Chest radiograph unknown 10

Anshuman Bansal


David Marker


Publication Date: 2009-09-09


This is a portable AP chest x-ray of a patient in the ICU. There are several lines and devices that have been introduced into the patient for monitoring and treatment. Click the annotations button on the right before you attempt the questions. You may need to view the image in the original size by clicking the button on the right. Warning: this is a fairly difficult CXR to follow for a beginner.

  1. In which vessel does the central line labeled "1" likely enter the body?

    Right subclavian vein

    Correct! This is a large bore catheter to allow for continous venovenous hemodialysis.
    Left external jugular vein

    Incorrect. The catheter labeled "1" is on the patient's right side.
    Right subclavian artery

    Incorrect. This is a venous catheter so it would enter in a vein. Try again!

  2. The tube labeled "2" enters the patients nose and then follows a path distally. Can you determine where the distal tip lies?


    Correct. This is a nasogastric tube likely to allow for enteral feeds and to allow suctioning of the stomach.
    Lung bronchi

    Incorrect. When placing a nasogastric tube it is possible to pass it into the trachea and bronchus. This is highly undesirable as it can cause a pneumonia. In this patient this tube is not in a bronchus. Try again!

  3. Can you determine where the distal tip of the central line labeled "3" lies?

    SVC and right atrial junction

    Correct. This is the ideal location for the distal tip of a central line.

    Incorrect. Except in certain circumstances, central lines are normally venous. Try again.
    Pulmonary vein and left atrium

    Incorrect. This line enters the body in the left subclavian vein and goes centrally into the left brachiocephalic vein and then the superior vena cava.

  4. Do you know what the structures labeled "4" are?

    EKG leads

    Correct. It is not possible to tell which structures are inside the patient and which are placed on the patient with just one view. These are likely EKG leads as you can see the clips that they attach to.
    Central lines

    Incorrect. It would be unlikely that a patient would have central lines that lie in such an orientation.
    Nasogastric tubes

    Incorrect. It would be unlikely that a patient would have nasogastric tubes that lie in such an orientation.