Nigerian Journal of Cardiology

: 2013  |  Volume : 10  |  Issue : 1  |  Page : 36--37

Management of trigeminocardiac reflex in facial fractures

Mohammad Akheel1, Suryapratap S Tomar2,  
1 Department of Oral and Maxillofacial Surgery, NMCH, Nellore, Andhra Pradesh, India
2 Department of Neurosurgery, NMCH, Nellore, Andhra Pradesh, India

Correspondence Address:
Mohammad Akheel
Oral and Maxillofacial Surgery, Block 5, 4H, VGN laparasiene, Nolambur, Mogappair West, Chennai - 600 037, Tamil Nadu

How to cite this article:
Akheel M, Tomar SS. Management of trigeminocardiac reflex in facial fractures.Nig J Cardiol 2013;10:36-37

How to cite this URL:
Akheel M, Tomar SS. Management of trigeminocardiac reflex in facial fractures. Nig J Cardiol [serial online] 2013 [cited 2022 Sep 28 ];10:36-37
Available from:

Full Text


Craniomaxillofacial surgeons are very much concerned about intra-operative complications such as excessive bleeding and inadvertent damage to adjacent vital structures and post-operative complication such as infections and altered wound healing. Less are they aware of trigeminocardiac reflex (TCR), which presents itself most commonly as a life-threatening intra-operative complication and very rare post-operatively. TCR was first described as an oculocardiac reflex in 1908. [1] It was later found that this reflex also occurred during temporomandibular joint surgeries, orthognathic surgeries and during simple elevation of zygomatico-complex fractures, which involves activation of any of the three branches of the trigeminal nerve. [2] TCR is characterized by cardiac arrhythmia, ectopic beats, atrioventricular block, bradycardia, syncope, vomiting, and asystole.

A 21-year-old young man reported to Department of Oral and Maxillofacial surgery following a road traffic accident with gross edema of face bilaterally. Glasgow coma scale was 15/15 (E4 V5 M6). Computed tomography revealed Le Fort II fracture of the frontal bone and fracture of right parasymphysis of mandible. His medical history was not remarkable. Patient was planned for fixation of his facial fractures under general anesthesia. Intra-operatively while, elevation the zygomatic body and arch, he became bradycardic followed by asystole for 11 s. Immediately, cardiac massage was given by the surgeon with administration of 0.5 mg atropine and 1 mg epinephrine. The whole episode lasted for 1 min 05 s. The patient was kept under close supervision for 24 h post-operatively and discharge after 3 days and regular follow-ups were performed on the out-patient basis. He suffered no permanent damage of cardiac tissue as demonstrated by pre- intra- and post- operative electrocardiograms. No further cardiac pathology could be found.

The TCR previously known as oculocardiac reflex is believed to be caused by traction or compression of the extraocular muscles or the eyeball, leading to transmission of afferent impulses via TCR pathway to gasserian ganglion. This decreases the pulse rate by their communication with efferent portion of the vagus nerve from the cardiovascular center of the medulla to the heart. [2],[3] This reflex is described not only in surgery of the zygomatic bone or orbit, but also in maxillary and mandible procedures. It can be provoked in any patient even without a pre-existing cardiac disease. Kayikçioglu et al. [4] mentioned that a minimum period of 15-20 s of stimulation is necessary to elicit the reflex leading to at least 20% or more reduction in heart rate or presence of arrhythmias.

Management of TCR pathway includes preoperative information to anesthetist, cardiac massage, and immediate administration of 0.5 mg IV atropine and 1 mg IV epinephrine. [5] Hence, every craniomaxillofacial surgeon, anesthetist, and cardiologist must be aware of this life-threatening complication that is associated with head and neck surgery.


1Lang S, Lanigan DT, van der Wal M. Trigeminocardiac reflexes: Maxillary and mandibular variants of the oculocardiac reflex. Can J Anaesth 1991;38:757-60.
2Schaller B, Cornelius JF, Prabhakar H, Koerbel A, Gnanalingham K, Sandu N, et al. The trigemino-cardiac reflex: An update of the current knowledge. J Neurosurg Anesthesiol 2009;21:187-95.
3Schaller B, Probst R, Strebel S, Gratzl O. Trigeminocardiac reflex during surgery in the cerebellopontine angle. J Neurosurg 1999;90:215-20.
4Kayikçioglu O, Kayikçioglu M, Erakgün T, Güler C. Electrocardiographic changes during subconjunctival injections. Int Ophthalmol 1999;23:37-41.
5Bohluli B, Ashtiani AK, Khayampoor A, Sadr-Eshkevari P. Trigeminocardiac reflex: A MaxFax literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:184-8.