1. Pericardial Effusion Case Studies
Chelsea Wilson, MD; Emily Lipsitz, PA-C
Department of Emergency Medicine
Carolinas Medical Center & Levine Children’s Hospital
Charlotte, North Carolina
Michael Gibbs, MD, Faculty Editor
The Chest X-Ray Mastery Project™

2. Disclosures
 This ongoing chest X-ray interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 The goal is to promote widespread mastery of CXR interpretation.
 There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.

3. Process
• Many are providing clinical cases and presentations are then shared with
all contributors on our departmental educational website.
• Contributors from many Carolinas Medical Center departments, and now…
Brazil, Chile, and Tanzania.
• We will review a series of CXR case studies and discuss an approach to the
diagnoses at hand: PERICARDIAL EFFUSION.

4. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Chest X-Ray Presentations And Much More!

5. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

6. It’s All About The Anatomy!

7. Before Now
33-Year-Old With A Complex Malignancy Now Presents With Dyspnea.

8. Before Now
33-Year-Old With A Complex Malignancy Now Presents With Dyspnea.
The Cardiac
Silhouette Now
Looks Bigger And
More Globular

9. ED Bedside Ultrasound: Pericardial Effusion
*
*
*
*
33-Year-Old With A Complex Malignancy Now Presents With Dyspnea.

10. 78-Year-Old With
Hypertension And
Atrial Fibrillation
Presents With
Dyspnea.

11. Before Now
78-Year-Old With Hypertension And Atrial Fibrillation Presents With Dyspnea.

12. Before Now
78-Year-Old With Hypertension And Atrial Fibrillation Presents With Dyspnea.
The Cardiac
Silhouette Now
Looks Bigger And
More Globular.

13. *
*
*
*
*
*
A Chest CT Obtained To Rule Out
Pulmonary Embolus Instead Reveals
A Large Pericardial Effusion.
78-Year-Old With
Hypertension And
Atrial Fibrillation
Presents With
Dyspnea.

14. On Presentation Post-Procedure
78-Year-Old With Hypertension And Atrial Fibrillation Presents With Dyspnea.

15. On Presentation
Pericardiocentesis
 300 cc of fluid removed
 Cardiac silhouette smaller
Post-Procedure
78-Year-Old With Hypertension And Atrial Fibrillation Presents With Dyspnea.

16. Thoughts On Pericardial Effusions
• Think about the possibility of a pericardial effusion in patients with
chest pain, dyspnea, syncope or pre-syncope.
• Slowly accumulating pericardial effusions stretch the pericardium and
enlarge the cardiac silhouette on CXR. A careful comparison with old
CXRs is helpful.
• Rapidly accumulating pericardial effusions (e.g.: stab wounds, blunt
trauma) typically ARE NOT associated with cardiac silhouette
enlargement on CXR.
• The liberal use of bedside point-of-care ultrasound is diagnostic.

17. See You Next Week!Chest X-Ray Two Weeks Ago
History Of
Pacemaker
Placement At An
Outside Facility
Two Weeks Ago.

18. History Of
Pacemaker
Placement At An
Outside Facility
Two Weeks Ago.
Now Presents To
The CMC ED
With Weakness
And Dyspnea.

19. Large Pericardial Effusion Due To
Pacemaker Lead Perforation Of The Right Ventricle.
History Of
Pacemaker
Placement At An
Outside Facility
Two Weeks Ago.
Now Presents To
The CMC ED
With Weakness
And Dyspnea.

20. History Of Pacemaker Placement At An Outside Facility Two Weeks Ago.

21. History Of Pacemaker Placement At An Outside Facility Two Weeks Ago.
ED Bedside ECHO: Large Pericardial Effusion (*)
Cardiac
Apex
***
*
**

22. Pericardiocentesis And 1300 cc Of Bloody Fluid Is Removed
History Of
Pacemaker
Placement At An
Outside Facility
Two Weeks Ago

23. Prospective observational study of 968 patients undergoing heart
rhythm device implantation or upgrade who underwent echo before and
24h after operation:
• Pericardial Effusion documented in 98 patients (10%)
• 1.5% (n=14) of whom progressed to cardiac tamponade requiring
pericardiocentesis in 86% (n=12) and surgical treatment in 14% (n=2)

24. Risk Factors: Female gender and antiplatelet therapy
Protective Factor: Previous cardiac surgery
Circulation Journal Vol.77, pp 975-981, April 2013

25. • Utilization of ventricular and atrial screw—in leads were associated with an
increase risk of post-procedural Pericardial Effusion (PE)
• Specifically an atrial active fixation lead was used in 86% of patients who
subsequently developed large PE with tamponade physiology
Circulation Journal Vol.77, pp 975-981, April 2013

26. 60-Year-Old With
Dyspnea.
Enlarged Cardiac Silhouette.

27. 60-Year-Old With Dyspnea. ED Bedside ECHO: Pericardial Effusion

28. 27-Year-Old
With One
Week Of
Chest Pain
and Dyspnea
Transferred
From An
Outlying
Hospital
After Chest
CT

29. 27-Year-Old With One Week Of Chest Pain and Dyspnea.

30. 27-Year-Old With One Week Of Chest Pain and Dyspnea.
Chest CT Obtained: Large Pericardial Effusion

31. 27-Year-Old
With One
Week Of
Chest Pain
and Dyspnea.
ECHO

32. 27-Year-Old
With One
Week Of
Chest Pain
and Dyspnea.
Pericardial Effusion: Pericardiocentesis = 250 cc Straw-Colored Fluid
Cardiac
Apex
**
*
*

34. Pericardial effusions size is based on simple semiquantitative echocardiographic
assessment of cardiac effusion measured in mm in diastole
European Heart Journal, Vol. 34, pp 1186-1197, 2013

35. 8 Months Ago Today
27-Year-Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Dyspnea.

36. Massive Pericardial Effusion
27-Year-Old Male
With ESRD On
Hemodialysis
Presents With
Two Weeks Of
Progressive
Dyspnea.

37. Massive Pericardial Effusion
27-Year-Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Dyspnea.

38. Massive Pericardial Effusion
*
*
*
*
**
* *
*
*
27-Year-Old Male With ESRD On Hemodialysis Presents With Two Weeks Of Dyspnea.

39. Pericardial
Drain In Place
2.7 Liters Of Fluid Removed!
27-Year-Old Male
With ESRD On
Hemodialysis
Presents With
Two Weeks Of
Progressive
Dyspnea.

40. 27-Year-Old Male
With ESRD On
Hemodialysis
Presents With
Two Weeks Of
Progressive
Dyspnea.
3 Months After
Pericardial
Drainage.

42. Three variables were independently predictive of pericardial effusion in late-stage CKD patients:
• Heart rate at admission, serum potassium and corrected calcium level
• Presence of any one of these abnormalities:
demonstrated 66% specificity and 55% sensitivity in identifying patients with pericardial effusion
• Presence of any two of these abnormalities:
demonstrated 97% specificity and 18% sensitivity in identifying patients with any pericardial effusion
Clinical Cardiology, Vol. 41, pp 660-665, 2018

43. 73-Year-Old
Female With
Progressive
Dyspnea

44. 73-Year-Old
Female With
Progressive
Dyspnea
Massive Pericardial Effusion

45. 73-Year-Old
Female With
Progressive
Dyspnea
73-Year-Old
Female With
Progressive
Dyspnea
*
*
*
*
*
Massive Pericardial Effusion

46.  Rapidly accumulating pericardial effusions cause swift increases in intrapericardial
pressure and tamponade physiology.
 Slowly accumulating pericardial effusions gradually distend the pericardium and
symptoms can be delayed.

47. If You Have Interesting Cases Of Pericardial Effusion, We Invite You
To Send A Set Of Digital PDF Images And A Brief Descriptive Clinical History To:
michael.gibbs@atriumhealth.org
Your De-Identified Case(s) Will Be Posted On Our Education Website And You
And Your Institution Will Be Recognized!