Immediate Management of Nasal Trauma with Neurological Symptoms
This patient requires urgent neuroimaging (CT head without contrast) before any symptomatic treatment, as new-onset dizziness and blurry vision following head/facial trauma are red flags for intracranial injury, and ibuprofen alone is insufficient until life-threatening pathology is excluded. 1
Critical Initial Assessment
Neuroimaging is mandatory as the first step when evaluating headache or neurological symptoms with red flags such as new onset symptoms following trauma, particularly with dizziness and visual disturbances 1. The CT scan must be obtained before initiating symptomatic treatment to rule out:
- Intracranial hemorrhage (subdural, epidural, subarachnoid)
- Skull fracture with or without brain injury
- Orbital fracture with potential muscle entrapment
- Cerebral contusion or edema 2, 1
Specific Examination Priorities
Beyond standard vital signs, perform targeted assessments for:
- Ophthalmologic evaluation: Visual acuity, pupillary examination, confrontational visual fields, extraocular movements, and assessment for diplopia, as facial trauma can cause orbital fractures with vision-threatening complications 2
- Oculocardiac reflex screening: Check for bradycardia, nausea, vomiting, or loss of consciousness, which may indicate entrapped orbital muscle requiring urgent surgical intervention 2
- Nasal examination: Assess for septal hematoma, CSF rhinorrhea (clear fluid drainage), and structural deformities 2
- Neurological examination: Mental status, cranial nerve function, motor/sensory testing, and cerebellar signs to assess for traumatic brain injury 1
Post-Imaging Management Algorithm
If Imaging Shows Significant Pathology:
- Orbital fracture with entrapment: Immediate surgical consultation if oculocardiac reflex present; repair within 2 weeks if symptomatic diplopia with positive forced ductions 2
- Intracranial hemorrhage: Neurosurgical consultation and admission 1
- Skull fracture: Specialist evaluation based on location and severity 2
If Imaging is Negative for Acute Pathology:
Treat the post-traumatic headache and concurrent upper respiratory symptoms:
- For headache: Naproxen 500-825 mg orally at onset (if no contraindications), can repeat every 2-6 hours as needed, maximum 1.5 g/day, limited to 3 consecutive days and no more than twice weekly overall to prevent medication-overuse headache 3
- Add antiemetic if nausea present: Metoclopramide 10 mg orally or IV provides synergistic analgesia beyond just treating nausea 3
- For congestion/rhinorrhea: These symptoms lasting 4 days suggest viral upper respiratory infection rather than acute bacterial sinusitis (which requires ≥7 days of symptoms) 2
Upper Respiratory Symptom Management
The 4-day history of congestion, runny nose, and sore throat most likely represents a viral upper respiratory infection, not requiring antibiotics 2. Supportive measures include:
- Adequate rest and hydration
- Warm facial packs and steamy showers
- Sleeping with head of bed elevated
- Continue NSAIDs for symptom relief 2
Antibiotics are NOT indicated unless symptoms persist beyond 7 days or worsen significantly, suggesting progression to acute bacterial sinusitis 2.
Diarrhea Consideration
The concurrent diarrhea may represent:
- Viral gastroenteritis (most likely given concurrent URI symptoms)
- NSAID-related GI effects from ibuprofen use 4
Monitor for dehydration and ensure adequate fluid intake. If diarrhea persists or worsens, consider holding NSAIDs temporarily 4.
Critical Red Flags Requiring Immediate Re-evaluation
Return immediately or call emergency services if:
- Worsening headache or new severe "thunderclap" headache
- Persistent or worsening visual changes
- Confusion, altered mental status, or difficulty speaking
- Seizure activity
- Persistent vomiting
- Clear fluid drainage from nose (possible CSF leak)
- Fever with severe headache or neck stiffness 1