Management of Acute Nasal Trauma with Syncope After Alcohol Intoxication
This 30-year-old requires immediate assessment for life-threatening complications—specifically septal hematoma and intracranial injury—before addressing the nasal fracture itself, as missing these can result in permanent disfigurement or death.
Immediate Priorities (First 15 Minutes)
Rule Out Critical Complications
Assess for septal hematoma immediately by examining the nasal septum for a bluish, fluctuant swelling that obstructs the nasal airway 1. This requires urgent drainage within 24-48 hours to prevent septal necrosis, saddle nose deformity, and abscess formation 1, 2.
Evaluate for signs of skull base fracture or intracranial injury:
- Clear rhinorrhea (CSF leak) 3, 2
- Periorbital ecchymosis ("raccoon eyes") 2
- Battle's sign (mastoid ecchymosis) 2
- Altered mental status beyond alcohol intoxication 3
The syncope is the critical red flag here—while likely vasovagal from pain/alcohol, you must exclude:
- Concussion or traumatic brain injury 3
- Ongoing intracranial bleeding 4
- Hemodynamic instability from blood loss 4
Control Active Epistaxis
If bleeding is present, apply firm sustained compression to the lower third of the nose for 10-15 minutes without interruption while the patient sits upright with head tilted slightly forward 4, 5, 6. If bleeding persists after compression, apply topical vasoconstrictors (oxymetazoline or phenylephrine spray) directly to the bleeding site 5, 6.
Diagnostic Workup
Imaging is NOT routinely indicated for isolated nasal fractures 1. However, this patient requires CT scan of the brain and facial bones given the syncope and mechanism of injury 4. The loss of consciousness mandates ruling out intracranial pathology before attributing symptoms solely to alcohol 4.
Plain radiographs are useless for nasal fractures and should not be ordered 1, 2.
Blood tests (CBC, coagulation studies) are only indicated if there was severe epistaxis requiring intervention 1.
Management of the Nasal Fracture
Timing Considerations
You have a 2-week window before displaced nasal bones begin to unite 1, 2. Do not attempt immediate closed reduction on-field or in the emergency department unless there is airway compromise 3. The acute swelling obscures the true deformity and makes assessment unreliable 2, 7.
Treatment Algorithm
For undisplaced fractures without functional symptoms (obstruction): Conservative management with ice, analgesia, and head elevation 1, 7.
For displaced fractures: Refer to ENT or facial plastic surgery within 5-7 days for closed reduction under local or general anesthesia 1, 2, 7. Waiting 3-5 days allows swelling to subside, making assessment and reduction more accurate 2, 7.
If septal injury is suspected (deviation, obstruction, hematoma), the patient requires evaluation by a specialist who can address both the bony and cartilaginous components, as isolated closed reduction of nasal bones without addressing septal pathology leads to persistent deformity in up to 50% of cases 2, 7.
Alcohol-Specific Considerations
The alcohol intoxication complicates your assessment in two critical ways:
Neurologic examination is unreliable—you cannot distinguish alcohol-induced altered mental status from traumatic brain injury 4. This mandates imaging rather than clinical observation alone 4.
Coagulopathy risk—chronic alcohol use may indicate underlying liver disease with impaired coagulation 5. If epistaxis was severe or difficult to control, check INR and platelet count 5, 1.
Disposition and Follow-Up
Admit or observe if:
- CT shows intracranial injury 4
- Septal hematoma requiring drainage 1, 2
- Persistent epistaxis despite packing 4
- Inability to assess neurologic status due to intoxication 4
Discharge with close follow-up if:
- CT brain is negative 4
- No septal hematoma 1
- Epistaxis controlled 4, 5
- Patient is neurologically intact once sober 4
Arrange ENT follow-up within 5-7 days for definitive assessment and potential closed reduction once swelling has subsided 1, 2, 7.
Critical Pitfalls to Avoid
Do not dismiss the syncope as "just alcohol"—loss of consciousness with head trauma requires imaging to exclude intracranial injury 4, 3.
Do not miss a septal hematoma—examine the septum directly in every nasal trauma patient, as this is a surgical emergency 1, 2.
Do not attempt immediate reduction—the acute swelling prevents accurate assessment and reduction, leading to suboptimal outcomes 3, 2, 7.
Do not order nasal X-rays—they provide no useful information and waste resources 1, 2.
Do not assume the fracture is "minor"—up to 50% of inadequately managed nasal fractures result in permanent cosmetic or functional deformity requiring subsequent rhinoplasty 2, 7.