Introduction

The laryngeal mask airway has revolutionised airway management in anaesthesia and seems set to do so for resuscitation. Its appeal is based largely on less need for skill and training than with either facemask or an endotracheal tube.1 All paramedic crews and emergency departments have the laryngeal mask as standard equipment, and its popularity in hospital resuscitation is growing. Gas leak and gastric inflation are well recognised complications of positive pressure ventilation with the laryngeal mask.2 3 We present a case in which the use of a laryngeal mask during an out of hospital cardiac arrest led to massive gastric dilation, gastric rupture, and a tension pneumoperitoneum.

Case history

A 71 year old man with a history of angina and hypertension developed chest pain and collapsed in a shopping centre. A bystander performed cardiopulmonary resuscitation for about seven minutes until a paramedic unit arrived. A paramedic inserted a laryngeal mask airway and started hand ventilation at a rate of 12 breaths/min with a 1600 ml self inflating resuscitation bag with reservoir and oxygen supply set to 12 litres per minute. Normal chest movement and auscultation of the chest confirmed correct placement of the mask. The paramedic then resumed chest compression at a rate of 100 per minute synchronous with ventilation. Three lead electrocardiography showed ventricular fibrillation. A single DC shock of 200 J restored sinus rhythm, with a good cardiac output after about five minutes of the paramedic starting cardiopulmonary resuscitation. The patient was then transferred to our emergency department; although some respiratory effort was noted, this was considered inadequate by the paramedic, who ventilated the patient by hand throughout the 25 minute journey to hospital. The paramedic saw no episodes of retching, coughing, or vomiting.

On the patient's arrival in the emergency department, doctors noted the following in the …