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Left internal jugular
10%
9/86
Left subclavian
42%
36/86
Right brachiocephalic
12%
10/86
Right external jugular
Right subclavian
17%
15/86
Select Answer to see Preferred Response
This patient with sudden shortness of breath, decreased oxygen saturation, and a chest radiograph demonstrating a left pneumothorax has likely sustained an injury related to an attempt at left subclavian central venous access. Central venous access, also known as a central line, is a form of venous access in a large, centrally-located vein. Common sites for central access include the internal jugular vein, the subclavian vein, or the femoral vein. Central venous access allows for the delivery of medication or fluids during resuscitation that may not be adequately delivered in a smaller peripheral vein. There are certain situations that require central access, such as hemodialysis or chemotherapy. A potential complication of central venous access is injury to the lung pleura. The incidence of pneumothorax is highest with subclavian vein access, as this vessel is located at the apex of the lung. An upright chest X-ray or ultrasonography can be used to detect pneumothorax. In the chest radiograph, there will be a notable area lacking lung markings. In severe cases, tension physiology may result, with tracheal deviation and mediastinal shift. Figure/Illustration A shows a left pneumothorax. The collapsed lung is accentuated on this radiograph taken during expiration, and the borders are outlined in white (marked with a white arrow). There is also tracheal deviation and mediastinal shift away from the affected side. Incorrect Answers: Answer 1: The left internal jugular vein is an option for central venous access; however, this is less of a risk of pneumothorax compared to the left subclavian vein. Answer 3: The right brachiocephalic vein would not be the primary access point for a central line. The brachiocephalic vein is proximal to the internal jugular vein and the subclavian vein. This is also known as the innominate vein and leads to the superior vena cava. Answer 4: The right external jugular vein would be a much less likely cause of a left-sided pneumothorax. The external jugular vein enters the subclavian vein. Answer 5: The right subclavian vein would be a much less likely cause of a left-sided pneumothorax. Bullet Summary: Central venous access through the subclavian vein can result in a pneumothorax, which can be detected by ultrasonography or chest radiograph.
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