• Jonathan B Weaver and Avinash B Kumar.
• Department of Anesthesiology, Division of Critical Care, Vanderbilt University Medical Center, Nashville, TN, United States. Electronic address: jonathan.b.weaver@vanderbilt.edu.
• J Clin Anesth. 2017 Feb 1; 37: 136-138.

DesignCase report.SettingOperating room.Patient25YF, ASA IV E who underwent an emergent decompressive craniectomy for refractory intracranial hypertension secondary to acute intracranial hemorhage.InterventionsA 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.MeasurementsEKG, arterial blood pressure, heart rate, resp. rate, introperative tranesophageal echocardiogram (TEE), Pulse oximetry, serial arterial blood gases, introperative bronchoscopy, ventilatory peak pressures.Main ResultsA 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.ConclusionsTension pneumomediastinum was the likely etiologic factor for the acute hemodynamic collapse and should be considered in the differential diagnosis of intraoperative circulatory arrest.Copyright © 2016 Elsevier Inc. All rights reserved.

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