Iatrogenic oculocardiac reflex in a patient with head injury

A 16-year-old girl with a history of a recent fall from the third floor was transferred to the emergency room. On presentation, the patient, who had sustained multiple facial fractures, was in clinical shock with a blood pressure 80/40 mm Hg, heart rate 130/min, tachypnea (>30/min), Po2 50 mm Hg, and So2 82%, and she was intubated for airway protection. Severe nasal hemorrhage was detected (hematocrit: 22%), therefore a bilateral anteroposterior balloon nasal catheter was inserted and inflated with air. Bleeding was controlled. A few minutes later, her heart rate dropped to 40/min. Atropine was administered intravenously and the rate increased to 60/min. Computed tomography of the head revealed brain and subarachnoid hemorrhage, multiple fractures of the facial skeleton, and a round foreign body, full of air, compressing the left eye. The medial wall and the floor of the ipsilateral orbit were also fractured, establishing a naso-orbital communication. The left catheter was immediately removed. Heart rate was restored to normal. Facial fractures were addressed surgically. Patient's vision is intact.