Tag Archives: guideline

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

Serial Abdominal Examination: The Practice Guideline

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Last week, I published a preliminary practice guideline for nonoperative management of abdominal stab wounds. Click here to view it. A key part of that guideline is the serial abdominal exam. Surgeons talk about this a lot, but how do you do it? I posted about many of the details here.

The serial exam is nuanced enough so that it deserves its own clinical practice guideline! You won’t find this in any doctor or nursing books. It’s really simple, but the devil is truly in the details.

Click this image or the link below to download the guideline. I’ve also posted a Microsoft publisher version in case you want to modify it to suit your center.

Please feel free to email or post comments and questions in the area below this post!

References:

Guidelines

When To Call: Orthopedic Surgery

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And here’s the last in my short “When To Call” series. This one’s a little different, and quite a bit longer. That’s due to the complexity and sheer number of potential orthopedic problems.

When consulting a specialty service, always keep the patient paramount in your decision making. Then think about how soon and under what context they really need to see the patient. Can it wait until morning? Do they even really need to be seen in the ED, or can this be an outpatient visit?

Tomorrow: Expectations on how your consultants should go about their business when seeing your patients.

Guidelines, protocols

Why Can’t I Do Things The Way I Want?

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Most trauma centers have a book of practice protocols or guidelines. Actually, it is required by the American College of Surgeons verification standards. All centers must have a massive trauma protocol. Many have pain management or alcohol withdrawal or a number of other protocols. The question sometimes arises: why do we need another protocol? Why can’t I do it my own way?

I’ve looked at the literature, and unfortunately there’s not a lot to go on. Here are my thoughts on the value of protocols/guidelines.

In my view, there are a number of reasons why protocols need to be developed for commonly encountered issues.

  • They allow us to build in adherence to any known literature support (evidence based).
  • They help conserve resources by standardizing care orders and resource use. This means they save money!
  • They reduce confusion. Nurses do not have to guess what cares are necessary based on the specific admitting surgeon.
  • They reduce errors for the same reason. All patients receive a similar regimen, so potential errors are more easily recognized.
  • They promote team building, particularly when the protocol components involve several different services within the hospital.
  • They teach a consistent, workable approach. This is especially important to our trainees. When they graduate, they are familiar with a single, evidence based approach that will work for them in their practice.

Tomorrow, I’ll write about imaging guidelines, and how they can help avoid VOMIT (victims of medical imaging technology).

Bottom line: It’s interesting that there are so many articles about practice guidelines, but very few explaining why they are important. Although the proof is not necessarily apparent in the literature, protocol and guideline development is important for trauma programs for the reasons outlined above. But don’t develop them just so you can have an encyclopedia of fifty! Identify common problems that can benefit from the consistency they provide. It will turn out to be a very positive exercise and reap the benefits listed above.