Recognizing correct placement of lines and tubes: critical care rads

Question 1

Correct placement of ETT

Answer 1

Tip > 5 cm from carina (carina is usually at level of T4). Affected about 2 cm by flexion and extension of neck.

Question 2

Correct placement of tracheostomy tube tip

Answer 2

1/2 way between stoma and carina (around T3). Not affected by flexion/extension of neck, unlike ETT.

Question 3

Correct placement of central venous catheter

Answer 3

Tip in SVC

Question 4

Correct placement of picc line

Answer 4

Tip in SVC

Question 5

Correct placement of swan ganz catheter

Answer 5

Tip in proximal R or L pulmonary artery

Question 6

Correct placement of pleural drainage tube

Answer 6

Anterior-superior for pneumothorax; posteroinferior for effusion

Question 7

Correct placement of pacemaker

Answer 7

Tip at apex of RV; others in RA and/or coronary sinus

Question 8

Correct placement of AICD

Answer 8

One lead in SVC and other in RV

Question 9

Correct placement of NG tube

Answer 9

Tip in stomach

Question 10

5 indictations for ETT

Answer 10

Assist ventilation Isolate trachea to permit control of airway Prevent gastric distention Provide direct route for suctioning Administer meds

Question 11

Most common malposition of ETT

Answer 11

Because of the shallower angle and wider diameter, into the right main bronchus leading to atelectasis or right sided tension pneumo.

Question 12

4 indications for tracheostomy

Answer 12

Patients with airway obstruction nat or above level of larynx In resp failure requiring long term intubation >21 days Airway obstruction during sleep apnea Paralysis of muscles affects swallowing or respiration

Question 13

Immediately after placing tracheostomy, look for signs of “whoops”, such as … ?

Answer 13

Signs that you perforated the trachea, like pneumomediastinum, pneumothorax, or subQ emphysema.

Question 14

Most common long-term complication of tracheostomies and most common location of this

Answer 14

Tracheal stenosis, which can occur at the entrance stoma, level of the cuff, or at the tip of tube, but is most common at the stoma.

Question 15

3 indications for central venous catheters

Answer 15

Venous access not suitable for peripherall venous administration (e.g., chemo) Measurement of CVP Maintain and monitor intravascular blood volume

Question 16

Most common malposition of central venous catheter

Answer 16

Often tips land in right atrium or internal jugular vein if inserted via subclavian vein. If in the RA, they could produce cardiac arrhythmia!!

Question 17

Next step after initial placement of CVC fails

Answer 17

Obtain a chest radiograph before trying insertion of the other side to avoid possibility of producing B/L pneumothoraces.

Question 18

Indications for PICC lines

Answer 18

Long term venous access (months) Administer rx such as chemo, abs Frequent blood sampling Because of small size, could be inserted into antecubital vein.

Question 19

2 reasons swan ganz catheters are used

Answer 19

Monitor hemodynamic status of critically ill patients Help in differentiating cardiac from non-cardiac pulmonary edema

Question 20

Most common significant complication of swan ganz catheter

Answer 20

Pulmonary infarction from occlusion of pulmonary artery by catheter or from emboli arising from catheter.

Question 21

Most commonly, malpositioning of chest tubes lead to what ?

Answer 21

Inadequate drainage, rather than serious complications. This includes times when its inadvertently placed in the major fissure.

Question 22

What type of device is this?

Question 23

What type of device is this?

Question 24

What happened here? (Black arrow)

Answer 24

NG tube (aka Dobbhoff tube) entered the trachea instead of the esophagus and its tip extends to the right lower lobe bronchus. Always get a CXR to confirm placement before you start feeding the pt through this tube for this reason! NG tubes are the most COMMONLY MALPOSITIONED of all tubes and lines. Ideally, it should be post-pyloric, in the duodenum or jejunum.