Approach to the Critical Patient

Immediate priorities

Airway and hemorrhage threats

Septal hematoma — the critical do-not-miss

Red flag recognition

Critical alarm features requiring urgent action

Monitoring and disposition targets

Vital sign priorities

Consultation triggers

History

Mechanism and injury context

Mechanism of injury

Injury timing

Symptom characterization

Primary complaints

Alarm symptoms

Risk factors and history

Bleeding risk

Prior nasal history

Social context

Pediatric-specific history

Physical Exam

Facial and nasal inspection

Facial inspection

Nasal palpation

Anterior rhinoscopy — mandatory

Rhinoscopy with headlamp and nasal speculum

Orbital and neurological exam

Extraocular movements

Pupillary exam

Visual acuity screen

Cranial nerve V exam

Occlusion and otoscopy

Dental occlusion

Otoscopy

Oropharynx

PITFALLS

Missed septal hematoma

Missed associated fractures

Differential Diagnosis

Life-threatening and urgent diagnoses

Basilar skull fracture

Naso-orbital-ethmoid (NOE) fracture

Le Fort fracture

Orbital floor blowout fracture

Zygomatic complex fracture

Common mimics

Nasal soft tissue contusion without fracture

Septal fracture without nasal bone fracture

Nasal cartilage injury

Septal hematoma

Nasal bone fracture subtypes

Type I — simple, non-displaced (13.8%)

Type II — displaced fractures

Type III — comminuted with telescoping or depression (2.6%)

Laboratory Tests

Routine workup

Isolated nasal fracture without complications

Targeted lab testing

Bleeding and coagulation assessment

Pregnancy testing

Point-of-care glucose

CSF rhinorrhea workup

Beta-2 transferrin assay

Diagnostic Tests

Scoring Systems

Nasal fracture classification (CT-based)

MRI

MRI for nasal bone fracture

CT

CT maxillofacial without contrast

CT head without contrast

Ultrasound

Point-of-care ultrasound (POCUS) for nasal fracture

Disposition

Discharge criteria

Safe for ED discharge

Admission criteria

Indications for hospital admission

Specialist consultation triggers

Immediate consultation

Outpatient referral

Treatment

Epistaxis control

Acute hemorrhage management

Septal hematoma drainage

Incision and drainage procedure

Analgesia

First-line analgesia — multimodal approach

Opioid analgesia

Local and regional anesthesia for reduction

Closed reduction

Timing of closed reduction

Closed reduction technique

Conservative management (non-displaced fractures)

Non-displaced fracture care

Delayed surgical options

Open septorhinoplasty

Special Populations

Pregnancy

Imaging considerations in pregnancy

Analgesia in pregnancy

Septal hematoma drainage in pregnancy

Geriatric

Fall epidemiology

Anticoagulation considerations

Fracture healing and reduction

Analgesia in elderly

Pediatrics

Epidemiology and anatomy

Septal hematoma in children

Imaging in children

Reduction in children

Analgesia in children

Background

Epidemiology

Incidence and prevalence

Etiology distribution

Fracture type distribution (CT-based series)

Pathophysiology

Anatomic vulnerability

Cartilaginous septum injury

Swelling dynamics

Associated injury mechanism

Therapeutic Considerations

Clinical vs radiographic diagnosis

Reduction timing evidence

Antibiotic use evidence

Opioid stewardship

Patient Discharge Instructions

copy discharge instructions

Diagnosis and overview

Home care instructions

Follow-up instructions

Return to emergency department immediately for

References

Guidelines and key sources

ACR Appropriateness Criteria — Imaging of Facial Trauma Following Primary Survey

Hwang K, Yoon JM — Analysis of Nasal Bone Fractures: A 17-Year Study of 3785 Patients

Kucik CJ, Clenney T, Phelan J — Management of Acute Nasal Fractures

Paliwoda ED et al. — Acute Management of Nasal Bone Fractures: A Systematic Review and Practice Management Guideline

Trujillo O, Lee C — Nasal Fractures: Acute, Subacute, and Delayed Management

Septal hematoma and complications

Ali HM et al. — Nasal Septal Hematoma in Children: Time to Diagnosis and Resulting Complications

Sayin I et al. — Nasal Septal Hematoma and Abscess in Children

Guchlerner L et al. — Nasal Septal Hematoma Is a Rare and Self-Recognizable Complication of Nasal Bone Fracture

Imaging and ultrasound

Caglar B et al. — The Accuracy of Bedside USG in the Diagnosis of Nasal Fractures

Noy R et al. — Ultrasound for Management of Pediatric Nasal Fractures

Westfall E et al. — Nasal Bone Fractures and the Use of Radiographic Imaging: An Otolaryngologist Perspective

Analgesia and treatment

Qaseem A et al. — Nonpharmacologic and Pharmacologic Management of Acute Pain From Non-Low Back Musculoskeletal Injuries (ACP/AAFP)

Anne S et al. — Clinical Practice Guideline: Opioid Prescribing for Analgesia After Common Otolaryngology Operations (AAO-HNS)

Pinto R, Wright R, Ghosh S — Nasal Fractures: A Dedicated Clinic Providing Reduction Under Local Anaesthesia

Usman S — Management of Head and Neck Injuries by the Sideline Physician