Sajith et al report a case of oesophagogastric injury and massive pneumoperitoneum after out-of-hospital intubation by paramedics.1 The patient had received 25 min of cardiopulmonary resuscitation (CPR) with chest compression by the LUCAS device before restoration of cardiac output. Unfortunately, the circumstances of the initial oesophageal intubation are not described in detail. Oesophageal, gastric or even laryngeal ruptures after oesophageal insertion of medical devices (endotracheal tube, ECHO probe, Combitube, nasogastric tube) is a recognised but rare event.2^–7 This is usually caused by physical injury from repeated blind insertion or difficult intubation attempts rather than the inflation pressure or the cuff of the device.

The maximal inflation pressure of an AMBU bag via an endotracheal tube is 45 cm H₂O.8 The power exerted by a LUCAS device onto the chest is 530–600 N/m (Medtronic, Watford, UK distributors for Jolife AB, Lund, Sweden, manufacturers of LUCAS; personal communication), a multiple of the force exerted by a hand and a bag-valve-mask. The force of chest compression and its relation to chest injuries has previously been described.9 10 It seems likely that the perforation with subsequent …