In this EM Cases, Best Case Ever podcast Rajiv interviews Dr. Allan Shefrin, a pediatric emergency physician at The Children’s Hospital of Eastern Ontario where he is also PEM division lead in point-of-care ultrasound. They discuss a case of tension hydrothorax in a school-aged child and the role of POCUS in PEM.

Produced by Rajiv Thavanathan, Podcast editing by Richard Hoang,

Blog post written by Tanishq Suryavanshi, edited by Anton Helman, February, 2020

What is tension hydrothorax?

Tension hydrothorax is a massive pleural effusion presenting with hemodynamic abnormalities secondary to mediastinal compression. Massive is defined as occupying greater than 2/3rd of the hemithorax, with 10% of pleural effusions being massive.

Causes of tension hydrothorax

Tension hydrothorax can result from a number of causes, including: Trauma, chylothorax, pancreatitis, cirrhosis, parapneumonic effusions, and autoimmune diseases, but by far the most common cause is malignancy.

Indications for tube thoracostomy for hydrothorax

  • Associated pneumothorax or hemothorax
  • Respiratory and/or hemodynamic instability
  • Grade III–V parapneumonic effusions

While there are no absolute contraindications to tube thoracostomy in patients with tension hydrothorax, adherence of the lung to the chest wall and history of pleurodesis are relative contraindications, in which case a thoracentesis may be indicated.

Case Report of Tension Hydrothorax in Am J Emerg Med (2018)

Dr. Shefrin’s Paper on the Role for POCUS in PEM Training

Drs Shefrin and Thavanathan have no conflicts of interest to declare.


  1. Fuchs S, Terry M, Adelgais K, et al. Definitions and assessment approaches for emergency medical services for children. Pediatrics. 2016;138(6). doi:10.1542/peds.2016-1073
  2. Vinck EE, Garzón JC, Peterson T, Villarreal R, Cabrera L, Van den Eijnden L. Tension hydrothorax: Emergency decompression of a pleural cause of cardiac tamponade. Am J Emerg Med. 2018;36(8):1524.e1-1524.e4. doi:10.1016/j.ajem.2018.04.041
  3. Lewis D, Rang L, Kim D, et al. Recommendations for the use of point-of-care ultrasound (POCUS) by emergency physicians in Canada. CJEM. 2019;21(6):721-726. doi:10.1017/cem.2019.392
  4. Shefrin AE, Warkentine F, Constantine E, et al. Consensus Core Point-of-care Ultrasound Applications for Pediatric Emergency Medicine Training. AEM Educ Train. 2019. doi:10.1002/aet2.10332