All posts by The Trauma Pro

Guidelines

When To Call Facial Surgery

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This is a continuation of the when to call series that started last week. Facial injuries are another problem area where trauma professionals just reflexively call their plastic / ENT / OMFS surgeon for anything that happens to the face. This results in many unnecessary calls at off hours in centers that have them on call, and many unnecessary transfers in those that don’t.

The trauma group at the University of Arizona-Tucson recently published a paper that was presented at the annual meeting of the Western Trauma Association early this year. They sought to develop a facial injury guideline to standardize inter-hospital transfers for patients with facial fractures. With only a little effort, it could also be used to reduce the need for facial consultant services at higher-level trauma centers.

They retrospectively reviewed five years of data covering patients with craniomaxillofacial trauma transferred to their center. These patients were primarily transferred for the management of these injuries. The researchers analyzed the usual demographics, mode of transport, eventual ED disposition, insurance type, and hospital cost and reimbursement. Comprehensive information on what the facial service did was also reviewed.

A facial injury guideline (FIG) was developed using an expert panel of facial surgeons. They judged each incoming transfer as appropriate if the patient required immediate operation shortly after arrival, had an intervention during the hospital stay, or was admitted to a floor bed. In cases where there was no consensus on appropriateness, the presence of “alarming signs” was used as a tie-breaker for appropriateness. These generally consisted of visual disturbances, restricted eye motion, retrobulbar hemorrhage, and either a mandibular condyle neck fracture or a bilateral mandibular fracture. Transfer appropriateness was then tested against the FIG guidelines.

Here are the factoids:

  • Of the 511 patients transferred to this Level I center, half (51%) were deemed potentially unnecessary since they did not require intervention or admission
  • Of the remaining 252 patients, 54% were admitted to a floor bed, 15% had emergent surgery, and 79% underwent other intervention while in the hospital
  • Four-fifths of the potentially unnecessary transfers had a facial surgery consultation, and most were discharged from the ED with a median length of stay of six hours

Based on these findings, the FIG was finalized. Here’s the full guideline:

Click here to view the full-size guideline

And here is the algorithm that includes the alarming signs to look for:

Click here to view the algorithm with alarming signs

Bottom line: So how can you use this information?

If you are a Level III or IV trauma center / transferring hospital, first use the FIG guideline to determine if a transfer is necessary. If the interpretation requires additional information (yellow blocks), refer to the algorithm to determine if the patient exhibits alarming signs that justify transfer. Patients with “do not transfer” conditions (red blocks) should be scheduled for outpatient follow-up with the appropriate specialist.

If you are a Level I or II center with facial surgery coverage, patients with injuries in the red blocks can be followed up as an outpatient. If you really, really want to consult a specialist, do so during regular business hours, because they are most likely going to schedule the patient for an outpatient visit anyway. Patients with injuries in the green blocks, and those in the yellow blocks with alarming signs, should generate a consult immediately. All others are not urgent or emergent and can wait until morning.

Reference: Look me in the face and tell me that I needed to be transferred:
Defining the criteria for transferring patients with isolated facial injuries. J Trauma Acute Care Surg. 2025 May 9. doi: 10.1097/TA.0000000000004651. Epub ahead of print. PMID: 40341445.

Guidelines

When To Call Urology

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This is the second post in my series about calling your consultants wisely. The previous post focused on ophthalmology (heh heh). This one provides some useful guidance on calling your urology consultant.

This set of guidelines is concise enough to fit on an index card. The reason is that there are very few urologic injuries that can’t wait to be seen until the next day. Even simple bladder injuries (and most are) can easily be repaired by the trauma surgeon. There’s no magic to it.

In the next post, I’ll share some guidelines for managing facial injuries that were very recently published.

Click here to download the pdf file

Guidelines

When To Call Your Consultants

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One of the growing problems in trauma care is accessing surgical subspecialists when needed. Across the US, it is getting increasingly more difficult to recruit specialists in urology, reconstructive plastic surgery, hand surgery, oral/maxillofacial surgery, and ophthalmology.

This is a challenge for all levels of trauma centers. For Level I centers, it’s primarily a recruitment issue. For Levels II-IV, it becomes a transfer issue. For all levels, the real question is, when do you really need to call them? One reason for the shortage problem is that we tend to call too much, bothering them when they are not needed.

The best practice for trauma centers of all levels is to collaborate with subspecialists and develop a practice guideline that lists commonly encountered clinical problems in their field, along with the consult and follow-up expectations for each. Frequently, a large portion of patients can go home and follow up with the subspecialist as an outpatient.

I’ve prepared several sample practice guidelines for you to use in your conversations with your own subspecialists. Today, I’ll publish my ophthalmology guideline. In the next post, I’ll cover urology. And finally, I’ll review some new guidelines for facial injuries that were recently published.

Here’s the eye guideline. You can download it by clicking on it or using the links below.

Or click this link to download

Complications

Giving Vitamin D After Fracture: Helpful Or Not?

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The role of Vitamin D in fracture healing is well known. So, of course, trauma professionals have tried to promote Vitamin D supplementation to counteract the effects of osteoporosis. A meta-analysis of 12 papers on the topic, relating to hip and other non-vertebral fractures, showed a roughly 25% risk reduction for any non-vertebral fractures in patients taking 700-800 IU of Vitamin D supplements daily.

Sounds good, right? So what about taking Vitamin D after a fracture occurs? Seems like it should promote healing, right? A large meta-analysis published in an orthopedic journal examined this very question.

Unfortunately, there was a tremendous variability in the interventions, outcomes, and measures of variance. The authors were limited to summarizing individual papers, and a proper meta-analysis could not be conducted.

Here are the factoids:

  •  81 papers made the cut for final review
  • A whopping 70% of the population with fractures had low Vitamin D levels
  • Vitamin D supplementation in hospital and after discharge did increase serum levels
  • Only one study, a meeting abstract which has still not seen the light of day in a journal, suggested a trend toward fewer malunions following a single loading dose of Vitamin D

Bottom line: Vitamin D is an excellent idea for people who are known to have, or are at risk for, osteoporosis and fractures. It definitely toughens up the bones and lowers the risk of fracture. However, the utility of giving it after a fall has not been shown. Of the 81 papers reviewed, none showed a significant impact on fracture healing. The only good thing is that Vitamin D supplements are cheap. Giving them may make us think that we are helping our patient heal, but it’s not. 

What about the use of calcitonin for preventing future fractures? Find that in my next post!

References:  

  • What is the role of vitamin D supplementation in acute fracture patients? A systematic review and meta-analysis of the prevalence of hypovitaminosis D and supplementation efficacy. J Orthopaedic Trauma 2016 Feb;30(2):53-63.
  • Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials. JAMA 293(18):2257-2264, 2005.
Abdomen

More Targeted Angioembolization For Blunt Splenic Injury

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There has been a steady shift in the management of blunt splenic injury over the past thirty years. Prior to that, these injuries were usually treated with a trip to the operating room, and most often with splenectomy. There was a time when operative “splenic salvage” procedures were popular, like splenorrhaphy or wrapping the organ in a mesh bag.  But this faded as surgeons worried about the possibility of continued bleeding.

As CT scans improved in resolution, the ability to identify these injuries and grade them in a way that roughly predicted the risk of bleeding also improved, and the movement toward nonoperative splenic preservation began. As the availability of interventional radiology increased, it became an important tool in boosting the success rate of nonoperative management. The success rate numbers I typically cite for nonoperative management of carefully selected patients are 85% without IR, and up to 93% when it is used as an adjunct.

Different trauma centers developed their own indications for the use of interventional radiology. Some used this study on most of their patients with spleen injuries. Some based their usage on spleen injury grade. Some looked at the presence of contrast extravasation or pseudoaneurysm.

Any time different providers or groups or trauma centers treat the same problem differently, it’s important to ask, “Who is actually doing it right?” They can’t all be.

A multi-institutional group hypothesized that CT scans may now be so accurate that this study can help us use interventional radiology more selectively and maintain the same high success rate in avoiding surgery. Retrospective data on blunt splenic injury management were collected at a single Level I trauma center (the R Adams Cowley Shock Trauma Center) over a 7.5-year period. It focused on patients with injury grades above I, and reviewed the usual demographics, mechanisms, and the specific findings identified on CT scan. This center transitioned to a less aggressive treatment approach halfway through the study period.

During the first half, the management and use of angiography were at the discretion of the individual surgeons. In the second half, all Grade III and any Grade IV injury with “low-risk” features (isolated pseudoaneurysm, small hemoperitoneum, intact parenchyma) were scheduled for angiography within 12 hours and embolization of any vascular injuries identified.  Grade V injuries and grade IV injuries with “high-risk” features (large hemoperitoneum, pseudoaneurysm >10mm, significant parenchymal disruption) underwent angiography within two hours with mandatory splenic artery embolization.

All patients underwent repeat CT between 48 and 72 hours later.  The authors followed the change in their rate of splenic artery embolization, splenectomy, and delayed splenectomy. Their secondary endpoints were ICU and hospital lengths of stay.

Here are the factoids:

  • There were 369 patients enrolled in the first half of the trial, and 471 in the second half
  • The rate of embolization decreased from 29% to 17%
  • Splenectomy rate remained the same (30% vs 34%)
  • Delayed splenectomy rate increased from 1.9% to 3.6%, but was not statistically significant (p = 0.14)
  • Hospital length of stay increased significantly (by one day) after the transition to the new algorithm

The authors concluded that implementing their treatment algorithm reduced the use of angiography without increasing overall or delayed splenectomy rates.

Bottom line: The authors acknowledged several limitations in their study, including the arbitrary definition of “high-risk” findings, surgeon and angiography variability based on surgeon preference, and the study’s retrospective nature.

At first blush (heh-heh), their new algorithm looks like it could reduce the overall utilization of angiography and embolization. However, I see several issues that might make their results difficult to generalize to other trauma centers:

  • The algorithm was not religiously followed, and there were multiple opportunities for surgeon judgment to cloud the results
  • The splenectomy rate was over 30% both pre- and post-change!! This is the highest rate I’ve ever seen. This means that despite their decreased use of angiography, they are still losing far too many spleens.
  • Their new two-hour to angio algorithm does not fit into the 60-minute response required at ACS trauma centers, so those centers can’t readily adopt it.

I’m a big believer in conservative management of solid organ injuries in carefully selected patients (primarily vital signs and abdominal exam). This paper gives us a hint on how a change in indications for interventional radiology might favorably impact the use of this tool. However, this paper won’t change my practice because the parameters this center used are still too loose and variable, evidenced by their sky-high splenectomy rate to date.

For now, maintain a fixed set of indications for immediate (within 60 minutes) and delayed (add to elective IR schedule), and carefully select your patients for possible nonoperative management. In this way, you can optimize your use of interventional radiology and take out far fewer than 30% of injured spleens.

Reference: A more targeted embolization strategy in blunt splenic trauma reduces procedural volume without increasing splenectomy rates. Journal of Trauma and Acute Care Surgery:10.1097/TA.0000000000004710, July 17, 2025.