Bilateral pneumothorax complicated by extraperitoneal air.

To cite: van Beek D, Fernandes N, Hazekamp M, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014205463 DESCRIPTION An 11-month-old male child with Down syndrome was admitted to the pediatric intensive care unit (PICU) after an uncomplicated correction of his complete atrioventricular septal defect. On postoperative day 5, there was an acute incident after administration of an enema which started with a decrease in tidal volumes. Eventually, there was no air entry, resulting in desaturation and subsequently a bradycardia with no cardiac output. Cardiopulmonary resuscitation was started. The abdomen of the patient was distended. The differential diagnosis included tension pneumothorax and abdominal perforation. A bilateral needle decompression was performed immediately. This temporarily resulted in improved ventilation and disappearance of the abdominal distention. The X-ray showed a bilateral pneumothorax with air located in the anterior extraperitoneal space in the abdomen (figure 1). The cardiothoracic surgeon inserted pleural drains bilaterally, resulting in lasting improvement. The patient was discharged from the PICU in good clinical condition 10 days after the incident. Extraperitoneal air without intraperitoneal air is very rare and can easily be mistaken for air in the intraperitoneal cavity. It results from extravasation of air from the thoracic cavity to the area between the parietal peritoneum and the transversalis fascia. This route might have resulted from the mediastinal drain that was in place the first postoperative days.