A 55 year old man is brought in by EMS with chest pain. He finds it difficult to lay flat, and is diaphoretic on exam. He has a history of esophageal cancer that is in remission for 5 years. His ekg is normal, and his vital signs are as follows: T 99°F (36.67°C) HR 110, BP 98/60, RR 35, 90% on RA. On auscultation, you hear the following:
You subsequently perform an A4C view of his heart, and this is the view you obtain.
What does the clips show? What is the diagnosis? (Click the button for the answer!)
The bedside ultrasound clip shows a shallow, and angled view of the heart from near it’s apex. The view is obscured by air, but the movement of the air is in keeping with the beat of the heart, not the patient’s respirations. X-ray confirmed the pneumopericardium (as seen below). He was transferred to the thoracic surgical team, and a pericardial window was opened. The patient was subsequently discharged after an uneventful hospital stay.
Pneumopericardium is most often reported to be traumatic in nature,1 as well as non-traumatic pathology such as esophageal perforation.2
Common sonographic findings of pneumopericardium include comet-tail artifacts inside the pericardium, varied visualization of the heart dependent on the respiratory cycle (as was seen in our case),3 and a-lines within pericardium, obscuring the view of the heart.2
The various examples of pneumopericardium are seen below:
Case Courtesy of David Kirschner, MD Peer Review by Jacob Avila, MD and Terren Trott, MD
Md Noor J, Eddie EA. Cardiac A-lines in fast scan as a sign of pneumopericardium. Ultrasound J. 2019; 11(1):7. [PMID: 31359168]
Derr C, Drake JM. Case report Esophageal rupture diagnosed with bedside ultrasound. American Journal of Emergency Medicine. 30: 2093e1-2093.e3. 2012. [PMID: 22386338]
Bobbia X, et al. Pneumopericardium diagnosis by point-of-care ultrasonography. Journal of Clinical Ultrasound. 41:235-237. 2013. [PMID: 22585663]