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PubMed1995

Effect of antagonism of mivacurium-induced neuromuscular block on postoperative emesis in children.

The routine use of cholinesterase inhibitors to antagonize residual neuromuscular block may be associated with increased postoperative emesis. Rapid spontaneous recovery from mivacurium may obviate the need for these drugs. In this randomized, double-blind, placebo-controlled study of 113 healthy children who had received mivacurium as part of a standardized anesthetic regimen, we compared the incidence of postoperative complications after spontaneous recovery and after the use of neostigmine-glycopyrrolate or edrophonium-atropine. The anesthetic regimen consisted of halothane, nitrous oxide, fentanyl, 2 micrograms/kg intravenous (i.v.), mivacurium in an initial dose of 0.2 mg/kg, followed by an infusion, adjusted to maintain > or = 1 evoked contraction response to a supramaximum train-of-four stimulus. At the end of the procedure, patients received by random assignment one of three drug combinations: 1) neostigmine 70 micrograms/kg + glycopyrrolate 10 micrograms/kg, i.v., 2) edrophonium 1 mg/kg + atropine 10 micrograms/kg, i.v., and 3) saline. The trachea was extubated when evoked responses to peripheral nerve stimulation and clinical signs of adequate neuromuscular recovery were present. Postoperative pain was treated with morphine and emesis with metoclopramide. There were no significant differences between the three groups with respect to age, surgery, intraoperative fentanyl, and mivacurium use, time from the end of surgery to tracheal extubation, postanesthesia care unit (PACU) arrival and discharge, or in postoperative oxygen saturation values and analgesic requirements. Compared to the placebo group, emesis occurred more often in the PACU in patients receiving the neostigmine-glycopyrrolate combination, but not after edrophonium-atropine.(ABSTRACT TRUNCATED AT 250 WORDS)

Anesthesia Recovery Period↗

PubMed1997

The duration of impairment of autonomic control after anticholinergic drug administration in humans.

Impaired parasympathetic control of heart rate is associated with increased incidence of cardiac dysrhythmias and ischemia. Anticholinergic drugs, commonly administered during reversal of neuromuscular blockade, suppress parasympathetic control in the early postoperative period. This could potentially be detrimental in patients at risk of cardiovascular complications. The duration of parasympathetic impairment by two anticholinergic drugs were compared in this double-blind randomized cross-over study. Fourteen healthy volunteers received a single intravenous injection of atropine 20 micrograms/kg or glycopyrrolate 8 micrograms/kg during two different study sessions. The methods of spontaneous baroreflex analysis and spectral analysis of heart rate variability generated indices of beat-by-beat parasympathetic modulation of heart rate. Both drugs resulted in a marked decrease in baroreflex sensitivity and high-frequency heart rate variability. The times to return to baseline values were approximately doubled after atropine compared to glycopyrrolate (177 +/- 22 vs 82 +/- 8 min for baroreflex sensitivity, 212 +/- 16 vs 111 +/- 14 min for high-frequency power, and 171 +/- 18 vs 95 +/- 18 min for high-frequency power normalized to total power; P < 0.01 for all variables). Atropine leads to more prolonged impairment of parasympathetic control than equipotent doses of glycopyrrolate, and its use may thus be less desirable in high-risk patients in the early postoperative period.

Atropine↗

PubMed1984

Cardiac dysrhythmias and heart rate changes at induction of anaesthesia: a comparison of two intravenous anticholinergics.

Glycopyrrolate, 0.2 mg, or atropine, 0.6 mg, was administered intravenously together with methohexitone for the induction of anaesthesia in unpremedicated patients. The use of atropine, compared with glycopyrrolate, was associated with a greater rise in heart rate, a greater number of patients whose heart rates doubled, and a higher incidence of dysrhythmias. Glycopyrrolate is recommended for use as an intravenous anticholinergic agent, particularly in patients with cardiovascular impairment.

Adolescent↗

PubMed1995

Anticholinergic prophylaxis does not prevent emesis following strabismus surgery in children.

One hundred and twenty-one children were studied in this prospective, randomized double-blind, placebo-controlled comparison of the effectiveness of anticholinergic prophylaxis for the prevention of emetic symptoms following strabismus surgery. The children were allocated to three groups, to receive placebo (n = 40), glycopyrrolate (n = 40) or atropine (n = 41). The incidence of intraoperative oculocardiac reflex (OCR) and of postoperative emetic symptoms for 24 h was recorded. The incidence of OCR was 55% in the placebo group compared with 5% and 2% in the glycopyrrolate and atropine groups respectively (P < 0.05). Thirty percent (12/40) of patients in the placebo group, 25% (10/40) in the glycopyrrolate group, and 22% (9/41) in the atropine group experienced nausea and/or vomiting (difference not significant). It is concluded that prophylactic administration of anticholinergic agents during strabismus surgery in children despite being effective against the occurrence of the oculocardiac reflex, does not reduce the incidence of emetic symptoms.

Antiemetics↗

PubMedDate not supplied

Parenteral anticholinergics in dogs with normal and elevated intraocular pressure.

Dogs given parenteral anticholinergic drugs have been thought to be at risk for development or exacerbation of elevated intraocular pressure (IOP). In a randomized, blinded, placebo-controlled study, we evaluated the effect of intramuscular glycopyrrolate (0.01 mg/kg) on pupil diameter and IOP in unanesthetized normal dogs. Treatment with glycopyrrolate did not change pupil diameter or IOP from baseline, nor were there differences between glycopyrrolate and saline-treated (control) dogs. In addition, the authors retrospectively reviewed the medical records of 2,828 dogs undergoing general anesthesia between April 1987 and September 1990 to determine if there was an association between parenteral anticholinergic medication and postanesthetic elevation in IOP. The authors also determined the frequency of bradycardia requiring anticholinergic therapy during anesthesia in dogs with glaucoma. Of the 2,828 cases reviewed, the records of 46 dogs coded for glaucoma were examined in detail. The 46 dogs underwent 62 episodes of anesthesia, with 23 episodes including exposure to an anticholinergic drug. An increase in IOP from preanesthetic to postanesthetic measurement occurred in three dogs. One of these dogs received anticholinergic medication for bradycardia during anesthesia. The postanesthetic elevation in IOP in this dog was probably not drug related. Preanesthetic anticholinergic administration did not affect the incidence of anticholinergic administration for bradycardia during the anesthetic episode. Anticholinergic therapy during anesthesia was more frequent when the preanesthetic medication included an opiate drug. These studies do not indicate an association between parenteral anticholinergic administration and elevations in IOP.

Anesthesia, General↗

PubMedDate not supplied

Xerostomic complaints induced by an anti-sialogogue in healthy young vs. older adults.

Complaints of xerostomia and salivary hypofunction are common in older adults. However, recent studies reported that dehydration-induced salivary hypofunction caused fewer xerostomic complaints in older compared with young adults. This may predispose older adults to developing oral problems that will subsequently not receive attention from health care providers. Since many medications are known to inhibit salivation, this study attempted to determine if an anticholinergic drug (glycopyrrolate) had a differential effect on xerostomic complaints in young vs. older adults. Eighteen young (age 20-38 yrs) and 18 older (age 60-77 yrs) healthy adults were given a 4.0 micrograms/kg dose of i.v. glycopyrrolate. For 6 hrs after drug administration, stimulated parotid salivary flow was collected, and an eight-item Visual Analogue Scale (VAS) subjective xerostomia test was given. At several time points post-i.v. glycopyrrolate, salivary flow rates were consistently lower in older compared with young adults. For some measures of xerostomic complaint (time to first complaint; time to maximum complaint; mean maximum complaint), there were no age-related differences for all VAS items. However, a trend for increased xerostomic complaints in older adults was demonstrated (time to recovery; total duration of complaint; number xerostomic at 6 hrs). These findings suggest that, given equal doses of an anti-sialogogue, salivary hypofunction is greater in healthy older adults, while increased complaints of xerostomia are not as consistent.

Adult↗

PubMed2002

Role of the autonomic nervous system in the reduced maximal cardiac output at altitude.

After acclimatization to high altitude, maximal exercise cardiac output (QT) is reduced. Possible contributing factors include 1) blood volume depletion, 2) increased blood viscosity, 3) myocardial hypoxia, 4) altered autonomic nervous system (ANS) function affecting maximal heart rate (HR), and 5) reduced flow demand from reduced muscle work capability. We tested the role of the ANS reduction of HR in this phenomenon in five normal subjects by separately blocking the sympathetic and parasympathetic arms of the ANS during maximal exercise after 2-wk acclimatization at 3,800 m to alter maximal HR. We used intravenous doses of 8.0 mg of propranolol and 0.8 mg of glycopyrrolate, respectively. At altitude, peak HR was 170 +/- 6 beats/min, reduced from 186 +/- 3 beats/min (P = 0.012) at sea level. Propranolol further reduced peak HR to 139 +/- 2 beats/min (P = 0.001), whereas glycopyrrolate increased peak HR to sea level values, 184 +/- 3 beats/min, confirming adequate dosing with each drug. In contrast, peak O(2) consumption, work rate, and QT were similar at altitude under all drug treatments [peak QT = 16.2 +/- 1.2 (control), 15.5 +/- 1.3 (propranolol), and 16.2 +/- 1.1 l/min (glycopyrrolate)]. All QT results at altitude were lower than those at sea level (20.0 +/- 1.8 l/min in air). Therefore, this study suggests that, whereas the ANS may affect HR at altitude, peak QT is unaffected by ANS blockade. We conclude that the effect of altered ANS function on HR is not the cause of the reduced maximal QT at altitude.

Acclimatization↗

PubMedDate not supplied

The Frey syndrome: a simple, effective treatment.

The benign but socially embarrassing problem of gustatory sweating and flushing (Frey syndrome) has been studied in the past in search of a simple but effective treatment. Twenty-two patients participated in clinical trials of glycopyrrolate on an investigational basis, 17 of which have been followed up for four to five years. Double-blind comparisons of the efficacy and side effects of topical scopolamine (solution and cream) and glycopyrrolate (roll-on lotion, solution, and cream) are also presented. The use of 1% glycopyrrolate roll-on lotion and cream were associated with an average of three days of complete control of gustatory sweating and a remarkably low incidence of side effects.

Administration, Topical↗

PubMed2000

The role of anticholinergics in bronchoscopy. A randomized clinical trial.

BACKGROUND: Anticholinergic medications have been utilized frequently prior to bronchoscopy and are thought to facilitate the drying of secretions to limit the amount of required topical anesthetic on the airway mucosa, prevent cardiac arrhythmias during the procedure, and increase patient comfort. OBJECTIVE: To determine if atropine or glycopyrrolate, two anticholinergic agents utilized most frequently in this setting, have any significant role for this purpose. DESIGN: Double-blind, placebo-controlled study, in which patients were randomly selected to receive atropine (0.01 mg/kg body weight, IM injection), glycopyrrolate (0.005 mg/kg, IM injection), or saline solution placebo (approximately 2 mL, IM injection) 15 to 45 min prior to being sedated with midazolam until judged to be lightly sedated. SETTING: A large academic teaching hospital in the midwestern United States. PARTICIPANTS: Two hundred seventeen outpatients referred for bronchoscopy who satisfied inclusion and exclusion criteria. MEASUREMENTS AND RESULTS: Using a modified visual analog scale (0 to 100 mm), the bronchoscopist and the nurse anesthetist estimated the antisialagogic effect, effectiveness in cough suppression, and overall patient comfort during the procedure. The patients completed a similar questionnaire after recovering from the procedure. Patients were also monitored for complications (cardiac arrhythmias, oxygen desaturation, hypertension, wheezing, or coughing severe enough to curtail the procedure). There was no significant difference found among atropine, glycopyrrolate, and placebo for the primary end point of secretion control. In addition, there was no difference found between either medication and placebo for effectiveness of cough suppression, amount of topical anesthetic used, complication rates, or overall patient comfort. CONCLUSION: The use of anticholinergic agents prior to bronchoscopy did not affect performance of bronchoscopy or complication rates, and there was no appreciable benefit from the resultant reduction in airway secretions in a population of patients receiving concurrent sedation with benzodiazepines.

Aged↗

PubMed2004

Evaluation of the effects of premedication on gastroduodenoscopy in cats.

OBJECTIVE: To evaluate the effects of hydromorphone, hydromorphone and glycopyrrolate, medetomidine, and butorphanol premedication on the difficulty and time required to pass an endoscope into the stomach and duodenum of cats anesthetized with ketamine and isoflurane. DESIGN: Randomized complete block crossover study. ANIMALS: 8 purpose-bred adult female cats. PROCEDURES: Each cat was premedicated and anesthetized 4 times with an interval of at least 7 days between procedures. Cats were premedicated with hydromorphone, hydromorphone and glycopyrrolate, medetomidine, or butorphanol administered IM. Twenty minutes after premedication, sedation was assessed by use of a subjective ordinal scale. Cats received ketamine administered IM, and 10 minutes later a cuffed orotracheal tube was placed and anesthesia maintained with isoflurane. Cats breathed spontaneously throughout the procedure. When end-tidal isoflurane concentration was stable at 1.4% for 15 minutes, endoscopy was begun. The times required to pass the endoscope through the cardiac and pyloric sphincters were recorded, and the difficulty of endoscope passage was scored by use of a subjective ordinal scale. RESULTS: No significant differences in difficulty or time required to pass the endoscope through the cardiac and pyloric sphincters were found among premedicant groups. Premedication with medetomidine resulted in the greatest degree of sedation and longest time to return to sternal recumbency. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that hydromorphone, hydromorphone and glycopyrrolate, medetomidine, and butorphanol at the doses tested can be used satisfactorily to premedicate cats prior to general anesthesia for gastroduodenoscopy.

Analgesics↗

PubMed1999

Cardiovascular effects of epidurally administered oxymorphone and an oxymorphone-bupivacaine combination in halothane-anesthetized dogs.

OBJECTIVE: To evaluate cardiovascular effects of epidurally administered oxymorphone (OXY) and an OXY-bupivacaine combination (O/B) in halothane-anesthetized dogs. ANIMALS: 6 dogs. PROCEDURE: In a randomized crossover design study, dogs were anesthetized with halothane and given OXY, O/B, and saline solution (SAL). Eucapnia and end-tidal halothane concentration of 1.2% were established. Heart rate (HR), systemic and pulmonary arterial pressures, central venous pressure (CVP), and cardiac output were measured at baseline and 5, 15, 30, 45, 60, and 75 minutes after treatment. At 90 minutes, glycopyrrolate was administered IV, and measurements were repeated at 95 minutes. Cardiac index (CI), stroke volume, stroke index, systemic vascular resistance (SVR), and left ventricular work were calculated. End-tidal halothane concentration was decreased to 0.8% from 17 to 45 minutes and to 0.5% from 47 to 95 minutes for OXY and O/B, whereas for SAL, it was maintained at 1.5 and 1.2%, respectively. Samples were obtained at 0, 2, 5, 15, 30, 45, 60, and 95 minutes for measurement of serum opiate concentration and comparison with values after IM administration of OXY. RESULTS: HR decreased, but CVP and SVR increased in response to OXY and O/B. These changes were reversed after IV administration of glycopyrrolate, resulting in significant increase in CI, compared with that in response to SAL. Serum opiate concentration increased markedly and peaked within 15 minutes after OXY and O/B administration but did not differ from values after IM administration. CONCLUSIONS: Epidural administration of OXY results in rapid systemic uptake and decreased HR. Glycopyrrolate administration improves HR, resulting in improved CI at equipotent halothane concentrations.

Analgesia, Epidural↗

PubMed2002

Adverse reaction to atropine and the treatment of organophosphate intoxication.

Atropine is the drug of choice for treatment of organophosphate nerve agent and insecticide intoxication and has been used for this indication for several decades. Adverse reactions to atropine may occur, and are of two types: toxic and allergic. Toxic reaction, the most common form, results from the anti-muscarinic effects of the drug. Since it is most probably related to interpersonal variation in sensitivity to atropine, toxic effects may appear at the usual therapeutic doses. The second type, allergic reaction, includes local manifestations, usually after the administration of eyedrops, and systemic reaction in the form of anaphylaxis. Since most patients manifest only a mild reaction, allergy testing is not performed and the prevalence of allergy to atropine is therefore not known. Severe allergic reaction to atropine is rare, as evidenced by the small number of case reports in the literature despite the drug's extensive use. Alternative anti-muscarinic drugs recommended for OP poisoning include glycopyrrolate and scopolamine. Glycopyrrolate is a peripheral anti-muscarinic drug that has been studied in comparison to atropine for many clinical indications, while scopolamine is an anti-muscarinic drug with both peripheral and central effects. An acceptable alternative regimen for patients with proven allergy to atropine is a combination of glycopyrrolate with centrally active drugs such as benzodiazepines or scopolamine.

Atropine↗

PubMed1991

Nuclear imaging of the stomach of healthy dogs.

To evaluate the use of technetium pertechnetate (99mTcO4) as a means of estimating gastric mucosal integrity, nuclear images of the empty stomach were obtained from 6 dogs at 20, 40, 60, 120, 180, and 240 minutes after IV administration of the radiopharmaceutical. Blood and gastric secretion samples were collected during the same time intervals. The left lateral-view image of the stomach was used to calculate the relative fraction of the dose in the stomach and the count density ratio. Between 20 and 40 minutes and 40 and 60 minutes, significant differences (P less than 0.001) were apparent in the amount of 99mTcO4 in the stomach. Blood concentration of 99mTcO4 decreased significantly (P less than 0.001), whereas gastric secretion concentration increased significantly (P less than 0.001) over time. Qualitative assessment of the gastric nuclear scans and the statistical analytic results indicated that the optimal time for imaging the canine stomach was between 40 and 60 minutes after radiopharmaceutical administration. In a second study, the same dogs were pretreated with the H2-receptor antagonist cimetidine and the cholinergic antagonist glycopyrrolate to block gastric secretions. Over time, changes in the relative dose fraction in the stomach and the density ratio were the same as values obtained during the experiment performed without use of cimetidine and glycopyrrolate. Results of the study indicate that nuclear imaging with 99mTcO4 outlines normal canine gastric mucosa and that pretreatment with cimetidine and glycopyrrolate has no effect on the quality of the gastric image.

Animals↗

PubMed1980

Cimetadine as a preoperative medication to reduce the complications of aspiration of gastric contents.

In an effort to decrease gastric residual and acid content prior to operation and thus to decrease the risk of aspiration, a prospective clinical trial comparing three drugs was carried out. Eighty-four patients undergoing elective craniotomy for a space-occupying lesion were studied. Twenty-eight patients were premedicated with the anticholinergic atropine (0.01 mg/kg); 28 patients were administered the anticholinergic glycopyrrolate (0.005 mg/kg); and 28 patients were given three preoperative doses of cimetadine and no anticholinergic. Gastric acidity was elevated above pH 2.5 in 93% of those receiving cimetadine, in comparison to 54% for glycopyrrolate and 29% with atropine. In addition, the stomach was completely dry in 54% following cimetadine, and in only 25% and 11% following glycopyrrolate and atropine. Cimetadine is more effective as a preanesthetic agent than anticholinergic drugs in decreasing gastric residual and acid content, and essentially eliminates the risk of aspiration.

Adolescent↗

PubMed1993

Alterations in the arrhythmogenic dose of epinephrine after xylazine or medetomidine administration in halothane-anesthetized dogs.

Eight dogs (12.5 to 21.5 kg) were assigned at random to each of 3 groups that were not given glycopyrrolate (HS, HX, HM) and to each of 3 groups that were given glycopyrrolate (HGS, HGX, HGM). Dogs were anesthetized with halothane (1.31% end-tidal concentration), and ventilation was controlled (PCO2 35 to 40 mm of Hg end-tidal concentration). Glycopyrrolate was administered IV and IM at a dosage of 11 micrograms/kg of body weight, each. Saline solution, xylazine (1.1 mg/kg, IM), or medetomidine (15 micrograms/kg, IM) was administered 10 minutes after baseline arrhythmogenic dose of epinephrine (ADE) determination. Redetermination of the ADE at the same infusion rate was started 10 minutes after drug administration. Arrhythmogenic dose was determined by constant infusion of epinephrine at rates of 1.0 and 2.5 micrograms/kg/min. The ADE was defined as the total dose of epinephrine inducing at least 4 ectopic ventricular depolarizations within 15 seconds during a 3-minute infusion or within 1 minute after the end of the infusion. Total dose was calculated as the product of infusion rate and time to arrhythmia. Statistical analysis of the differences between baseline ADE and posttreatment ADE for groups HS, HX, and HM was performed by use of one-way ANOVA.(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenergic alpha-Agonists↗

PubMed1993

Alterations in the arrhythmogenic dose of epinephrine after xylazine or medetomidine administration in isoflurane-anesthetized dogs.

Eight dogs (body weight, 12.5 to 21.5 kg) were assigned at random to each of 3 treatment groups (IS, IX, IM) that were not given glycopyrrolate and to each of 3 groups that were given glycopyrrolate (IGS, IGX, IGM). Dogs were anesthetized with isoflurane (1.95% end-tidal concentration), and ventilation was controlled (PCO2, 35 to 40 mm of Hg end-tidal concentration). Glycopyrrolate was administered IV and IM at a dosage of 11 micrograms/kg of body weight, each. Saline solution, xylazine (1.1 mg/kg, IM), or medetomidine (15 micrograms/kg, IM) was administered 10 minutes after baseline ADE determination. Redetermination of the ADE at the same infusion rate was started 10 minutes after drug administration. Arrhythmogenic dose was determined by constant infusion of epinephrine at rates of 1.0, 2.5, and 5.0 micrograms/kg/min. The ADE was defined as the total dose of epinephrine that induced at least 4 ectopic ventricular depolarizations within 15 seconds during a 3-minute infusion, or within 1 minute after the end of the infusion. Total dose was calculated as the product of infusion rate and time to arrhythmia. Statistical analysis of the differences between baseline and treatment ADE values was performed by use of one-way ANOVA. Mean +/- SEM baseline ADE values for groups IS, IX, and IM were 1.55 +/- 0.23, 1.61 +/- 0.28, and 1.95 +/- 0.65 micrograms/kg, respectively. Differences for groups IS, IX, and IM were -0.12 +/- 0.05, -0.31 +/- 0.40, and -0.17 +/- 0.26, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenergic alpha-Agonists↗

PubMed2005

Pharmacokinetic and pharmacodynamic evaluations of the zwitterionic metabolite of a new series of N-substituted soft anticholinergics.

PURPOSE: This study was conducted to evaluate the zwitterionic common metabolite of a novel series of N-substituted soft analogs of glycopyrrolate both as racemates and as 2R isomers. METHODS: Activities were assessed using both in vitro (receptor binding assay, guinea pig ileum pA2 assay) and in vivo techniques (rabbit mydriatic response, rat cardiac effects). Pharmacokinetic characterizations in rats were also performed. RESULTS: The metabolite was highly water-soluble and very stable in buffer solutions as well as in rat biological media. Following i.v. administration in rats, it was very rapidly eliminated, mainly through renal excretion with a half-life of about 10 min. Receptor binding and guinea pig ileum assays indicated this metabolite as more than 1 order of magnitude less active than its parent soft drugs or glycopyrrolate. Moderate M3/M2 muscarinic receptor subtype selectivity was observed, further reducing the likelihood of cardiac side effects. The metabolite showed to some extent mydriatic effect and protective effect against carbachol-induced bradycardia, but of much shorter durations than glycopyrrolate; it had, however, no effect on resting heart rate. CONCLUSIONS: N-Substituted zwitterionic metabolites retain some, but only considerably reduced activity of their parent quaternary ammonium ester soft anticholinergic drugs, and they are very rapidly eliminated from the systemic circulation. They are suitable for their assigned role within the framework of inactive metabolite-based soft anticholinergic design.

Administration, Topical↗

PubMed2005

The falcine trigeminocardiac reflex: case report and review of the literature.

BACKGROUND: Trigeminocardiac reflex (TCR), the reproducible hypotension and bradycardia upon stimulation of the trigeminal nerve, has been reported during craniofacial surgery and during surgery within the cerebellopontine angle, petrosal sinus, orbit, and trigeminal ganglion. Whereas the falx cerebri is known to be innervated by the nervus tentorii, a recurrent branch of V1, there have been no reports to date of this response upon mechanical stimulation of the falx. CASE DESCRIPTION: We report a case of immediate, reproducible, and reflexive response of asystole upon stimulation of the falx cerebri during operative resection of a parafalcine meningioma in a 53-year-old woman. Upon recognition of the reproducible relationship between falcine stimulation and increased vagal tone, the patient was given glycopyrrolate in an effort to block cholinergic hyperactivity. After glycopyrrolate was given, no further dysrhythmias occurred. CONCLUSION: In this patient, mechanical stimulation of the falx likely resulted in the hyperactivity of the trigeminal ganglion, thereby triggering TCR. The dorsal region of the spinal trigeminal tract includes neurons from hypoglossal and vagus nerves, and projections have been seen between the vagus and trigeminal nuclei. The vagus provides parasympathetic innervation to the heart, vascular smooth muscle, and abdominal viscera. Vagal stimulation via these connections after trigeminal nerve activation likely accounts for the reflexive response of asystole seen in this patient. This is confirmed by the observation that the reflex was inhibited by the anticholinergic effects of glycopyrrolate. Awareness of TCR allows for early detection and appropriate treatment.

Blood Pressure↗