Tension pneumomediastnum: A rare cause of acute intraoperative circulatory collapse in the setting of unremarkable TEE findings.

DESIGN: Case report.

SETTING: Operating room.

PATIENT: 25YF, ASA IV E who underwent an emergent decompressive craniectomy for refractory intracranial hypertension secondary to acute intracranial hemorhage.

INTERVENTIONS: A 25Y caucasian female presented with acute intracranial hemorrhage with intraventricular extension secondary to Moya Moya disease. Post admisison, she underwent an emergent decompressive craniectomy for medically refractory intracranial hypertension. Introperatively (post dural closure and bone flap removal) the patient developed acutely worsening peak and plateau pressures followed by pulseless electrical activity necessitating CPR with epinephrine and Vasopressin before return of circulation before return of circulation. Intraoperative TEE done during return of circulation, was essentially non diagnostic, the patient had normal breath sounds throughout, and non-contributory bronchoscopy findings.

MEASUREMENTS: EKG, arterial blood pressure, heart rate, resp. rate, introperative tranesophageal echocardiogram (TEE), Pulse oximetry, serial arterial blood gases, introperative bronchoscopy, ventilatory peak pressures.

MAIN RESULTS: A post operative chest CT revealed extensive pneumomediastinum with subcutaneous emphysema. The focussed introperative echocardiogram showed preserved left ventricular function and no evidence of tamponade physiology.

CONCLUSIONS: Tension pneumomediastinum was the likely etiologic factor for the acute hemodynamic collapse and should be considered in the differential diagnosis of intraoperative circulatory arrest.