Ultrasound may safely replace chest radiograph after tube thoracostomy removal in trauma patients.

INTRODUCTION: A chest radiograph (CXR) is routinely obtained in trauma patients following tube thoracostomy (TT) removal to assess for residual pneumothorax (PTX). New literature supports the deference of a radiograph after routine removal procedure. However, many surgeons have hesitated to adopt this practice due to concern for patient welfare and medicolegal implications. Ultrasound (US) is a portable imaging modality which may be performed rapidly, without radiation exposure, and at minimal cost. We hypothesized that transitioning from CXR to US following TT removal in trauma patients would prove safe and provide superior detection of residual PTX. MATERIALS AND METHODS: A practice management guideline was established calling for the performance of a CXR and bedside US 2 h after TT removal in all adult trauma patients diagnosed with PTX at a level 1 trauma center. Surgical interns completed a 30-minute, US training course utilizing a handheld US device. US findings were interpreted and documented by the surgical interns. CXRs were interpreted by staff radiologists blinded to US findings. Data was retrospectively collected and analyzed. RESULTS: Eighty-nine patients met inclusion criteria. Thirteen (15%) post removal PTX were identified on both US and CXR. An additional 11 (12%) PTX were identified on CXR, and 5 (6%) were identified via US, for a total of 29 PTX (33%). One patient required re-intervention; the recurrent PTX was detected by both US and CXR. For all patients, using CXR as the standard, US displayed a sensitivity of 54.2%, specificity of 92.3%, negative predictive value of 84.5%, and positive predictive value of 72.2%. The cost of care for the study cohort may have been reduced over $9,000 should US alone have been employed. CONCLUSION: Bedside US may be an acceptable alternative to CXR to assess for recurrent PTX following trauma TT removal.

Analysis of Admission Thromboelastogram Profiles in 1369 Male and Female Trauma Patients.

INTRODUCTION: Recent studies have demonstrated a hypercoagulable thromboelastrogram (TEG) in female trauma patients compared with males, conferring a possible survival advantage. We hypothesized that TEG profiles would reveal a relative hypercoagulable state in female compared with male trauma patients. METHODS: A prospective review was conducted on all adult trauma patients admitted to the trauma service at an American College of Surgeons-verified level I trauma center from December 2019 to June 2021 who, per our institutional protocol, received a thrombelastotgraphy on their initial arrival to the trauma center if classified as a level I or II trauma activation. The thromboelastography values of male and female trauma patients were compared as the primary outcome variables of interest. The secondary outcomes investigated were hospital length of stay, surgical interventions, and ventilatory requirement. RESULTS: A total of 1369 patients met inclusion criteria, with 878 (64.1%) male and 491 (35.9%) female. Female patients had a higher median alpha angle (74.8 versus 72.6°, P < 0.001), maximum amplitude (69.3 versus 66.2 mm, P < 0.001), and shorter median K time (1.0 versus 1.2 s, P < 0.001). Female patients had a shorter hospital length of stay (4 versus 5 d, P < 0.001), had a lower rate of surgical intervention (14.6% versus 25.5%, P < 0.001), and had lower rates of mechanical ventilation (19.3% versus 39.5%, P < 0.001). CONCLUSIONS: Female trauma patients were found to have hypercoagulable indices on TEG at the time of initial trauma evaluation compared with males. Intrinsic differences in sex coagulation profiles should be further investigated to optimize modern resuscitation strategies.

Gangrenous Cholecystitis From Gallbladder Volvulus With a Hiatal Hernia.

Gallbladder volvulus is a rare condition involving the rotation of the gallbladder about the cystic duct and vascular pedicle, compromising biliary drainage and blood flow. This report describes a case of gallbladder volvulus presenting in an 88-year-old female with acute onset of right upper quadrant abdominal pain, nausea, and vomiting. Complete work-up included a physical exam, laboratory studies, and computed tomography (CT), which was notable for a markedly distended gallbladder with circumferential wall thickening, pericholecystic fluid, a 12 mm common bile duct, and a hiatal hernia. Given that her initial presentation was consistent with acute cholecystitis, we elected to perform laparoscopic cholecystectomy. The definitive diagnosis of gallbladder volvulus was made intraoperatively after decompression of the gallbladder and visualization of counterclockwise rotation of the gallbladder around the hilum and the infundibulum. This case illustrates the challenge in preoperative diagnosis of gallbladder volvulus, which requires high clinical suspicion to provide prompt surgical intervention.