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.
