ICU Lines and Tubes

ICU RadiologyICU Radiology

Lines, Tubes, and OtherThingsLines, Tubes, and OtherThings

Adam Guttentag MD

Endotracheal TubessEndotracheal Tubess

Positioning:Positioning:

Below thoracic inletBelow thoracic inlet

> 2 cm above carina (carinaat T5-T7 > 95%)> 2 cm above carina (carinaat T5-T7 > 95%)

Tube tip moves with flexionand extension of neckTube tip moves with flexionand extension of neck

Balloon cuff properlyinflatedBalloon cuff properlyinflated

Tube tip centered intracheal lumenTube tip centered intracheal lumen

atx RUL complete with#31F30.JPG 00031501Macintosh HD BA578DA3:

Endotracheal TubesEndotracheal Tubes

Complications:Complications:

Traumatic intubationTraumatic intubation

Pharyngeal/esophageal intubationPharyngeal/esophageal intubation

High position laryngeal damageHigh position laryngeal damage

Low position carinal irritation,RMSBintubationLow position carinal irritation,RMSBintubation

Granulation tissueGranulation tissue

Tracheomalacia, tracheal stenosisTracheomalacia, tracheal stenosis

Fistula to: innominate artery esophagusFistula to: innominate artery esophagus

All tracheal tubes bypass normal defenses and allowcolonization of tracheobronchial tree.All tracheal tubes bypass normal defenses and allowcolonization of tracheobronchial tree.

ETT balloon cuff.jpg 00031501Macintosh HD BA578DA3:

Endotracheal TubesEndotracheal Tubes

ct stenosis.JPG 0003151EMacintosh HD BA578DA3:

Endotracheal TubesEndotracheal Tubes

$G:\new photos\tracheal stenosis from tracheostomy\axial.JPG$

$G:\new photos\tracheal stenosis from tracheostomy\coro.JPG$

$G:\new photos\tracheal stenosis from tracheostomy\DSCN0041(6).JPG$

Endotracheal TubesEndotracheal Tubes

Tracheostomy TubesTracheostomy Tubes

Tube should be centered intrachea and have enoughlength.Tube should be centered intrachea and have enoughlength.

Look forpneumomediastinum,cervical emphysemaLook forpneumomediastinum,cervical emphysema

Small leak around tube OKimmediately post-opSmall leak around tube OKimmediately post-op

Atx LLL A.JPG 00031501Macintosh HD BA578DA3:

Nasogastric TubesNasogastric Tubes

Side-hole in stomach for properfunctionSide-hole in stomach for properfunction

Complications:Complications:

Traumatic insertionTraumatic insertion

Tracheal or bronchial placementTracheal or bronchial placement

»High risk of ptx»High risk of ptx

to RLL via esoph loop.JPG 00031518Macintosh HD BA578DA3:

to LLL.JPG 00031518Macintosh HD BA578DA3:

to RLL via esoph.JPG 00031518Macintosh HD BA578DA3:

Nasogastric tubeNasogastric tube

to pleura.JPG 00031518Macintosh HD BA578DA3:

Nasogastric tubeNasogastric tube

Dobbhoff TubeDobbhoff Tube

Placement beyondpylorus allowscontinuous feedingPlacement beyondpylorus allowscontinuous feeding

Stylet can perforatetube if re-advancedStylet can perforatetube if re-advanced

to jejunum.JPG 00031513Macintosh HD BA578DA3:

HH pre.jpg 00031513Macintosh HD BA578DA3:

RLL bronchus via HH.jpg 00031513Macintosh HD BA578DA3:

Dobbhoff TubeDobbhoff Tube

coils in neck .jpg 00031513Macintosh HD BA578DA3:

Dobbhoff TubeDobbhoff Tube

Dobbhoff TubeDobbhoff Tube

to RLL via LMSB.JPG 00031513Macintosh HD BA578DA3:

Dobbhoff TubeDobbhoff Tube

to pleura.JPG 00031513Macintosh HD BA578DA3:

Dobbhoff TubeDobbhoff Tube

stylet out.JPG 00031513Macintosh HD BA578DA3:

Central Venous CathetersCentral Venous Catheters

Best position:Best position:

Central to last valves insubclavian and jugularveinsCentral to last valves insubclavian and jugularveins

Medial to inner marginof first ribMedial to inner marginof first rib

Up to 1/3 initiallymisplacedUp to 1/3 initiallymisplaced

DSCN0034.JPG 00031577Macintosh HD BA578DA3:

Central Venous CathetersCentral Venous Catheters

$X:\photos\mediastinum\med hematoma CVC stick\pa post.jpg$

$X:\photos\mediastinum\med hematoma CVC stick\pa pre.JPG$

Central Venous CathetersCentral Venous Catheters

Complications:Complications:

PneumothoraxPneumothorax

BleedingBleeding

Ectopic infusion into pleura ormediastinumEctopic infusion into pleura ormediastinum

Air embolismAir embolism

Catheter embolismCatheter embolism

Central Venous CathetersCentral Venous Catheters

to IVC.JPG 0003150FMacintosh HD BA578DA3:

Central Venous CathetersCentral Venous Catheters

LIJ to LSCV.JPG 0003150FMacintosh HD BA578DA3:

Central Venous CathetersCentral Venous Catheters

to azygos.JPG 0003150FMacintosh HD BA578DA3:

Central Venous CathetersCentral Venous Catheters

Central Venous CathetersCentral Venous Catheters

ANGIO.JPG 00031546Macintosh HD BA578DA3:

$X:\photos\Anatomy and Variants\Anatomy sup int vein .jpg$

$X:\photos\Anatomy and Variants\Anatomy azygos arch .jpg$

Right

Left

Central Venous CathetersCentral Venous Catheters

to sup intercostal v.JPG 0003150FMacintosh HD BA578DA3:

Central Venous CathetersCentral Venous Catheters

PACLOSE.JPG 00031540Macintosh HD BA578DA3:

Central Venous CathetersCentral Venous Catheters

DSCN0006(2).JPG 0003157EMacintosh HD BA578DA3:

DSCN0007(2).JPG 0003157EMacintosh HD BA578DA3:

Central Venous CathetersCentral Venous Catheters

AFTER.JPG 0003155CMacintosh HD BA578DA3:

BEFORE.JPG 0003155CMacintosh HD BA578DA3:

quinton perf angio davis.jpg 0003155CMacintosh HD BA578DA3:

Old film

Central Venous CathetersCentral Venous Catheters

ANGIO1.JPG 00031566Macintosh HD BA578DA3:

Central Venous CathetersCentral Venous Catheters

Central Venous CathetersCentral Venous Catheters

ANGIO2.JPG 00031566Macintosh HD BA578DA3:

ANGIO3.JPG 00031566Macintosh HD BA578DA3:

Central Venous CathetersCentral Venous Catheters

Central Venous CathetersCentral Venous Catheters

DSCN0035.JPG 00031577Macintosh HD BA578DA3:

DSCN0036.JPG 00031577Macintosh HD BA578DA3:

DSCN0038.JPG 00031577Macintosh HD BA578DA3:

DSCN0037.JPG 00031577Macintosh HD BA578DA3:

Central Venous CathetersCentral Venous Catheters

cath frag in SVC.JPG 0003150FMacintosh HD BA578DA3:

pa cath .jpg 000738B6Macintosh HD B9800875:

Central Venous CathetersCentral Venous Catheters

before close .jpg 000738B6Macintosh HD B9800875:

$C:\Documents and Settings\guttenta\Desktop\new pix\subclavian vein anatomy.jpg$

Central Venous CathetersCentral Venous Catheters

cordis frag in RLL.JPG 0003150FMacintosh HD BA578DA3:

central line pinched.JPG 0003150FMacintosh HD BA578DA3:

Central Venous CathetersCentral Venous Catheters

pa port in place.jpg 0003150EMacintosh HD BA578DA3:

Central Venous CathetersCentral Venous Catheters

pinched catheter.JPG 00031514Macintosh HD BA578DA3:

Swan-Ganz CatheterSwan-Ganz Catheter

Ideally in central left orright PAIdeally in central left orright PA

Complications:Complications:

ThrombosisThrombosis

InfarctionInfarction

PA perforationPA perforation

HemorrhageHemorrhage

PseudoaneurysmformationPseudoaneurysmformation

via R SVC.JPG 00031609Macintosh HD BA578DA3:

Swan-Ganz CatheterSwan-Ganz Catheter

coils in LPA.JPG 0003151DMacintosh HD BA578DA3:

loop in LPA.JPG 0003151DMacintosh HD BA578DA3:

Swan-Ganz CatheterSwan-Ganz Catheter

loop in RA.JPG 0003151DMacintosh HD BA578DA3:

Swan-Ganz CatheterSwan-Ganz Catheter

swan coiling back to IJ.JPG 0003151DMacintosh HD BA578DA3:

Swan-Ganz CatheterSwan-Ganz Catheter

to hep vein via PA.JPG 0003151DMacintosh HD BA578DA3:

Swan-Ganz CatheterSwan-Ganz Catheter

swan adventure 2.jpg 0003151DMacintosh HD BA578DA3:

Swan-Ganz CatheterSwan-Ganz Catheter

Swan-Ganz CatheterSwan-Ganz Catheter

via LSVC.jpg 00031609Macintosh HD BA578DA3:

Swan-Ganz CatheterSwan-Ganz Catheter

$X:\photos\cardiovascular\Pseudoaneurysm PA Berger\pseudoaneurysm berger #1.jpg$

$X:\photos\cardiovascular\Pseudoaneurysm PA Berger\pseudoaneurysm berger #2.jpg$

$X:\photos\cardiovascular\Pseudoaneurysm PA Berger\pseudoaneurysm berger #3.jpg$

Findings develop over 12 hours

Swan-Ganz CatheterSwan-Ganz Catheter

KNOTTED.JPG 0003151DMacintosh HD BA578DA3:

Pacemakers and AICDsPacemakers and AICDs

Ventricular lead to RVapexVentricular lead to RVapex

Atrial lead curlssuperiorlyAtrial lead curlssuperiorly

Look for malposition orchange in positionLook for malposition orchange in position

Check wires for breakageor sharp bendCheck wires for breakageor sharp bend

bivent AICD.jpg 00031519Macintosh HD BA578DA3:

Pacemakers and AICDsPacemakers and AICDs

DSCN0041(2).JPG 000315EBMacintosh HD BA578DA3:

DSCN0043(3).JPG 000315EBMacintosh HD BA578DA3:

Biventricular AICD

Pacemakers and AICDsPacemakers and AICDs

DSCN0016(2).JPG 000315DFMacintosh HD BA578DA3:

DSCN0017(1).JPG 000315DFMacintosh HD BA578DA3:

Pacemakers and AICDsPacemakers and AICDs

echo shot.JPG 000315E5Macintosh HD BA578DA3:

Pacemakers and AICDsPacemakers and AICDs

DSCN0026.JPG 000315DCMacintosh HD BA578DA3:

DSCN0025.JPG 000315DCMacintosh HD BA578DA3:

Pacemakers and AICDsPacemakers and AICDs

pa initialpost placement.JPG 0003150BMacintosh HD BA578DA3:

pa later.JPG 0003150BMacintosh HD BA578DA3:

pa late close.JPG 0003150BMacintosh HD BA578DA3:

lat later.JPG 0003150BMacintosh HD BA578DA3:

Pacemakers and AICDsPacemakers and AICDs

pacer leads OK.jpg 0003151AMacintosh HD BA578DA3:

LATER.JPG 0003151AMacintosh HD BA578DA3:

Pacemakers and AICDsPacemakers and AICDs

DSCN0021(1).JPG 000315F0Macintosh HD BA578DA3:

DSCN0022(2).JPG 000315F0Macintosh HD BA578DA3:

Pacemakers and AICDsPacemakers and AICDs

embolized wire to PA.JPG 00031519Macintosh HD BA578DA3:

Pacemakers and AICDsPacemakers and AICDs

“Twiddler’s syndrome”

twiddled port.JPG 00031501Macintosh HD BA578DA3:

Intraaortic Balloon PumpIntraaortic Balloon Pump

Used in cardiogenic shock, unstableangina, acute MIUsed in cardiogenic shock, unstableangina, acute MI

Reduces afterloadReduces afterload

Increases coronary perfusionIncreases coronary perfusion

Tip: distal to LSCA orificeTip: distal to LSCA orifice

Should project just below archShould project just below arch

Complications:Complications:

DissectionDissection

Branch occlusionBranch occlusion

Balloon ruptureBalloon rupture

IABP OK.jpg 00031516Macintosh HD BA578DA3:

Intraaortic Balloon PumpIntraaortic Balloon Pump

IABP high.jpg 00031516Macintosh HD BA578DA3:

high position.JPG 00031516Macintosh HD BA578DA3:

Chest TubesChest Tubes

Best if not in fissureBest if not in fissure

Look for tip directedtowards hilumLook for tip directedtowards hilum

Side-hole in pleural spaceSide-hole in pleural space

Watch for “ghost lines”after removalWatch for “ghost lines”after removal

CT in plase.jpg 000315A4Macintosh HD BA578DA3:

Chest TubesChest Tubes

ghost line, ptx.jpg 000315A4Macintosh HD BA578DA3:

Chest TubesChest Tubes

Chest TubesChest Tubes

DSCN0012(7).JPG 00031F2EMacintosh HD BA578DA3:

chest tube outside ribs.jpg 00031510Macintosh HD BA578DA3:

kinked chest tube o#31517.jpg 00031510Macintosh HD BA578DA3:

Chest TubesChest Tubes

Chest TubesChest Tubes

Chest TubesChest Tubes

DSCN0061.JPG 00031590Macintosh HD BA578DA3:

DSCN0062.JPG 00031590Macintosh HD BA578DA3:

Chest TubesChest Tubes

DSCN0034.JPG 00031587Macintosh HD BA578DA3:

DSCN0033.JPG 00031587Macintosh HD BA578DA3:

DSCN0038.JPG 00031587Macintosh HD BA578DA3:

Coronary Artery StentCoronary Artery Stent

Coronary Artery StentCoronary Artery Stent

coronary stent.jpg 00031501Macintosh HD BA578DA3:

Sternal DehiscenceSternal Dehiscence

pa new.jpg 00031F2FMacintosh HD BA578DA3:

lat sternum.jpg 00031F2FMacintosh HD BA578DA3:

pa old.jpg 00031F2FMacintosh HD BA578DA3:

$X:\photos\Cartoons\I hate this place.jpg$