What is the immediate management for a nasal fracture?

Immediate Management of Nasal Fracture

Apply firm sustained compression to the lower third (soft part) of the nose for at least 5 minutes as the first-line treatment for any active bleeding from a nasal fracture. 1, 2

Initial Assessment Priorities

Before addressing the nasal fracture itself, immediately assess for life-threatening conditions:

• Airway compromise from bleeding into the oropharynx or posterior pharynx 1, 2
• Hemodynamic instability from blood loss (tachycardia, syncope, orthostatic hypotension) 1
• Concurrent injuries including concussion, ocular injury, or cerebrospinal fluid leak 3
• Septal hematoma which requires urgent drainage to prevent cartilage necrosis 3, 4

Bleeding Control Algorithm

Step 1: Nasal Compression

• Apply firm sustained compression to the lower third of the nose for 5 minutes or longer without interruption 1, 2
• The patient or caregiver may assist with compression 1
• Do not prematurely check if bleeding has stopped during the compression period 2
• This simple measure stops bleeding in the majority of cases 2

Step 2: If Bleeding Continues

• Remove any blood clots and perform anterior rhinoscopy to identify the bleeding site 1, 2
• The source is commonly Kiesselbach's plexus in the anterior nasal septum 2
• Apply topical vasoconstrictors (oxymetazoline or phenylephrine), which stop 65-75% of nosebleeds 2
• Consider nasal cautery (chemical or electrical) for localized bleeding sites after anesthetizing the area 1, 2

Step 3: If Still Uncontrolled

• Apply nasal packing 1, 2
• Use resorbable packing specifically for patients on anticoagulants/antiplatelets or with bleeding disorders 1, 2

Imaging Decisions

CT maxillofacial is the imaging modality of choice when imaging is indicated for nasal fractures, as it provides superior detection of fractures compared to plain radiographs (sensitivity 53-82% for radiographs vs. near 100% for CT). 1

However, imaging is not required for all nasal fractures:

• Simple, isolated nasal fractures with minimal displacement may be managed clinically 3, 5
• CT is indicated for complex injuries, associated facial fractures, or when surgical planning is needed 1
• Plain radiographs have limited diagnostic value and do not alter management 1

Reduction Timing

• Do not attempt immediate closed reduction on the field/sideline unless there is airway compromise or the practitioner has specific experience 3
• Optimal timing for closed reduction is typically 3-10 days post-injury after edema subsides but before significant healing occurs 5, 6
• Severe septal fracture-dislocations may require primary septal reconstruction under general anesthesia to minimize secondary deformities 6

Critical Pitfalls to Avoid

• Failing to maintain compression for the full 5 minutes is the most common error in initial management 2
• Overlooking anticoagulant medications can lead to inadequate management; initiate first-line treatments before considering reversal of anticoagulation 1, 2
• Missing septal hematoma on examination, which appears as a boggy, bluish swelling of the septum and requires urgent drainage 4
• Attempting immediate reduction through traumatic edema, which obscures anatomy and increases failure rates 6

Documentation Requirements

Document the following risk factors that increase bleeding frequency or severity:

• Personal or family history of bleeding disorders 1, 2
• Current anticoagulant or antiplatelet medications 1, 2
• Intranasal drug use 2
• Hypertension, prior nasal surgery, or previous trauma 2

Patient Instructions

• Apply nasal saline sprays and humidification for prevention 2
• Provide clear instructions on proper home compression technique for future episodes 2
• Advise when to seek additional care: persistent bleeding >30 minutes, signs of infection, or breathing difficulty 1
• If the patient returns to sports, recommend wearing a face mask for 6 weeks after injury 3