This patient was being monitored, but his cardiopulmonary collapse occurred suddenly and rapidly. He received immediate resuscitation following advanced cardiac life support protocols. Unfortunately, there was no attempt to remove the material that had been employed as packing to control his epistaxis. It remains conjecture whether removal of this material could have altered his outcome. However, the gauze probably should have been removed to maximize his chance of survival.
Conclusion
This case demonstrates the clinical importance of the TCR to providers in the VA health care system, particularly to those who treat epistaxis. Because they are typically older, veterans are a high-risk group. Age is important due to the higher incidence of epistaxis in the older populace, and interventions are more often necessary in older patients with epistaxis. In addition, posterior bleeds occur more frequently in older patients. The resulting stimulation of the trigeminal nerve from interventions to control a posterior bleed may be a more potent provocation for the TCR. Finally, older patients often have comorbid illnesses requiring medications that may augment the TCR. Therefore, the veteran’s age and comorbid illnesses and medications may lead to greater susceptibility of a poor outcome, should the TCR occur as a result of interventions undertaken to control epistaxis.
VA practitioners should, therefore, be aware of the possible occurrence of the TCR in all patients with epistaxis, particularly when invasive manipulations of areas innervated by the trigeminal nerve are required. Evidence suggests that complications of the TCR range from mild bradycardia that responds to simple maneuvers to severe bradycardia and asystole requiring intervention with vagolytics. In rare cases, cardiac dysfunction may lead to death if the TCR is not suspected and early appropriate measures, such as removal of packing materials, are not undertaken.
Although the estimated complication rate of epistaxis and its treatment remains low (about 3%), the authors hope that this report will alert HCPs and that they will remain aware of the TCR as a potentially serious occurrence, even with mild to moderate manipulation of areas innervated by the trigeminal nerve. 6
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner , Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.