Cardiac asystole complicating zygomatic arch fracture

Evaluation of Trigeminocardiac Reflex in Patients Undergoing Elevation of Zygomatic Fractures

Aim

Trigeminocardiac reflex (TCR) manifests as typical hemodynamic perturbations including a sudden lowering of heart rate, mean arterial blood pressure (MABP), cardiac arrhythmias, and asystole. In literature, TCR has been seen during ocular surgeries, Lefort fractures, and craniofacial surgeries. However, the prevalence of the TCR has not been studied in zygomatic complex fractures . The aim of this study was to assess the prevalence of TCR in patients undergoing elevation with/without fixation of zygomatic complex fractures and isolated zygomatic arch fractures under local anesthesia and general anesthesia and to evaluate the prevalence of TCR in different age groups.

Materials and methods

The study comprised 26 participants diagnosed with zygomatic fractures indicated for surgical intervention. The aim of the study was to find the prevalence of TCR in patients undergoing surgical intervention (elevation of zygomatic complex fractures with/without fixation) under local anesthesia and general anesthesia. The heart rate and blood pressure were measured preoperatively, intraoperatively and postoperatively.

Results

Variation in heart rate was seen in patients undergoing surgery under local anesthesia and general anesthesia. However, a decrease in the heart rate i.e., bradycardia was noted intra-operatively in 75% of the patients operated under local anesthesia. The prevalence of TCR was noted intra-operatively in 23% of cases operated under general anesthesia. No significant changes were seen in the blood pressure of the patients.

Conclusion

In our study, we found out that the prevalence of TCR was more in the patients operated under local anesthesia i.e., 75% of patients. Out of the patients operated under general anesthesia i.e., 23% of patients showed TCR. No significant variations in blood pressure were observed in patients operated under local anesthesia or general anesthesia. The prevalence of TCR was found more often in the age group of 31-45 years in our study.

Suspected vagal reflex and hyperkalaemia inducing asystole in an anaesthetised horse

A 10‐year‐old 466 kg mustang gelding presented to an equine referral hospital for surgical repair of nasal, frontal and lacrimal bone fractures from an unknown trauma. Surgical repair was performed under general anaesthesia, including a right‐sided maxillary regional anaesthetic block with mepivacaine hydrochloride. Progressive hyperkalaemia was documented perianaesthetically (T‐3 mins; 134 mins after induction; potassium 6.4 mmol/L (ref 3.5‐5.1 mmol/L). Perianaesthetic bradycardia was attributed to alpha −2 agonist infusion administration, and other characteristic ECG changes (flattened P waves, narrow T waves of increased amplitude, prolonged QRS complex) were not documented. Asystole occurred 137 min after induction of anaesthesia; however, a review of the available literature suggests the degree of hyperkalaemia documented was unlikely to be the primary cause of asystole but may have been a contributing factor. It is hypothesised that a trigeminocardiac reflex was the primary contributory factor to asystole in the described case, and may represent a maxillomandibulocardiac reflex that has not been previously described in the horse.

Recurrent Atrial Tachyarrhythmia Triggered by Percutaneous Balloon Rhizotomy of the Trigeminal Nerve

Stimulation of sensory branches of the trigeminal nerve is known to cause sudden bradycardia (trigeminocardiac reflex). However we report a case where percutaneous balloon rhizotomy of the trigeminal ganglion provoked atrial tachyarrhythmias during two separate treatments. On both occasions the patient was treated with antiarrhythmic drugs and reverted to sinus rhythm within days. Our case demonstrates that surgery involving the trigeminal nerve may cause variable cardiovascular effects that are often clinically significant. Possible mechanisms and management of arrhythmias in this setting are discussed.

Trigemino-Cardiac Reflex: A Phenomenon Neglected in Maxillofacial Surgery?

BACKGROUND

Trigemino-cardiac reflex is a physiologic response of the body to pressure effects in the region of distribution of the trigeminal nerve. Oral and maxillofacial surgical procedures can induce the development of this reflex, which leads to significant changes in the heart rate and sinus rhythms. This study intends to evaluate the effects of this reflex in patients with facial fractures and its subsequent management.

PATIENTS AND METHODS

A total of thirty-seven patients with facial fractures who reported to the Department of Oral and Maxillofacial Surgery at Basaveswar Teaching and General Hospital, Gulbarga during a period from July 2015-March 2016 were considered for the study.

RESULTS

A male preponderance is observed with the most susceptible age group being 21-30 years. Twenty-three patients sustained mid-facial fractures alone, nine patients had isolated mandible fractures and five patients had fractures of both the mid-face and mandible. A relative bradycardia was observed in the patients with mid-facial trauma, both at the time of presentation and also during the surgical reduction of midfacial fractures which improved after completion of procedure in most of the patients. However, in two patients, the bradycardia progressed to a cardiac asystole during midface manipulation which required immediate halt of the procedure and intravenous administration of atropine.

CONCLUSION

Trigeminocardiac reflex though physiologic, which usually tends to subside without complications is not to be neglected in the surgeries of the maxillofacial skeleton. A propensity for unforeseen complications due to this reflex has to be avoided by meticulous monitoring of the ECG.

Trigeminocardiac Reflex: A Reappraisal with Relevance to Maxillofacial Surgery

PURPOSE

The purpose of this paper was to undertake a review of literature on trigeminocardiac reflex in oral and maxillofacial online data-base and discuss the pathophysiology, risk factor assessment, presentation of the reflex, prevention, management with emphasis on the role of the attending anaesthetist and the maxillofacial surgeon.

MATERIALS AND METHODS

The available literature relevant to oral and maxillofacial surgery in online data-base of the United States National Library of Medicine: Pubmed (http://www.ncbi.nlm.nih.gov/pubmed/) was searched. The inclusion criterion was to review published clinical papers, abstracts and evidence based reviews on trigeminocardiac reflex relevant to oral and maxillofacial surgery.

RESULTS

Sixty-five articles were found with the search term "trigeminocardiac reflex" in the literature searched. Eighteen articles met the inclusion criteria for this study. The relevant data was extracted, tabulated and reviewed to draw evidence based conclusions for the management of trigeminocardiac reflex.

CONCLUSIONS

Conclusions were drawn and discussed based on the reviewed maxillofacial literature with emphasis on the anaesthetist's and the surgeon's role in the management of this detrimental event in maxillofacial surgical practice.

Sudden asystole due to trigeminocardiac reflex during transsphenoidal surgery for pituitary tumor

BACKGROUND

A sudden attack of an asystolic phenomenon is an extremely rare event during transsphenoidal surgery (TSS). It may be caused by an extreme type of trigeminocardiac reflex (TCR) during the manipulation of the trigeminal nerve or its innervated structures.

CASE DESCRIPTION

We report two cases of sudden asystole and a case of severe bradycardia due to TCR during TSS. All patients were managed successfully by cessation of the surgical manipulation or with the injection of an anticholinergic agent.

CONCLUSIONS

Although TCR occurs rarely and usually is self-limiting, surgeons should be cautious of its occurrence, especially when manipulating the cavernous sinus during TSS. This allows the early detection and appropriate treatment of this manifestation. Stopping the surgical procedure as soon as TCR occurs is likely to normalize the vital parameters. In addition, if further manipulations are inevitable, the administration of anticholinergic medication should be considered cautiously to improve surgical outcomes.

Trigemino-cardiac reflex during orbital floor reconstruction: a case report and review

Trigemino-cardiac reflex is occurrence of hypotension and bradycardia upon surgical manipulation of areas supplied by the trigeminal nerve, and has been reported during craniofacial maxillofacial and ocular surgeries. Communication between the anaesthetic and surgical team is essential, and cessation of the precipitating stimulus is the first and most important therapeutic step. We report a case of immediate, reproducible, and reflexive response of Bradycardia and dysrhythmia upon manipulation of orbital fracture during orbital floor reconstruction in a 65-year-old man. Upon recognition of the reproducible relationship between falcine stimulation and increased vagal tone, the patient was given atropine in an effort to block cholinergic hyperactivity. After atropine administration, no further dysrhythmias occurred and surgery was carried uneventfully.

Classification of potential risk factors for trigeminocardiac reflex in craniomaxillofacial surgery

PURPOSE

Trigeminocardiac reflex (TCR) in craniomaxillofacial surgery can lead to severely life-threatening situations. At least mild forms are probably much more common than the existing surgical literature suggests. Therefore, the aim of this presentation of cases and literature review was to evaluate the predisposing factors leading to a classification of risk factors for potential TCR and to give information concerning preventive measures and management procedures.

PATIENTS AND METHODS

All surgery reports from the Department of Cranio-Maxillofacial and Oral Surgery in the University Hospital in Zurich between 2003 and 2008 were searched for severe intraoperative cardiovascular complications, and a literature review was performed for publications concerning asystole or bradycardia during maxillofacial surgical procedures.

RESULTS

Three incidents were revealed in which severe bradycardia--in 2 cases followed by asystole--had occurred. All incidents were successfully managed.

CONCLUSION

All craniomaxillofacial surgeons involved in orbital surgery in general and in the treatment of midface fractures, eyelid surgery, and orthognathic procedures in particular should be aware of the possibility of the TCR and should be familiar with its prevention and therapy.

The trigemino-cardiac reflex: an update of the current knowledge

The trigemino-cardiac reflex (TCR) is clinically defined as the sudden onset of parasympathetic activity, sympathetic hypotension, apnea, or gastric hypermotility during central or peripheral stimulation of any of the sensory branches of the trigeminal nerve. Clinically, the TCR has been reported to occur during craniofacial surgery, manipulation of the trigeminal nerve/ganglion and during surgery for lesion in the cerebellopontine angle, cavernous sinus, and the pituitary fossa. Apart from the few clinical reports, the physiologic function of this brainstem reflex has not yet been fully explored. The manifestation of the TCR can vary from bradycardia and hypotension to asystole. From the experimental findings, the TCR represents an expression of a central reflex leading to rapid cerebrovascular vasodilatation generated from excitation of oxygen-sensitive neurons in the rostral ventro-lateral medulla oblongata. By this physiologic response, the systemic and cerebral circulations may be adjusted in a way that augments cerebral perfusion. This review summarizes the current state of knowledge about TCR.

Trigemino-cardiac reflex: the trigeminal depressor responses during skull base surgery

OBJECTIVE

To observe and analyze the occurrence and management of the trigemino-cardiac reflex (TCR) defined as the phenomenon of abrupt drops in heart rate (HR) and blood pressure during skull base surgery.

METHOD

One hundred patients underwent skull base surgery for various lesions were recruited and great attention was paid to heart rate and blood pressure throughout the surgical procedure to screen intraoperative TCR.

RESULT

Twelve patients had TCR intro-operatively, all patients showed abrupt drops in HR of 38% from a mean of 78 beats/min to a mean of 49 beats/min, mean arterial blood pressure (MABP) decreased 33% from a mean of 93 mmHg to a mean of 60 mmHg, respectively. TCR was resolved spontaneously in eight patients, but had to be offset by intraoperative administration of relatively higher dose atropine in another four patients.

CONCLUSION

(1) Manipulation at or near the trigeminal nerve during the skull base surgery may cause TCR, even if premedication with anticholinergic drug is used; (2) cessation of irritation from surgical manipulation to disrupt the reflex is the most important step to offset TCR; (3) continuous, especially repeated TCR in some rare cases occasionally necessitates the administration of high dose atropine.

Trigemino-cardiac reflex during transsphenoidal surgery for pituitary adenomas: Methodological description of a prospective skull base study protocol

A systematic clinical neuroscience protocol is described for the use to examine the trigemino-cardiac reflex (TCR) response in humans. Target neurosurgical conditions are operations that require manipulations around the peripheral and central part of the trigeminal nerve and its branches, e.g. the cerebellopontine angle or the sellar region. To assess the hemodynamic and cardiac responses of patients after TCR initiation, anesthetic monitoring has been applied. The TCR is defined as a drop of more than 20% of the heart rate and the mean arterial blood pressure compared with the baseline values before the stimulus and coinciding with the surgical manipulation at or around any branches of the trigeminal nerve. By help of illustrative cases, we present for the first time preliminary results regarding the differentiation of the TCR in a central and a peripheral induction during transsphenoidal surgery of pituitary adenomas. Based on these results, we can conclude that we have developed a battery of preoperative examination procedures based on event-related diagnostics that was useful to differentiate different subgroups of TCR during transsphenoidal surgery. The presented protocol can be performed directly pre-, intra- and postoperatively and applied for assessment of TCR even in patients with known risk factors.

Delayed trigeminocardiac reflex induced by an intraorbital foreign body. Case report

OBJECTIVE

To emphasize the importance of the mechanism and surgical approach to trigeminocardiac reflex (TCR) developing 48 h after orbital trauma due to a foreign body.

CASE REPORT

After gunshot injury of a 17-year-old male patient, computerized tomography evaluation revealed a right globe perforation and an intraorbital metallic foreign body in the right orbita adjacent to the lateral wall. The ocular perforation was repaired, but the foreign body was not removed. Constant bradycardia (45/min) developed 48 h after the operation. Since there were no cardiological findings, a temporary cardiac pacemaker was inserted and on the 6th postoperative day, the foreign body was removed through orbitolateral approach. After the removal of the foreign body, bradycardia completely recovered.

CONCLUSION

In the presence of an intraorbital foreign body accompanied by globe perforation, TCR may develop 48 h after the trauma and insertion of a temporary pacemaker may be required to control the cardiac rhythm. In this paper, the delayed TCR complication presented an indication for the removal of the intraorbital foreign body.

Trigemino-cardiac reflex during transsphenoidal surgery for pituitary adenomas

BACKGROUND

The trigemino-cardiac reflex (TCR) is a well-recognized phenomenon consisting of bradycardia, arterial hypotension, apnea, and gastric hypermotility. It occurs during ocular surgery or other manipulations around the orbit and can also be elicited by stimulation of the central part of the trigeminal nerve during surgery for processes of the cerebellopontine angle. The present retrospective study was conducted to determine if TCR occurs during transsphenoidal surgery in the same way.

METHODS

TCR was defined as a drop in mean arterial blood pressure (MABP) and the heart rate (HR) of more than 20% to the baseline values before the stimulus and coinciding with manipulation of the trigeminal nerve. Pre-, intra-, and postoperative HR and MABP were retrospectively reviewed in 117 patients who underwent resection of pituitary adenomas near the trigeminal nerve at the cavernous sinus in the supine position. Tumor invasiveness was classified according to the modified Hardy criteria.

RESULTS

Of the 117 patients with immunohistochemically and/or electromicroscopically proven pituitary adenoma, 12 (10%) patients demonstrated intraoperative evidence of TCR according to the strict inclusion criteria. In these 12 patients, the HR and MABP decreased by a mean of 43 and 54%, respectively, from the preoperative mean levels during microsurgical manipulation near the cavernous sinus and returned to physiological levels within 10 min after cessation of this surgical maneuver. The percentage of invasive adenomas (grade III-IV) was significantly higher in the TCR subgroup than in the non-TCR subgroup (83% versus 22%).

CONCLUSION

The present results give evidence for the first time that TCR may occur during transsphenoidal surgery in the supine position for resection of pituitary adenomas near the cavernous sinus, leading to a significant decrease in HR and MABP under a standardized anesthetic protocol.

The falcine trigeminocardiac reflex: case report and review of the literature

BACKGROUND

Trigeminocardiac reflex (TCR), the reproducible hypotension and bradycardia upon stimulation of the trigeminal nerve, has been reported during craniofacial surgery and during surgery within the cerebellopontine angle, petrosal sinus, orbit, and trigeminal ganglion. Whereas the falx cerebri is known to be innervated by the nervus tentorii, a recurrent branch of V1, there have been no reports to date of this response upon mechanical stimulation of the falx.

CASE DESCRIPTION

We report a case of immediate, reproducible, and reflexive response of asystole upon stimulation of the falx cerebri during operative resection of a parafalcine meningioma in a 53-year-old woman. Upon recognition of the reproducible relationship between falcine stimulation and increased vagal tone, the patient was given glycopyrrolate in an effort to block cholinergic hyperactivity. After glycopyrrolate was given, no further dysrhythmias occurred.

CONCLUSION

In this patient, mechanical stimulation of the falx likely resulted in the hyperactivity of the trigeminal ganglion, thereby triggering TCR. The dorsal region of the spinal trigeminal tract includes neurons from hypoglossal and vagus nerves, and projections have been seen between the vagus and trigeminal nuclei. The vagus provides parasympathetic innervation to the heart, vascular smooth muscle, and abdominal viscera. Vagal stimulation via these connections after trigeminal nerve activation likely accounts for the reflexive response of asystole seen in this patient. This is confirmed by the observation that the reflex was inhibited by the anticholinergic effects of glycopyrrolate. Awareness of TCR allows for early detection and appropriate treatment.

Trigeminocardiac reflex: a unique case of recurrent asystole during bilateral trigeminal sensory root rhizotomy

BACKGROUND

The trigeminocardiac reflex is the sudden-onset of dysrhythmia and hypotension during manipulation of any of the branches of the trigeminal nerve. The trigeminal nerve and cardioinhibitory vagus nerve constitute the afferent and efferent pathways in the reflex arc. The trigeminocardiac reflex has been reported to occur during craniofacial surgery, balloon-compression rhizolysis of the trigeminal ganglion, and tumour resection in the cerebellopontine angle.

PATIENT & METHOD

A 2-year-old male patient with haemangioma near the sella turcica underwent rhizotomies of both sides of the dorsal sensory roots, of the trigeminal nerves for palliation of intractable trigeminal pain.

RESULTS

In this report, we experienced two unexpected episodes of asystole after transection of the sensory roots of the trigeminal nerves.

CONCLUSION

Sectioning of the intracranial dorsal sensory root of the trigeminal nerve provides clear evidence of the central role of the trigeminal nerve as the afferent pathway of the trigeminocardiac reflex arc.

Oculocardiac reflex induced by zygomatic fracture; a case report

Oculocardiac reflex has been recognized as the result of mechanical stimulation to the orbital tissue. The authors encountered a case of severe arrhythmia due to oculocardiac reflex in a patient with a zygomatic fracture. Previous health examinations suggested no abnormalities in the heart in his schooldays, and the initial diagnosis of his arrhythmia as complete A-V block due to injury (using ECG and cardiac ultrasonography). Because his arrhythmia did not improve spontaneously, he underwent cardiac pacing. After repair of the fracture, his arrhythmia completely disappeared. The pacemaker was removed on the first postoperative day. The pathogenesis of this rare case will be discussed.

Trigeminocardiac reflex during surgery in the cerebellopontine angle

OBJECT

In different experimental studies authors have analyzed the autonomic responses elicited by the electrical, mechanical, or chemical stimulation of the trigeminal nerve system. The trigeminocardiac reflex (TCR) is a well-recognized phenomenon that consists of bradycardia, arterial hypotension, apnea, and gastric hypermotility. It occurs during ocular surgery and during other manipulations in and around the orbit. Thus far, it has not been shown that central stimulation of the trigeminal nerve can also cause this reflex.

METHODS

The TCR was defined as clinical hypotension with a drop in mean arterial blood pressure (MABP) of more than 20% and bradycardia lower than 60 beats/minute. Pre-, intra-, and postoperative heart rate (HR) and MABP were reviewed retrospectively in 125 patients who underwent surgery for tumors of the cerebellopontine angle (CPA), and they were divided into two groups on the basis of the occurrence of the TCR during surgery. Of the 125 patients, 14 (11%) showed evidence of the TCR during dissection of the tumor near the trigeminal nerve at the brainstem. Their HRs fell 38% and their MABPs fell 48% during operative procedures as compared with preoperative levels. After cessation of manipulation, the HRs and the MABPs returned to preoperative levels. Risk factors for the occurrence of the TCR were compared with results from the literature.

CONCLUSIONS

The authors' results show the possibility of occurrence of a TCR during manipulation of the central part of the trigeminal nerve when performing surgery in the CPA.

Is there a cholinergic and an adrenergic phase of the oculocardiac reflex during strabismus surgery?

We investigated the counterregulatory effect of the oculocardiac reflex (OCR) in 25 infants and children during strabismus surgery under three experimental conditions. In group 1, a series of measurements were recorded when the OCR was elicited by traction. The beat-to-beat heart rate reduction ranged from -26 to -64 beats/min (median: -46 beats/min). Constant traction increased heart rate in all patients from +23 to +50 beats/min (median: +30.5; P < 0.001). After a sudden release of the stimulation, heart rate rose further from +6 to +40 beats/min (median: +15; P < 0.001). In group 2, atropine (0.01 mg/kg) was administered 3-4 min prior to the same manipulations as in group 1. Constant traction changed heart rate from -1 to +20 beats/min (median: +4.5; P < 0.01). In group 3, a retrobulbar blockade suppressed the OCR and the counterregulation completely. These findings indicate that there is an active counterregulatory process which maintains heart rate during traction at the extraocular muscles after the bradycardic reflex has been initiated. The bradycardia and the counterregulation may be referred to as cholinergic and adrenergic phrases of the OCR. Atropine eliminates the cholinergic phase. Our study indicates that there may be receptors and afferent fibres for both phases, which can be blocked by local anaesthetics.

Bradycardia and the trigeminal nerve

A review of the literature suggests that the oculocardiac reflex is part of a wider phenomenon involving any structure supplied by the trigeminal nerve. This can lead to potentially fatal complications in maxillofacial surgery. A review of the literature is discussed and two further cases are reported.

Cardiac dysrhythmias complicating maxillofacial surgery

Cardiac asystole, bradycardia and other dysrhythmias are complications associated with surgery of the craniofacial and maxillofacial structures. These dysrhythmias have been discussed frequently in ophthalmology but less attention has been paid to this problem in the maxillofacial surgery literature. Eight patients, 6 men and 2 women, who underwent maxillofacial surgery during a 16-month period at the Victoria General Hospital, Halifax, Canada demonstrated either asystole or bradycardia. This group of patients represents 1.6% of the total number of patients treated during the 16-month period. Six patients demonstrated either asystole or bradycardia during stretching of the soft tissues associated with advancement of the maxilla after bony mobilization. Two patients had either asystole or bradycardia during manipulation of the temporalis muscle fibres during surgery to correct total bony ankylosis of the temporomandibular joint. The etiology of this relatively rare but troublesome complication is discussed.

A technique for reducing fractures of the zygomatic complex under local anaesthesia

Fractures of the zygomatic complex are common. A technique is described which enables the majority of these fractures to be reduced under local anaesthetic, intravenous sedation and analgesia on an out-patient basis. The benefits to the patient and to the hospital are highlighted.

Sinus arrest complicating a bitemporal approach to the treatment of pan-facial fractures

Two cases are reported in which the treatment of pan-facial fractures via a bi-temporal flap approach was complicated by cessation of activity of the sinuatrial node (sinus arrest). The anatomical, physiological and anaesthetic implications of this potentially fatal complication are discussed.