0:00

This is an ER patient who presented to

0:03

Radiology for PA and lateral view of the chest after

0:06

two placement to confirm adequate placement.

0:09

And so here are job is to make

0:12

sure that the lines and tubes are projecting in

0:15

the right spaces oftentimes. These are done

0:18

as portable examinations, and it may be hard to

0:21

actually low collides.

0:24

The depth of a line without the lateral View and

0:27

so in those situations, I'll usually talk about how and

0:30

where a line or two projects versus

0:33

having a lateral and an AP

0:36

where you can tell much better where it's actually

0:39

placed. So that being said, let's take a look at this examination

0:42

here.

0:44

Where you do see lines and twos monitoring wires that are

0:47

overlying the patient. That's not why we're here.

0:50

We're actually looking at the course of the autographic tube

0:54

that's in place, which you can see coursing along the esophagus

0:57

which is a normal expectation and

1:00

you obviously want to see the weighted tip fall

1:03

below the diaphragm. However, it's moving off to

1:06

the right side and it's not really following the normal and

1:09

expected view which would be to curve toward the GE Junction and

1:12

to land in the stomach. So this is the gastric bubble

1:15

here and we're heading in the wrong direction. So

1:18

if we do a little bit of window and leveling, we'll

1:21

see the course a little bit better and this

1:24

is actually going into the airway along the

1:27

trachea along here.

1:29

Down along the very slight angle into the

1:32

right lower lobe bronchus and

1:35

his wedged very peripherally in the

1:38

lower lobe of the right lung now

1:41

you may or may not believe me, but we've got a lateral view so

1:44

that we can actually confirm this.

1:46

And what we see again is the endotrachal tube

1:49

in the airway and it's coursing posteriorly

1:52

away from the stomach which the

1:55

G Junction should be here and it's wedged here in the right lower lobe.

1:59

So this is obviously not ideal in terms of the placement.

2:02

You want to call the clinicians immediately and

2:05

have them remove completely the tube

2:08

and start again. Obviously. If we

2:11

were to leave it here the patient were to get fed will have a massive

2:14

aspiration event on our hands, which is not ideal for

2:17

the patient.

2:18

We want to take a look at the other aspects of the

2:21

radiograph. So again take a look at the lung Fields. The left

2:24

lung field is clear. There's some scatter atelectasis

2:27

on the right side. The mediastinum

2:30

looks fine. There's unfolding of

2:33

the aorta here. We see sternotomy wires,

2:36

and the Heart itself is not enlarged.

2:40

The bones will also review to make sure that there's

2:43

no obvious lesion. There's no fracture even

2:46

though we're doing this for a tube check. We

2:49

want to make sure that we're again consistently looking for any and everything

2:52

that could be and should be reported below the

2:55

diaphragm and then the soft tissues so really in

2:58

this patient with a question of line and

3:01

two placement the oral gastric tube

3:04

is

3:05

Ectopically placed in the right lower lobe bronchus

3:08

and really kind of wedged in the lung. We want to

3:11

get that removed immediately.

3:13

We do have some follow-up cases that are very similar. So oftentimes

3:16

following the path of least resistance. The

3:19

right lower lobe is the recipient of these errantly

3:22

a placed tubes, but you

3:25

can also see them on the other side.

3:28

So this is a case again done for the same reason

3:31

where the oral gastric tube heads down

3:34

the left main stem Broncos and you might say well it's heading

3:37

to the left and we think that it's actually in the

3:40

stomach and it just needs to be advanced.

3:42

However, when you look at the angle and where

3:45

the esophagus should run it doesn't

3:48

really cross midline and come into the stomach right here,

3:51

but if you look at the airway, you can actually see the left lower lobe

3:54

bronchus here and that's sitting and projecting

3:57

over that area.

3:58

So if we look at it on the edge enhanced views

4:01

again, you can see that it's really crossing midline

4:04

a little bit too early. And this is probably also wedged

4:07

in the left lower lobe. We don't have a lateral

4:10

on this one. So we did alert the clinician to remove

4:13

the tube and to start fresh.

4:16

In terms of looking at some of the complications and things

4:19

that can happen. Again. We have a similar

4:22

case with a patient who has been

4:25

intubated and has had an

4:28

oral gastric tube placed and the requisition was for

4:32

Are we in the right spaces? So again, you don't want

4:35

to get distracted by things that are shiny and new or

4:38

things that are just shiny like all this contrast material

4:41

that's been aspirated here. But you do want to

4:44

just go through methodically and ask yourself the question each and

4:47

every time am I missing something what about this? So

4:50

kind of going through systematically?

4:54

Looking at lines and tubes. There's an endotracheal tube. That's right along here.

4:58

And when we look at and try to window and level into where the Karina

5:01

is, this is really sitting right at the level of the Purina and

5:04

probably should be retracted. So the recron is

5:07

sitting right here the tube is sitting right here. So there's less

5:10

than a centimeter distance there. Ideally you

5:13

want to have it a little bit higher. So it would recommend retraction of

5:16

the endotracheal tube. This patient also

5:19

has an oral gastric tube, which as we follow it

5:22

along the course. It doesn't really hug the right side. The

5:25

patient is a little angulated. So you kind

5:28

of just follow it for a while. It's heading really far to the

5:31

left.

5:32

Well before you get below the diaphragm, we would expect

5:35

the GE Junction and following it around it leaves

5:38

the edge of the film. So we lose it. But the weighted

5:41

tip comes back into the field of view. And while this is

5:44

below the diaphragm, which ultimately you want to get below the

5:47

diaphragm. This is really perceptual. And remember that

5:50

on this frontal view the diaphragm which is cup shaped is

5:53

actually kind of diving deep right here. And if

5:56

you follow the orientation and the projection pathway

5:59

of the oral gastric tube, it's in the

6:02

long. It's following the airway right here. It's following the left lower low

6:05

bronchus and it's wedge deep deep deep into the

6:09

posterior sulcus on the left and it's

6:12

sitting below the diaphragm. In fact, it is sitting in the loan.

6:15

So again, we'd want to call very quickly and tell

6:18

them to remove this. We'd also want to make sure that because of

6:21

the topic placement we're looking for any evidence of

6:24

complication so they didn't feed the

6:27

patient on this view. So I think some of the contrast material that we see along

6:30

is not from this event. They

6:32

Have not gotten a Radiologists involved in reviewing

6:35

this case before and they fed without getting it

6:38

checked. But we also want to take a look at the lungs

6:41

and as we do that one thing that I'll

6:44

bring to your attention. Is this line along here.

6:47

And this patient also has a pneumothorax which as a

6:50

complication for this placement. They've probably

6:53

moved through parenchyma and out into the pleura

6:56

and we now have

6:58

a pneumothorax. There's no evidence of tension the right

7:01

side of the lung looks fine. We've talked about the basilar opacities

7:04

the heart and mediastinum given

7:07

the portable technique look fine take a look at the bones and

7:10

they're fine as well as a soft tissues.

7:13

Just as a edge enhanced image. It's

7:16

the same image. You can again see the pneumothorax along here.

7:19

You see the tube coming

7:22

down and really in the lung while it

7:25

projects below the diaphragm. It's actually just wedged within the lung and

7:28

you can see how low the endotracho tube tip

7:31

is in comparison to the Karina and it's

7:34

really sitting there. So both the endotracheal tube and the oral

7:37

gastric tube need to be adjusted the oral

7:40

gastric tube needs to be removed completely and

7:43

replaced the endotracho tube can

7:46

probably just do with the retraction of about three centimeters to

7:49

be an optimal positioning and then the patient should be reimaged

7:52

to make sure that everything is fine. And we do have that

7:55

follow-up examination and here we can see that the

7:58

oral gastric tube has been removed. So it's

8:01

no longer sitting in the field. The corona is here and

8:04

the tip of the endotracheal tube is here. So that's now adequately

8:07

placed and we can better see that that pneumothorax is

8:10

actually real and so now

8:13

Going to be managing a different issue, which is this pneumothorax that

8:16

was secondary to actrogenically placed oral

8:19

gastric tube into the lung and through

8:22

the pleura they'll be managing this so you'll be getting another

8:25

X-ray on this patient to see after the chest tube

8:28

gets placed at the lung is re-expanded and then they'll get the

8:31

oral gastric tube placed adequately.

8:33

But that's a conversation for another time. But here are some

8:36

examples again of what can happen when lines and tubes

8:39

are not placed adequately. I do have one other example to

8:42

share with you and this is on a CT. So

8:45

if you look at the scout view here again, lots of information on

8:48

the Scout this patient is covered in lots of

8:51

lines and tubes and what we see here are what

8:54

looks like in terms of its configuration a

8:57

swan against catheter. It doesn't

9:00

look like it's been extended distally enough to do any wedge

9:03

pressures, but it's probably sitting in the pulmonary artery.

9:06

There are a number of monitoring wires that are overlying the

9:09

patient. There's a catheter that's sitting

9:12

in the IVC along here. There's also

9:15

an ng2 that's sitting and projecting

9:18

over the stomach the patient may be

9:21

intubated as well. And so a lot of that stuff is

9:24

hard to see with the great overlap, but the CT will

9:27

help us sort this out. So really we'll go

9:30

through really quickly where our lines and tubes are located and look

9:33

for

9:33

Complications some of the other findings that we're not

9:36

going to spend a lot of time are and here in the right lung

9:39

field. It looks like there's an opacity and that may

9:42

be related to aspiration or pneumonia and then below the diaphragm. There's

9:45

lots of dilated small bowel Loops

9:48

that are gaseously dilated so

9:51

Let's take a look at where our lines

9:54

and tubes are now first. Just bring your attention to the endotracheal

9:57

tube.

9:59

Which from a perspective of the Carina is

10:02

adequately located. We also mentioned and observe

10:05

here the orogastric tube maintaining its

10:08

course in the esophagus.

10:11

And it moves below the diaphragm and into the stomach which is where we

10:14

want it to exist and to live.

10:17

We talked about the catheter in the IVC and

10:20

that's here.

10:22

And then let's take a look at the swan.

10:26

So we've got one other Central Phoenix catheter here, which is

10:29

coming down.

10:32

And we're following it back out.

10:36

And it kind of ends right here.

10:38

So sometimes it can be hard to kind of keep track of your lines and tubes

10:41

and so let's just be clear in terms of which ones

10:44

we're looking at. So we've got two that are coming in right here. And so

10:47

let's maybe start with the left again just to make sure that we're

10:50

looking at the correct one.

10:52

And this is the left.

10:54

the one that's more medial

10:57

Okay, and that one ends right here. So that one is the central

11:00

venous catheter that's coming from the left and that

11:03

one is kind of sitting over in this area here.

11:06

And that one is placed really in the right atrium. So

11:09

that could be pulled back a little bit to the SVC ra

11:12

right atrial juncture for

11:15

optimal placement. The one that's coming in from the right,

11:18

which is this one here is the one

11:21

that we're seeing projecting looping around into the main

11:24

pulmonary artery. So the swan gants

11:26

And that's this one right here coming through and

11:29

the thing that I'm observing in the track here is all this

11:32

gas that's sitting in the pericardium associated with

11:35

an along the line of where the swan Gantz

11:38

catheter is.

11:39

Again, lots of gas that's sitting around here and it's

11:42

sitting here in the pulmonary artery.

11:45

Now normally these do not have gas associated with

11:48

them. And so certainly they are placing this there's an opportunity

11:51

for puncture.

11:54

And so I would again make sure that this is

11:57

you know articulated to the clinical team immediately. We do

12:00

see a pericardial effusion that's beginning and when we

12:03

measure that fluid that's here.

12:05

It's not just simple fluid measuring one

12:08

or two houndsville units, but it's measuring about

12:11

less than 20 so it's not completely simple

12:14

all those low density. It's not completely heterogic but it's very concerning

12:17

given the gas and the trajectory of this line that

12:20

there's been again movement of

12:23

this catheter outside of its intended area and

12:26

that the gas is a secondary complication. So

12:29

we want to make sure that we report that there's some other findings that

12:32

you may notice in the periphery that we're not going to really talk about but

12:35

there's societies there's some gas here in the

12:38

radicals. Those are not necessary germane to our

12:41

discussion around the lines and tubes and being able to understand where

12:44

those are. There's also the Aerospace consolidation in

12:47

the right lower loan that we mentioned before

12:50

obviously want to remember to look at your soft tissues

12:53

your bones. Look at the media style structures. Look for any lymph node.

12:56

If you've given contrast which we did in this

12:59

case you want to look for any evidence of vascular abnormality. But

13:02

again, these were cases that kind of

13:05

took us through

13:06

Many things that can happen with lines and tubes that

13:09

go amiss or a rye in their intended

13:12

course, so hopefully you'll keep this in mind the next time you're looking

13:15

at lines and tubes question mark on the

13:18

requisition.