absence of a traumatic intubation. The initial management includes limiting airway pressure and fluid administration; percutaneous or surgical decompression may be required.