Previous article Table of Contents  Next article

LETTER TO EDITOR
Year : 2012  |  Volume : 6  |  Issue : 4  |  Page : 436-437

Bradycardia and hypotension during laryngoscopy for intubation in maxillofacial trauma


1 Department of Anaesthesia, Apollo Hospitals, Bilaspur, Chhattisgarh, India
2 Himalayan Institute of Medical Sciences, Dehradun, India

Correspondence Address:
Vinit K Srivastava
Department of Anaesthesia, Apollo Hospitals, Bilaspur, Chhattisgarh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1658-354X.105906

Rights and Permissions
Date of Web Publication10-Jan-2013
 


How to cite this article:
Srivastava VK, Agrawal S, Kumar R, Misra PP. Bradycardia and hypotension during laryngoscopy for intubation in maxillofacial trauma. Saudi J Anaesth 2012;6:436-7

How to cite this URL:
Srivastava VK, Agrawal S, Kumar R, Misra PP. Bradycardia and hypotension during laryngoscopy for intubation in maxillofacial trauma. Saudi J Anaesth [serial online] 2012 [cited 2022 Jun 25];6:436-7. Available from: https://www.saudija.org/text.asp?2012/6/4/436/105906

Sir,

Airway management in patients with facial trauma is usually challenging. Severe facial trauma often results in unstable tissues which can lead to bleeding, swelling, hematoma formation, and airway occlusion. Such patients may have an associated intracranial or cervical injury. Airway management in such cases is challenging and may be complicated with hemodynamic alterations.

A 54-year-old male patient was brought to our emergency department 6 h after an alleged history of road traffic accident. He was unconscious, irritable, producing inappropriate words but localizing pain response (GCS E2V3M5), heart rate 110/min, blood pressure 100/70 mmHg, respiratory rate 28/min, and oxygen saturation 95-97% on room air. Blood was continuously oozing into the oral cavity causing distress to the patient. Emergency endotracheal intubation was planned in emergency to prevent aspiration of blood and airway compromise.

We preoxygenated the patient with 100% oxygen using the Bains circuit. Due to lack of all the airway management apparatus in emergency and possibility of difficult airway, we administered injection (inj) glycopyrrolate 0.2 mg and propofol 100 mg followed by direct laryngoscopy. As the fracture segment of the mandible was falling down, laryngeal aperture was not visualized. An assistant was then asked to lift up the fractured segment of mandible forward and upward [Figure 1]. As soon as the mandible segments were lifted, there was sudden bradycardia (heart rate 36/min) with hypotension (blood pressure 66/38 mmHg). Laryngoscopy attempt was abandoned and inj. atropine 0.6 mg i.v. was administered. Following atropine administration, heart rate increased to 96/min and blood pressure 110/70 mmHg. After suctioning of oropharynx, we were able to intubate the trachea with 8.0 mm ID cuffed endotracheal tube orally. The patient was then shifted to radiology for necessary scans [Figure 2] and thereafter underwent emergency craniotomy, elevation of depressed fracture, duroplasty, evisceration (right eye), plating of maxilla, mandible, endoscopic cauterization of sphenopalatine artery, and tracheostomy. Intraoperatively the patient was stable.
Figure 1: Intubation procedure

Click here to view
Figure 2: Maxillofacial trauma

Click here to view


The possible causes of bradycardia and hypotension in our patient are hypoxic vagal stimulation, drugs, and laryngoscopy induced and stimulation of mandibular division of trigeminal nerve during dis-impaction, and lifting of the fractured segment of facial bones. Bradycardia during facial surgery has been described for different operations of the head and neck. [1],[2] One of the causes of bradycardia considered was stimulation of structures innervated by the trigeminal nerve, known as the oculocardiac reflex. The terms trigeminocardiac and trigeminovagal reflex have been proposed to include the additional, nonocular sources of this reflex. [3] As there is no episode of hypoxia, bradycardia and hypotension during first attempt of laryngoscopy and association of the response immediately after lifting up of fractured segments of mandible, trigeminovagal reflex due to stimulation of the mandibular division of the trigeminal nerve may have been the most likely cause. [4],[5]

We conclude that continuous and meticulous monitoring of the ECG and pulse waveform during intubation in maxillofacial trauma is of prime importance because of associated hemodynamic changes and by exercising extra vigilance during intubation, bradycardia, or asystole may be recognized immediately and managed effectively.

 
  References Top

1.Lang S, Lanigan DT, van der Wal M. Trigeminocardiac reflexes: Maxillary and mandibular variants of the oculocardiac reflex. Can J Anaesth 1991;38:757-60.  Back to cited text no. 1
    
2.Lübbers HT, Zweifel D, Grätz KW, Kruse A. Classification of potential risk factors for trigeminocardiac reflex in craniomaxillofacial surgery. J Oral Maxillofac Surg 2010;68:1317-21.  Back to cited text no. 2
    
3.Arasho B, Sandu N, Spiriev T, Prabhakar H, Schaller B. Management of the trigeminocardiac reflex: Facts and own experience. Neurol India 2009;57:375-80.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.Schaller B. Trigeminocardiac reflex. A clinical phenomenon or a new physiological entity? J Neurol 2004;251:658-65.  Back to cited text no. 4
    
5.Shearer ES, Wenstone R. Bradycardia during elevation of zygomatic fractures. A variation of the oculocardiac reflex. Anaesthesia 1987;42:1207-8.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]


This article has been cited by
1 Asystole during Suspension Laryngoscopy: Case Report, Literature Review, and Prophylactic Strategies
Arthur Justi Cassettari, Érica Cristina Campos e Santos, Graziela Oliveira Semenzati, Agrício Nubiato Crespo
Case Reports in Otolaryngology. 2020; 2020: 1
[Pubmed] | [DOI]
2 Severe bradycardia associated with suspension laryngoscopy
Richard F. Latuska,Nicholas O. Kuhl,C. Gaelyn Garrett,James M. Berry,Alexander Gelbard
The Laryngoscope. 2016; 126(4): 949
[Pubmed] | [DOI]
3 Airway Management of the Patient with Maxillofacial Trauma: Review of the Literature and Suggested Clinical Approach
Michal Barak,Hany Bahouth,Yoav Leiser,Imad Abu El-Naaj
BioMed Research International. 2015; 2015: 1
[Pubmed] | [DOI]



 

Top
 
Previous article    Next article
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  IN THIS Article
   References
   Article Figures

 Article Access Statistics
    Viewed3962    
    Printed44    
    Emailed0    
    PDF Downloaded129    
    Comments [Add]    
    Cited by others 3    

Recommend this journal