Broken nose, broken dives?

[Dirty-Dog]

Quick question, if there happens to be an ENT in the room...

I'm an ER/Flight nurse. Last weds (Apr 20th) a violent patient blind sided me and landed a solid punch to my nose. That's the only one he landed, but it was enough to break my nose.

Problem is, we're leaving for Cancun May 1st.

I'm a week out today, and I've still got quite a bit of swelling, and I am still running a low grade (max 100.2) fever. I can breath through it, but it's certainly restricted. It's not so swollen that it won't fit in my mask, and it's not so tender that I cannot pinch it if necessary to equalise.

The fracture is on the left side, and the alignment was good on the initial xrays.

Any reason why this ought to prevent me from diving next week? I'm OK spending two weeks laying on the beach sucking down tasty frozen drinks, but I'd rather dive.

Any suggestions for reducing the swelling? I've been doing ice packs and NSAIDS.

Thanks for any advice you can give.

 

[DocVikingo]

Bummer, dawg.

Might want to glance at this recent thread --> http://www.scubaboard.com/forums/diving-medicine/377539-please-help-medical-question.html

Sounds like you’re already doing the two most important things for the inflammation. Also, keep your head well-elevated when laying down/sleeping via pillows or raising of the head of the bed. A decongestant may make breathing easier.

I'd say if you can breathe and equalize normally (for obvious reasons Valsalvas may be out for the nonce) and are not distracted by discomfort whilst diving, go for it.

Nice thing is, either diving or vegging out, you win.

Best of luck.

Regards,

DocV

 

[doctormike]

Quick question, if there happens to be an ENT in the room...

I'm an ER/Flight nurse. Last weds (Apr 20th) a violent patient blind sided me and landed a solid punch to my nose. That's the only one he landed, but it was enough to break my nose.

Problem is, we're leaving for Cancun May 1st.

I'm a week out today, and I've still got quite a bit of swelling, and I am still running a low grade (max 100.2) fever. I can breath through it, but it's certainly restricted. It's not so swollen that it won't fit in my mask, and it's not so tender that I cannot pinch it if necessary to equalise.

The fracture is on the left side, and the alignment was good on the initial xrays.

Any reason why this ought to prevent me from diving next week?

Wow, too bad! Hopefully, you can equalize, etc... a nasal fracture shouldn't really affect that.

The main thing that we look for after an acute fracture is to rule out the presence of a septal hematoma (collection of blood under the mucosa lining the septum). This is very rare, but something that needs to be drained immediately. I don't know if anyone looked inside your nose, but in any case, it would be late for that at this point.

The second thing is the question of displacing the fracture by the pressure of the mask. It usually takes about 7-10 days for the fracture to heal, but I usually tell patients to avoid contact sports for two full weeks from the injury. I guess you would have to assess that by trying on the mask, but it is possible for steady pressure to displace the nasal bones. However, that would be more likely with side pressure, while a well fit mask would probably only press on the base of the nose at the top.

For swelling in general after any injury, it is cold packs for the first 24 hours, then warm packs after that..

Good luck, I wont ask you what you did to the patient...!

Mike

 

[Duke Dive Medicine]

Ouch. Hate to hear that. A little vecuronium takes the fight right out of guys like that. You can even ventilate them if you're feeling charitable

 

[DocVikingo]

The main thing that we look for after an acute fracture is to rule out the presence of a septal hematoma (collection of blood under the mucosa lining the septum). This is very rare, but something that needs to be drained immediately. I don't know if anyone looked inside your nose, but in any case, it would be late for that at this point.

Good point, doctormike.

As such hematomas can become infected within days after the fracture, do you think the reported low grade fever is of any clinical significance?

BTW, I agree that it seems considering drainage is more than a bit late in the game.

Regards,

Doc

 

[doctormike]

Good point, doctormike.

As such hematomas can become infected within days after the fracture, do you think the reported low grade fever is of any clinical significance?

BTW, I agree that it seems considering drainage is more than a bit late in the game.

Regards,

Doc

Well, I really couldn't say anything that specific over the Internet.

The bottom line is that while a hematoma is a big problem (because you can end up with collapse of the nasal dorsum if the septal cartilage dies), it is a very rare thing. I have taken care of hundreds of nasal fractures in children, and I have yet to see one. But still, it is the one thing that you need to rule out on the day of injury - other than that, there is no reason to see a nasal fracture patient until 2-3 days after injury so that you can examine them once the swelling goes down. We usually do a closed reduction around day 5-10.

If the OP is around some other docs, maybe someone could just take a look with an otoscope or something - a septal hematoma is usually pretty obvious... although at this point it is sort of late...

 

[Dirty-Dog]

Good luck, I wont ask you what you did to the patient...!

Mike

I subdued him with the minimum required force. Of course.

Ouch. Hate to hear that. A little vecuronium takes the fight right out of guys like that. You can even ventilate them if you're feeling charitable

I'm a big fan of vec. If he'd been an idiot in the helicopter, I'd have RSI'd him in a heartbeat. But I was just trying to help out the ER staff.

Well, I really couldn't say anything that specific over the Internet.

The bottom line is that while a hematoma is a big problem (because you can end up with collapse of the nasal dorsum if the septal cartilage dies), it is a very rare thing. I have taken care of hundreds of nasal fractures in children, and I have yet to see one. But still, it is the one thing that you need to rule out on the day of injury - other than that, there is no reason to see a nasal fracture patient until 2-3 days after injury so that you can examine them once the swelling goes down. We usually do a closed reduction around day 5-10.

If the OP is around some other docs, maybe someone could just take a look with an otoscope or something - a septal hematoma is usually pretty obvious... although at this point it is sort of late...

Well, I did not have a septal hematoma initially. Yesterday I saw the Workman Comp Dr and mentioned that I'd had a lot more swelling along the septum than I thought was good, considering that it was 6 days since the injury, and that I'd been running a low grade fever. He said everything looked fine and to see ENT in a few weeks after we got back from Cancun.

That didn't seem right to me, but he's a Dr and I'm a nurse, so what do I know, right?

Enough to blow him off. I was at the hospital for a meeting, so I asked one of our ER Dr's to take a peek (hard to look up your own nostril...). Big septal hematoma. Headed over to see an ENT (who happens to dive) to have it drained. Oooops. Aspirated pus, so I've got a septal hematoma and an abcess. I&D'd it, of course. Gotta love those nasal splints.

Started on Augment, and he says if I'm not a LOT better by tomorrow, then I need to go inpt for IV antibiotics. He's a bit worried about sepsis, since sepsis and septic emboli are apparently far too common with septal abcess.

On the other hand, it's 5 days before we dive. He says if I'm better tomorrow, the trip should be no problem. Just have to remove the splints before I hit the water the first time.

And I got the police report. They apparently know the guy well, since he's often violent. Class 1 felony assault, and he's looking at 5 years.

 

[doctormike]

Well, I did not have a septal hematoma initially. Yesterday I saw the Workman Comp Dr and mentioned that I'd had a lot more swelling along the septum than I thought was good, considering that it was 6 days since the injury, and that I'd been running a low grade fever. He said everything looked fine and to see ENT in a few weeks after we got back from Cancun.

That didn't seem right to me, but he's a Dr and I'm a nurse, so what do I know, right?

Enough to blow him off. I was at the hospital for a meeting, so I asked one of our ER Dr's to take a peek (hard to look up your own nostril...). Big septal hematoma. Headed over to see an ENT (who happens to dive) to have it drained. Oooops. Aspirated pus, so I've got a septal hematoma and an abcess. I&D'd it, of course. Gotta love those nasal splints.

Started on Augment, and he says if I'm not a LOT better by tomorrow, then I need to go inpt for IV antibiotics. He's a bit worried about sepsis, since sepsis and septic emboli are apparently far too common with septal abcess.

On the other hand, it's 5 days before we dive. He says if I'm better tomorrow, the trip should be no problem. Just have to remove the splints before I hit the water the first time.

And I got the police report. They apparently know the guy well, since he's often violent. Class 1 felony assault, and he's looking at 5 years.

Wow! I'm SO glad that you got that drained...! Might make a big difference in the ultimate support of your nasal dorsum and appearance of the external nose, not to mention the immediate infectious complications....

Good luck, happy diving!

Mike