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An elderly female with peritoneal carcinomatosis of ovarian origin was resuscitated following a pulseless electrical activity (PEA) cardiac arrest. Prehospital intubation attempts were unsuccessful and the patient received bag-valve-mask ventilation. En route, paramedics reported increasing difficulty ventilating and the patient's abdomen became distended, tense and tympanitic. After emergency department arrival, a postintubation radiograph of the chest was obtained ( figure 1 ). Tension pneumoperitoneum was diagnosed and abdominal decompression with a supraumbilical needle was performed. Despite initial improvement of vital signs, recurrent...