A 3.5-year-old child developed a tight oesophageal stricture following
ingestion of caustic soda. At the end of the fourth anaesthetic for o
esophageal dilatation, laryngospasm and difficulty in mask ventilation
was followed by cyanosis, bradycardia, and cardiac arrest. Chest X ra
y showed a large pneumopericardium, which was immediately aspirated bu
t unfortunately resuscitation was unsuccessful. It was presumed that d
uring attempted manual ventilation of the lungs in the presence of a c
losed glottis, air had been accidentally forced into the pericardium t
hrough a small tear in the fragile oesophagus.