Clinical

Paul J. Oxley, MD, FRCSC, Imran Ratanshi, MSc, MD, FRCSC, Kenneth F. Ryan, MD, FRCPC Atypical severe presentations of the oculocardiac : Two case reports

Physicians who treat patients with facial trauma need to know how to prevent or manage the occurrence of the oculocardiac reflex because it can cause severe hypotensive or bradycardic/asystolic events and cardiac arrest.

ABSTRACT: The oculocardiac reflex is a rare but agal are well known to cause a of this reflex due to direct surgical manipula- potential cause of severe hypotensive or brady- change in blood pressure or heart rate. tion of the temporalis muscle,7 but we were cardic/asystolic events in patients suffering from This is seen often in medicine and is not able to find any cases of asystole secondary facial trauma. Though the most common side effect termed a “vagal response.” The most common to indirect manipulation of the orbit or peri- of the oculocardiac reflex is , clinicians V example of vagal reflex stimulation used clini- orbital musculature. We also were not able to should be concerned about a further decline to cally involves slowing the heart rate with exter- find many cases of severe hypotension due to potentially fatal arrhythmias, asystole, and even nal carotid massage to correct supraventricular orbital pressure alone. cardiac arrest. This article presents two severe cases . However, other maneuvers, such as of the oculocardiac reflex in the setting of facial rubbing the eyes or temples, can also cause a Case data trauma. The first case involves cardiac arrest at the reduction in blood pressure or heart rate. The Patient 1 time of midface fracture reduction. The second case oculocardiac reflex is a reflex arc created by the A 59-year-old male suffered a fracture to the involves severe hypotension requiring vasopressor trigeminal and vagus nerves.1-3 It is defined as left zygoma due to a direct punch to the cheek. support secondary to severe intraorbital pressure. a slowing of the heart rate by more than 20% He was diagnosed with a depressed left zy- from baseline following globe manipulation or goma fracture with comminution of the orbital traction of the extraocular muscles. floor. His medical history was positive only Dr Oxley is a plastic surgeon in the Fraser As with any reflex, there is an afferent and for high blood pressure (treated with ramipril 1 Health Authority working at Royal Columbian efferent limb. The serves as and furosemide) and high cholesterol (treated and Surrey Memorial Hospitals. He is also the sensory or afferent limb, while the vagus with atorvastatin). His surgery was performed an assistant clinical professor in the UBC nerve serves as the motor or efferent limb of 16 days after the injury to allow time to come Division of Plastic Surgery. Dr Ratanshi is a the reflex arc. Therefore, the reflex is initiated by off ASA. No preoperative muscle entrapment plastic surgeon in the Fraser Health Authority activation of stretch receptors in the periorbital was present. working at Royal Columbian and Surrey and ocular soft tissue, either through direct Once the patient was successfully under 4 Memorial Hospitals. He has a fellowship traction or increased pressure. This leads to general anesthesia with an oral endotracheal in craniofacial surgery from Harvard stimulation of the vagal motor response, which tube, his upper buccal sulcus and lower lid University. He is also a clinical instructor in causes impulses to the sinoatrial node and trig- were infiltrated with 0.25% bupivacaine with the UBC Division of Plastic Surgery. Dr Ryan gers a slowing of the heart rate. 1:100 000 epinephrine. An intraoral incision is an anesthesiologist in the Fraser Health The most common signs of oculocardiac re- was made, and dissection was taken down to Authority at Royal Columbian Hospital. flex are bradycardia and hypotension. In severe the periosteum, which allowed a retractor to He is also a clinical assistant professor in cases, arrhythmia, asystole, and cardiac arrest be placed under his zygomatic arch. As soon 5,6 the UBC Department of Anesthesiology, can occur. This reflex is encountered primar- as the zygoma was reduced, the patient went Pharmacology and Therapeutics. ily with pathology causing acutely entrapped into asystole. muscles, such as orbital floor fractures.4 There The ECG tracing demonstrated persistent This article has been peer reviewed. are reported cases of asystole with activation and unresolving asystole. It was recognized

BC Medical Journal vol. 63 no. 3 | April 2021 117 Clinical Atypical severe presentations of the oculocardiac reflex immediately when the anesthetic machine his displaced orbit and skull base fractures was direct movement of the orbital bones and a monitor alarm sounded. The anesthesiologist tested. Intraocular pressures were measured to sudden change in orbital pressure. Due to the instructed the surgical team to cease operating be 28 mm Hg in the involved globe (OD) and patient being on ASA, the risk of postopera- immediately and take pressure off the operative 15 mm in the contralateral globe (OS). tive periorbital hemorrhage necessitated the site. Further treatment included intravenous An emergent lateral canthotomy and can- surgical delay. injection of 0.6 mg and 15.0 mg ephed- tholysis procedure was performed at the bed- In our second case, the displacement of the rine. As asystole persisted, CPR was initiated. side under local anesthesia (1% lidocaine with bony structures into the orbit, along with post- A wide complex agonal rhythm was noted as 1:100 000 epinephrine) to reduce the patient’s traumatic swelling, caused compression of the CPR commenced. Approximately 50 seconds of ocular pressures. Immediately after release and globe and orbital musculature. Despite propto- CPR was performed, during which time narrow with serial evaluations, OD ocular pressures sis, the orbit is a closed compartment, and this QRS complexes became evident on the ECG. decreased to 9 to 11 mm Hg, which were equal quickly caused a compartment syndrome to When CPR was stopped, a sinus rhythm was to the contralateral side at that time. Shortly develop. While an awake patient would com- present, along with a perfusing blood pressure. after orbital decompression, the patient’s blood plain of pain and visual changes, an intubated The approximate elapsed time from when the pressure and heart rate stabilized, and he no individual will have no signs or symptoms early event was recognized and spontaneous rhythm longer required vasopressor support. An oph- in the disease progression. The significant effect returned was between 60 and 90 seconds. Epi- thalmologist was consulted and did not identify of orbital compartment syndrome and the en- nephrine was not required because an accept- any evidence of intraocular trauma or globe suing oculocardiac reflex on the blood pressure able blood pressure was detected shortly after rupture. The patient underwent urgent opera- and heart rate was seen by the rapid removal of resumption of spontaneous sinus rhythm. Due tive reduction and internal fixation of his facial vaso-supportive medications after correction of to these events and clinically acceptable reduc- and depressed skull fractures within 24 hours the orbital pressure. tion of the midface fracture, the incision was of decompression. closed, and no plate fixation was performed. A Summary forced duction test showed no orbital muscular Discussion The oculocardiac reflex is a rare but potential entrapment. Various stimuli can cause activation of the ocu- cause of severe hypotensive or bradycardic/asys- The patient had an uneventful emergence locardiac reflex. Anesthesiologists, ophthal- tolic events in patients suffering from facial and extubation. He was transferred to the post- mologists, maxillofacial and plastic surgeons, trauma and should be considered quickly in anesthetic care unit in stable condition, alert and trauma teams, intensivists, and emergency phy- the clinical setting. n cooperative. Following hospital discharge, he sicians who deal with patients who have trauma underwent outpatient cardiology review, includ- to the structures of the orbit or face need to be References 1. Dunville LM, Sood G, Kramer J. Oculocardiac reflex. ing a stress test and 24-hour Holter monitor aware of this reflex, its potential consequences, StatPearls Publishing LLC. Last updated 28 June 2020. test. No cardiac disease was detected. and how to manage or prevent its occurrence. Accessed 12 September 2020. www.ncbi.nlm.nih.gov/ Though the most common side effect of books/NBK499832. Patient 2 the oculocardiac reflex is bradycardia, clinicians 2. Barnard NA, Bainton R. Bradycardia and the trigeminal nerve. J Craniomaxillofac Surg 1990;18:359-360. While driving, an 82-year-old male, who was should be concerned about a further decline to 3. Bhargava D, Thomas S, Chakravorty N, Dutt A. Trigemi- otherwise healthy and living independently, potentially fatal arrhythmias, asystole, and even nocardiac reflex: A reappraisal with relevance to maxil- was struck from the side in a motor vehicle cardiac arrest. Because the oculocardiac reflex lofacial surgery. J Maxillofac Oral Surg 2014;13:373-377. collision, which resulted in multiple injuries, is a vagal reflex, it should also be considered in 4. Pham CM, Couch SM. Oculocardiac reflex elicited by including complex midface and depressed skull orbital floor fracture and inferior globe displacement. patients with unexplained hypotension. The Am J Ophthalmol Case Rep 2017;6:4-6. fractures. The patient was admitted to the ICU only definitive treatment is the immediate ces- 5. Bainton R, Lizi E. Cardiac asystole complicating zygo- and assessed immediately by a plastic surgeon sation of the triggering stimulus. matic arch fracture. Oral Surg Oral Med Oral Pathol for management of his periorbital fractures. The In our first case, it is possible that the oral 1987;64:24-25. 6. Shearer ES, Wenstone R. Bradycardia during elevation trauma and ICU team was concerned about approach to the zygomatic arch caused mild of zygomatic fractures. A variation of the oculocardiac ongoing hemorrhage from concomitant pelvic irritation to the insertion of the temporalis reflex. Anaesthesia 1987;42:1207-1208. 7 and long bone fractures. The patient was hy- muscle, though Bhattacharjee’s report sug- 7. Bhattacharjee A, Rajaram P, Khatua A, et al. Two potensive and required vasopressor support of gested that the muscle’s involvement in the episodes of trigeminocardiac reflex during a pan facial 7 mcg/kg/min norepinephrine bitartrate. He reflex arc suggested that it was direct pressure on fracture surgery, a rare phenomenon—Case report and review of literature. J Clin Diagn Res 2017;11:ZD01-ZD03. was bradycardic at 45 to 55 beats per minute. the muscle that caused the reaction. It is more The Glasgow Coma Scale was 3T owing to likely that the delayed nature of the treatment sedation needs. Clinical evaluation demon- caused the asystole. By 16 days posttrauma, the strated significant proptosis. A diagnosis of bones would have started to knit together, and orbital compartment syndrome secondary to elevation of the zygoma would have caused

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