April 2009

By Mohammad Fahad Ali, OREXer ’08-09

Morning presentation: Echocardiography
Surgeries observed: (1) Closed reduction of nasal fracture, (2) Bilateral ORIF Mandible

Morning Meeting: Echocardiography

Dr. Harken invited a technician to explain the functional capabilities and versatility of an echocardiogram. The echocardiogram, also known as a cardiac ultrasound or just ECHO, works by sending a burst of sound waves via a probe into the body to create both 2 and 3-D real time images. A limitation of the echocardiogram is that the signal cannot penetrate through air, which makes viewing the lungs difficult. The output of the echocardiogram is extremely fine, with a resolution less than 1mm, outputting about 30 frames/second. The ECHO is also able to quantify blood flow and direction with an option known as the Doppler function. This function depicts faster blood flow with brighter colors.

 
The cardiac ultrasound is also able to determine the stroke volume (SV), cardiac output, and ejection fraction (EF). SV is determined by subtracting the end-diastolic volume (EDV) from the end-systolic volume (ESV). EDV is the volume of blood after filling of the ventricles, diastole, while EDS is the volume of blood left after contraction of the ventricles, systole. The EDV and ESV are best determined when a technician finds a frame when the ventricles are fully filled and another frame when the ventricles are fully contracted and then carefully traces by hand the volumes within the ventricles in these two states. Then calculations can be made, since Cardiac output=SV x heart rate and EF =SV/EDV x 100. A normal person has an EF around 65%, while an EF typically between 75-85% during exercise.

 
The technician showed an echocardiogram of a patient who had an EF of 11%. After systole, it could be observed that blood was pooling in both ventricles and thus leading to the low EF. This patient would be at high risk for cardiovascular problems with any physically demanding activity.

Closed reduction of nasal fracture

The patient was involved in a car accident, one problem leading to his nasal fracture, commonly referred to as a broken nose. On initial examination in the OR, the patient’s nose was significantly deformed and swollen. The patient had an extensively reduced ability to breathe through his nostrils. The patient was first put to sleep. Cocaine was then packed into his nostrils for vasoconstriction to help reduce the rupturing of blood vessels and led to less swelling post surgery. A tool, known as an elevator, was then inserted into one of the patient’s nostril. With the use of the elevator, the surgeons tried to realign the nasal septum, which divides the left and right nostrils. The septum starts to harden with the surrounding structures after about 36 hours. After the nose was realigned, a Denver nasal splint was put into hot water and then molded to the patient’s nose to provide structural support and reduce fluid buildup in the area, known as edema. Next, a rectangular tampon-like piece with a hollow inside was inserted into each nostril to allow airflow and prevent the nostrils from closing. The surgeons cleaned up and were ready to wake the patient. The surgeons had to hold the patient down as he was vigorously moving all extremities as he was being brought back to consciousness.

Bilateral ORIF Mandible

A teenager, about 16 years old, was assaulted at the BART station on Friday, 4/3/09. He was brought into the ED of Highland as a level two trauma. The patient was primarily attacked in the mouth. On initial observation of the patient and his mother in the quite room, the patient’s mouth appeared fairly disfigured and swollen; however, his braces seemed fairly intact. When asked to close his mouth, the patient was not able to and said he felt that his upper and lower jaws moved in opposing directions when he tried to do so. The patient was being treated for the last 5 days at Highland. The patient was worried that the procedure would be invasive and would require cutting into his cheek in order to allow the surgeons to properly realign his jaw. The surgeons commented in saying that the likelihood of needing to cut through the patient’s cheek is fairly low and that the entire procedure is most likely going to be done with just the patient’s mouth open. The patient was then brought to the OR and put to sleep.

 
A 3D scan of the patient’s head was being rotated and studied by the surgeons on a computer in the OR. The scan showed that the lower left jaw was fractured. The procedure involved cutting through the lower left gum line in order to allow the surgeons to realign the lower jaw, the mandible. Strong wire ties were used to fixate the jaw in the proper position. In the process, a tooth was removed. The surgeons expect a few more teeth to fall out fairly soon because of the loss of bone to the area. However, the loose teeth were not pulled out because the patient’s orthodontist or possibly the patient himself might want to keep those teeth by undergoing additional dental surgeries. The incision site was then closed and the patient was ready to be awakened.

 

Before the patient was brought back to consciousness, the anesthesiologist had the staff move close to the patient’s bed in order to reduce any violent movements by the patient. The reason the patient was to be carefully brought back to consciousness is because the material in his mouth could be damaged or misaligned if he made sudden movements. When the patient was being brought back to consciousness, the anesthesiologist was correct and the patient did act violently, but was fairly well pinned down by the staff.