Controversies in the Management of the Trauma Patient

ACR Appropriateness Criteria® Imaging of Facial Trauma Following Primary Survey

Maxillofacial trauma patients comprise a significant subset of patients presenting to emergency departments. Before evaluating for facial trauma, an emergency or trauma physician must perform a primary survey to ensure patient stabilization. Following this primary survey, this document discusses the following clinical scenarios for facial trauma: tenderness to palpation or contusion or edema over frontal bone (suspected frontal bone injury); pain with upper jaw manipulation or pain overlying zygoma or zygomatic deformity or facial elongation or malocclusion or infraorbital nerve paresthesia (suspected midface injury); visible nasal deformity or palpable nasal deformity or tenderness to palpation of the nose or epistaxis (suspected nasal bone injury); and trismus or malocclusion or gingival hemorrhage or mucosal hemorrhage or loose teeth or fractured teeth or displaced teeth (suspected mandibular injury). The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Less Operating and More Overtriage: National Trends in Interfacility Transfer of Facial Fracture Patients

BACKGROUND

The purpose of this study was to characterize demographics, injury patterns, and initial management trends of facial fracture patients who were subject to interfacility transfer.

METHODS

Using the National Trauma Data Bank from 2007 to 2015, facial fracture patients arriving by interfacility transfer were included in the study.

RESULTS

Over 9 years, 171,618 patients were included, with 37.5 percent having an isolated facial injury. Isolated facial injury patients tended to be younger, less frequently white, more frequently assaulted, and more frequently underwent facial fracture operative repair during the index admission (all, p < 0.001). From 2007 to 2015, insurance coverage increased from 54.6 to 79.0 percent (R2 = 0.90, p < 0.001). In addition, there was a 45 percent proportional increase in patients 50 to 89 years of age compared to a 20 percent decrease in patients 0 to 39 years of age (both, R2 = 0.99, p < 0.001). The proportion of transfer patients with isolated facial injury increased over the study period (32.0 to 39.4 percent, R2 = 0.90, p < 0.001); however, there was a decline in operative intervention (29.5 to 22.1 percent, R2 = 0.94, p < 0.001) and a 151 percent increase in the proportion discharged from the emergency department upon transfer arrival (R2 = 0.99, p < 0.001).

CONCLUSIONS

Facial fracture patients subject to interfacility transfer comprise a wide array of demographics and injury patterns, with most having concomitant injuries and only a minority undergoing immediate operative intervention. Over time, this demographic has become older, sustained more isolated facial injury, and undergone fewer immediate operative interventions and is more frequently insured and more frequently discharged from the emergency department upon transfer arrival, reflecting increasing rates of secondary overtriage.