A 48-year-old woman with a history of hypertension, psychiatric illness, and a previous suicide attempt overdosed on her blood pressure medication (calcium channel blocker). When found unresponsive by her partner on the bathroom floor, she was brought by ambulance to the emergency department (ED). A right subclavian central line was placed during resuscitation.
No blood return was obtained from any of the lines. The ED team thought this was likely due to severe hypotension (her systolic blood pressure was around 50 mm Hg), but there was some concern that the line was not in the proper position. A chest radiograph was obtained when the patient arrived in the intensive care unit (ICU). The initial reading noted that the line might have been in the right atrium (which is to say, inserted too far). However, the radiology attending physician concluded the line was in good position.
Reassured, the line was used by the cardiology team to deliver medications and fluids during pacemaker insertion. Several hours later, a repeat chest radiograph was ordered after the patient began to vomit. This radiograph showed whiteout of the right lung, and ultimately the clinicians realized that the tip of the subclavian line was actually within the lung. Approximately 1400 cc of fluid was then removed from her pleural space via thoracentesis. Fortunately, the patient made a full recovery.
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