Lines and tubes

Question 1

PICC line

Answer 1

• It is inserted through the peripheral veins (i.e. basilic vein, brachial vein, cephalic vein, or axillary veins)
• Correct placement is in the tip of the SVC
• It may accidentally end up in the internal jugular or in the the right atrium/ventricle

Question 2

Endotracheal tube

Answer 2

• Intubated through the oral cavity into the trachea
• Correct placement is ~5 cm above the carina, which is roughly halfway between the carina and the medial clavicle
• It is most commonly misplaced into the R or L main bronchi

Question 3

Chest tubes

Answer 3

• Placed via an incision just above a rib and inserted carefully towards pneumothorax/effusion/hematoma
• Correct placement of the tip is at the anterosuperior aspect for air and the posteroinferior aspect for fluid. The side-holes, marked by a radiopaque line, should not be outside of the chest wall.
• May be misplaced into the lung fissures, parenchyma, or mediastinum

Question 4

Swan-Ganz catheter

Answer 4

• Inserted through large veins (femoral, internal jugular, subclavian)
• Correct placement is in the proximal R or L pulmonary artery, ~2 cm from the hilum
• May be misplaced into the SVC, IVC, RA, RV, pulmonary trunk, or peripheral pulmonary arteries

Question 5

Cardiac pacemakers and ICDs

Answer 5

Correct placement is at least one lead at the apex of the right ventricle. Other leads may be in the SVC or RA.

The image shown has an ICD with leads in the RA and RV.

Question 6

Dubbhoff tubes/Feeding tubes

Answer 6

• Nasal cavity -> pharynx -> stomach -> duodenum
• Correct placement is with the tip in the 2nd or 3rd portion of the duodenum
• Very commonly misplaced into the stomach, but may also be misplaced into the trachea or lung

Question 7

NG tubes

Answer 7

• Nasal cavity -> pharynx -> stomach -> duodenum
• Correct placement is with the breaks/side holes extending about 10 cm into the stomach beyond the GEJ
• Commonly misplaced in the esophagus or the bronchi

Question 8

G tubes

Answer 8

• Provides direct trans-abdominal access to the stomach
• Correct placement is in the stomach with the balloon also in the stomach. When correctly placed, gastrographin shows the stomach and outlines the balloon.

Question 9

Central venous catheters

Answer 9

• Most commonly placed via internal jugular or subclavian vein, rarely femoral
• Correct placement is towards the medial end of the clavicle and descending down into the SVC along the spine