Presentation
Patient was brought to the hospital after being found at home unresponsive with low GCS and hypothermic. Admitted to critical care unit, where a central venous catheter and an NG tube were placed.
Patient Data
Correctly placed right CVC, tip just above the right atrium.
The NG tube crosses the carina / left main bronchus in satisfactory position. Tip position is slightly atypical, but, on balance, this is almost certainly in the stomach not the thorax, and is suitable for use.
Consolidation in the right lower lobe. No pneumothorax. Left lower lobe collapse.
The NG tube remains in an atypical position well to the right of the midline close to the lateral rib cage.
New large pleural effusion.
Small volume surgical emphysema in the right neck.
The NG tube lies outside and to the right of the esophagus in the neck and upper thorax, then courses through the posterior mediastinum. Locules of gas in the mediastinum adjecent to tube. The tip lies in the posterior right diaphragmatic recess in the pleural cavity now occupied by a large pleural effusion with locules of gas.
Right lung is largely collapsed. Left lower lobe partial collapse.
Case Discussion
This is a good learning case on the position of the nasogastric tube position.
On the initial radiograph post-insertion, the distal tube is malpositioned. This should prompt further investigation into the cause - usually by a limited CT, (depending on the local policy), or removal and re-insertion following a discussion with the primary clinician.
Following starting the feeding regime, the patient desaturated and became unwell, the radiograph demonstrating a feed related pleural effusion.
The CT then revealed the NG tube was malpositioned from the onset, the perforation likely occurring in the pharynx, above the limit of the scan. This then coursed along the posterior mediastinum to end in the right diaphragmatic recess.