Bradycardia during elevation of zygomatic fractures

Abstract

SummaryTwo cases cfsevere hrudycardiu are described which occurred during elevations of zygomatic fractures. The twa patients and the possible mechunisms involved are discussed. Key wordsComplications; bradycardia. Surgery; faciomaxillary.The oculocardiac reflex is a phenomenon well known to anaesthetists engaged in ophthalmic work. We report two cases that demonstrated what we believe to be a hitherto unreported variation of this reflex: that elicited by elevation of zygomatic fractures. Case histories Case IThis was a healthy, 43-year-old man who weighed 79 kg and had sustained a depressed left zygomatic fracture in an affray 5 days prior to hospital admission. He was medically fit, had no previous anaesthetic history and was unpremeditated. Anaesthesia was induced with thiopentone 425 mg followed by suxamethonium 75 mg. The trachea was intubated with an oral 9.5-mm cuffed tracheal tube. On return of some movement, atracurium 0.5 mg/kg was given and anaesthesia maintained with 0.5% halothane and 66% nitrous oxide in oxygen (fresh gas flow 6 litres/minute) using a Manley Servovent ventilator. Monitoring was by means of an ECG and oscillotonometer.Surgery proceeded uneventfully with the systolic blood pressure (BP) maintained at 120 mmHg and pulse at 80 beatsjminute in sinus rhythm. The pulse decreased to 60 beats/minute (sinus rhythm) a t the first attempt to elevate the fracture and recovered to 80 beats/minute immediately on cessation of the stimulus. The second and successful attempt to elevate the fracture caused the pulse to decrease to 30 beatsjminute with a junctional rhythm and then to sinus arrest for 4 seconds. This reverted spontaneously to a junctional rhythm at 30 beats/minute. Intravenous atropine 600 pg converted this to a sinus tachycardia of 120 beats/ minute with frequent ventricular ectopics. This gave way to a bigeminal rhythm which itself reverted spontaneously to a sinus tachycardia. This whole episode lasted one minute. The rest of anaesthesia was uneventful. Reversal of residual neuromuscular blockade was with neostigmine 2.5 mg and glycopyrronium 0.5 mg. A postoperative ECG was normal.

Trigeminocardiac reflexes

“…Since 1978, 15 cases of sudden bradycardia and/or asystole during cranio-maxillo-facial surgery have been reported. [6][7][8][9][10][11][12][13][14][15] In this issue, Lang et al 16 present three additional cases confirming that reflex bradycardic responses can occur after stimulation of sensory branches of the maxillary (V2) and mandibular (V3) divisions of the trigeminal nerve. In 1987, Bainton and Lizi,7 and Loewinger et al ,~ suggested that trigeminocardiac reflexes (TCR) can be elicited by stimulating afferent paths other than the ciliary nerves (branches of the ophthalmic division -Vn -of the trigeminal nerve) which are classically associated with the oculocardiac reflex (OCR).…”

Trigeminocardiac Reflex: A Reappraisal with Relevance to Maxillofacial Surgery

“…Though most authors concede to the fact that trigeminal cardiac response is a transient response to manipulation of the trigeminal nerve, which recovers on cessation of the stimulus [8,21], there are numerous reports of severe bradycardia and asystole, where the additional administration of anticholinergic agents is warranted. The use of intravenous atropine/glycopyrollate has been advocated.…”

Trigemino-Cardiac Reflex During Orbital Floor Reconstruction: A Case Report and Review

“…However, several other reports [9,20] showed occurrence of this bradycardia by stimulating non ocular sources. There after it is termed as trigemino-cardiac reflexes in 1988 as suggested by Shelly and Church [21].…”