Emergency Department Echocardiography Demonstrates Large Pericardial Effusion and Pendulous Cardiac Motion in Patient with Shortness of Breath and Electrical Alternans

A 49-year-old female with a history of congestive heart failure, breast cancer, and chronic obstructive pulmonary disease presented to the emergency department with 3 weeks of progressive shortness of breath and orthopnea. She was found to be hypoxic and in respiratory distress by paramedics. Examination revealed a middle-aged woman sitting upright and speaking short sentences. Her hypoxia was corrected with facemask oxygen, and vitals were otherwise unremarkable. Breath sounds were clear and heart sounds were regular but distant. She was noted to have extensive symmetric lower extremity edema and jugular venous distention. An electrocardiogram demonstrated electrical alternans (Figure 1). Laboratory work, including troponin and B-type natriuretic peptide, was essentially unremarkable. Bedside echocardiography was then performed by the emergency medicine resident (available as online Data Supplements at http://www.blackwell-synergy.com/doi/suppl/10.1111/j.1553-2712.2008.00140.x/suppl_file/acem_140_sm_VideoClipS1.mov and http://www.blackwell-synergy.com/doi/suppl/10.1111/j.1553-2712.2008.00140.x/suppl_file/acem_140_sm_VideoClipS2.mov), demonstrating a large pericardial effusion with swinging cardiac activity (Figures 2 and 3). Cardiology and cardiothoracic surgery were consulted. The patient was admitted and received a pericardiocentesis followed by a pericardiectomy for persistent effusion. Her workup for malignancy, infection, and other causes was ultimately negative, and she was discharged the following week.

Figure 1.  Electrocardiogram showing electrical aternans.

Figure 2.  Large pericardial effusion: long-axis view.

Figure 3.  Large pericardial effusion: short-axis view.