Pneumopericardium

Background

Air in the pericardium
Generally secondary to connection between pericardium and pleural cavity, bronchi, or GI tract
Most often found following trauma, severe asthma exacerbation, strangulation, or forceful drug insufflation

Causes of pneumopericardium

GI malignancy
PUD
Esophageal diverticula
Barotrauma
- Mechanical ventilation
- Vigorous bag-mask ventilation
- SCUBA diving/rapid ascent
- Drug insufflation (especially associated with crack cocaine)
Asthma
Valsalva
Infection pericarditis with gas-producing bacteria
Thoracic surgery
Pericardial fluid drainage
Blast injury
Blunt or penetrating thoracic trauma
Neonatal respiratory distress syndrome

Clinical Features

May present with tamponade physiology depending on size
Other features include:
- Dyspnea
- Cyanosis
- Chest pain
- Pulsus paradoxus
- Bradycardia
- Tachycardia
- May have subcutaneous emphysema
- May have succussion splash if there is also a pericardial effusion
- May have Hamman crunch

Differential Diagnosis

Thoracic Trauma

Airway/Pulmonary
Cardiac/Vascular
- Cardiac injury
  - Blunt cardiac injury
    - Cardiac contusion
    - Commotio cordis
  - Penetrating cardiac injury
  - Cardiac tamponade
- Traumatic aortic transection
Musculoskeletal
Other

Evaluation

Lucent line around the heart extending up to the main pulmonary arteries (solid white arrows). Air may accumulate inferior to the cardiac shadow, which crosses the midline above the diaphragm (i.e. continuous diaphragm sign)

Pneumopericardium on chest x-ray after battery button ingestion.

CT showing tension pneumopericardium, subcutaneous emphysema, bilateral pneumothorax, and a compressed heart.

Assess for underlying cause
CXR[1]
- Heart partially or completely surrounded by gas
- Pericardium sharply outlined by gas density on either side
- Continuous diaphragm sign may be present (diaphragm seen continuously across the midline
PoCUS[2]
- Bright spots moving along pericardial layer during diastole
- Comet-tail artefacts extending across heart and disappearing during systole

Management

Treat underlying cause
Conservative management usually sufficient (usually self-resolves)
If tamponade physiology, may require pericardiocentesis
- If communicating pneumothorax, chest tube placement may resolve both[3]

Disposition

If underlying cause is stable and patient is asymptomatic, may discharge home
Most patients will require admission for treatment of underlying cause

References

Bell, D. et al. Pneumopericardium. Radiopaedia.org. Retrieved March 8 2019.
Bobbia et al. (2013). Pneumopericardium diagnosis by point-of-care ultrasonography. Journal of Clinical Ultrasound, 4(14), May 2013.
Braiteh, F., and Malik, I. (2008). Pneumopericardium. Canadian Journal of Emergency Medicine, 179(10).

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[1] Bell, D. et al. Pneumopericardium. Radiopaedia.org. Retrieved March 8 2019.

[2] Bobbia et al. (2013). Pneumopericardium diagnosis by point-of-care ultrasonography. Journal of Clinical Ultrasound, 4(14), May 2013.

[3] Braiteh, F., and Malik, I. (2008). Pneumopericardium. Canadian Journal of Emergency Medicine, 179(10).