Oral and maxillofacial surgery
Trigeminocardiac reflex: A MaxFax literature review

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Trigeminocardiac reflex (TCR) is a shocking event in the course of operation involving the maxillofacial area. The authors have tried to present an overview on the history, clinical implications, literature review, anatomic and biologic basis, predisposing and triggering factors, and management of the event. Being familiar with the presentations, preventive measures, and management procedures are seemingly the most important aspects of the TCR to oral and maxillofacial surgeons and anesthesiologists.

Section snippets

The Trigeminocardiac Story

Joseph Breuer described the self-regulation of breathing through the vagus nerves in 1868, and Florian Kratschmer described the influences of reflexes of the nasal mucosa on breathing and circulatory in 1870.1 These are considered as the first steps in the description of trigeminal-mediated bradycardia or asystole, which is well known especially for anesthetists and surgeons dealing with the craniomaxillofacial structures.2, 3 Based on the studies of Kratschmer on cats and rabbits, a sudden

Problem Statement

Dysrhythmias as a result of surgical manipulation of the eye and relevant orbital structures have been well documented in the ophthalmology literature5; however, the occurrence of this reflex during other maxillofacial surgeries is not as recognized and no review article has discussed this phenomenon based on oral and maxillofacial surgery literature. To the best of our knowledge, about 23 cases of sudden bradycardia and/or asystole thought to be attributed to trigeminal-mediated reflex during

Maxillofacial Literature Review

In 1987, Bainton and Lizi11 reported a case of cardiac asystole complicating the operation of a zygomatic arch fracture. Another case of bradycardia during the elevation of a zygomatic arch fracture was reported in the same year by Loewinger et al.12 Also Shearer and Wensione13 reported episodes of bradycardia during elevations of zygomatic fractures in 1987. Robideaux10 documented a case of a sudden decrease in heart rate (from 90 to 54 beats per minute) consonant with surgical disimpaction of

Anatomic Description

The afferent limb of the oculocardiac reflex arc is via the ophthalmic division of the trigeminal nerve. It begins with afferent fibers of the long and short ciliary nerves that travel with the ophthalmic division of the trigeminal nerve, continues to the gasserian ganglion, and then joins the main sensory nucleus of the trigeminal nerve in the floor of the fourth ventricle. Short internuncial fibers in the reticular formation connect them with the efferent pathway from the motor nucleus of the

Biologic Relevance

There are endogenous physiological protective mechanisms detected in brain against ischemia. The TCR is seemingly an example of these protective physiologic entities.3 It may be part of a group of related responses generally defined as “oxygen-conserving reflexes.” Within seconds after the initiation of such a reflex, there is a powerful and differentiated activation of sympathetic nerves and consequently a primary cerebrovascular vasodilatation. The hibernation and ischemic tolerance appear to

Predisposing and Triggering Factors

It is well known that hypercarbia, hypoxemia, and insufficient anesthesia are predisposing factors in the occurrence of OCR. Also, the nature of the provoking stimulus, meaning its strength and duration, contribute to the significance of the HR and blood pressure decrease.2 On the other hand, OCR occurs more pronouncedly in children.6, 32 This is attributed to the higher resting vagal tone.3 The relation of these factors and the incidence of TCR have not been addressed through the

Clinical Implementation and Management

As Schaller and Buchfelder26 have mentioned, “The clinical importance of the TCR lies in the fact that its clinical features range from sudden onset of sinus bradycardia, bradycardia terminating asystole, asystole with no preceding bradycardia, arterial hypotension, apnea, and gastric hypermobility.” Recognition of bradycardia is the first step in treatment. Avoidance of predisposing or triggering factors, halting the surgical stimulus, IV administration of atropine or glycopyrrolate, and

Preventive Measures

It has been shown that OCR, airway irritability, and ventilatory interventions occur with lower incidence in spontaneously breathing children undergoing strabismus correction with 1.3 MAC sevoflurane in N2O than with halothane. Baseline heart rate and respiratory rate are higher with sevoflurane. Also, considerably fewer dysrhythmias are observed in children receiving sevoflurane than in those receiving halothane. It is then concluded that a comparatively greater depression of vagal activity by

Conclusions

Being familiar with the presentations, preventive measures, and management procedures are seemingly the most important aspects of the TCR to oral and maxillofacial surgeons and anesthesiologists. Further studies, preferably with a multicenter design, are necessary to confirm the nature, description, predisposing and triggering factors, and other aspects of this seemingly physiologic phenomenon.

References (33)

Cited by (41)

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  • Occurrence of trigeminocardiac reflex during dental implant surgery: An observational prospective study

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    Citation Excerpt :

    During the course of implant surgery, drilling or implant placement may trigger the sensory branches of trigeminal nerve and send signals from the Gasserian ganglion to the sensory nucleus of trigeminal nerve. Then, the signals are transferred to the vagus motor nucleus via short nerves and directed to the myocardium via the cardiac branch of vagus nerve.11–13 Schematic of implant surgery triggering the possibly of TCR pathway is shown in Fig. 1.

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