ABSTRACT:Recent multicenter studies have explored the current and desired clinical work for acute care surgeons. Acute care surgeons oversee and provide comprehensive care in trauma, surgical critical care, emergency general surgery, and burn patients. While these studies provide crucial data to guide planning at individual institutions to help address understaffed programs, translating this research into local practice and culture requires nuance and consideration of system (regional, institutional, department, and divisional) factors and individual surgeon goals. This opinion piece confronts the paradox at the heart of academic acute care surgery: how can surgeons deliver on educational and research missions when staffing models place the highest prioritization on clinical work? We present a practical, evidence-based framework that aligns sustainable clinical staffing with preservation of the tripartite academic mission in acute care surgery.

Acute care surgery (ACS) is a specialty that includes trauma, emergency general surgery, and surgical critical care. It has become a vital surgical specialty in the United States, providing surgical services, rescue functions, disaster response, and other important services. Despite its key role in patient care and hospital operations, ACS faces challenges to its sustainability. This overview targets readers who wish to understand the structure and scope of ACS and who work with or manage these practices. The goal is to provide an overview of ACS, its current challenges, and suggestions for developing the specialty. This consensus statement was created by the Acute Care Surgery Workforce Workgroup, which includes representatives from various national surgical organizations. The article combines current ACS models, staffing and compensation practices, and institutional value. It relies on expert agreements and national trends. Several key themes are examined. The value of ACS is shown through better patient outcomes, efficiency, cost savings, and support for institutional missions like disaster preparedness and education. Current ACS programs differ significantly in structure, but two main staffing models exist: traditional (historic) and time delineated. Each model has its own advantages and challenges regarding workload, sustainability, and academic involvement. Regardless of the staffing model, most physician compensation often depends on the measurement of work relative value units. However, these do not fully capture the extent and intensity of ACS work. Additional challenges for the specialty include inconsistencies in terminologies, the absence of board certification, and varying compensation standards. Acute care surgery is a crucial specialty that provides significant value to patients, hospitals, and health care systems. To maintain sustainability and quality, health care leaders need to consider the complexities of ACS practice discussed in this article as well as local demands. Staffing and compensation models should be sustainable and optimize for patient care. Recognizing both clinical and nonclinical contributions of ACS surgeons is essential for resilience and further development of the specialty.

INTRODUCTION:Advanced practice providers (APPs) have important roles in trauma, surgical critical care (SCC), and emergency general surgery (EGS), but their specific utilization, staffing patterns, and clinical responsibilities remain poorly characterized. This study aims to assess APP integration within US acute care surgery (ACS) programs. METHODS:A survey was distributed to division chiefs (12/2024) via the Society of ACS chiefs, assessing APP staffing, service coverage, procedures performed, patient-to-APP ratios, onboarding, and educational support. Descriptive statistics were used to analyze responses. RESULTS:57 of 74 (77%) ACS division chiefs responded, predominantly from university (63%), level-I centers (81%). All centers had trauma, SCC, and EGS. Nearly all centers (96%) had daytime APP coverage, 49% nighttime, 86% weekends, and 70% covered holidays. The median number of APPs per center was 14, with most assigned to trauma (n = 5, interquartile range [IQR], 3-9), SCC (n = 3, IQR, 0-7), then EGS (n = 2, IQR, 0-4). Maximum patient-to-APP ratios were highest in trauma (median 11, IQR, 7.5-12) and lowest in SCC (median 6, IQR, 4.8-6). Procedures performed by APPs included chest tubes (trauma: 59.6%; SCC: 54.4%) and central lines (trauma: 43.9%; SCC: 66.7%). In addition, 24.6% of trauma and 40.4% of EGS APPs assisted in the operating room. CONCLUSIONS:The role of APPs in ACS continues to expand with nearly all centers surveyed having daytime APP coverage. However, less than half had nighttime coverage. Understanding limitations to night staffing and future efforts to define optimal APP integration, training, intraoperative support, and workload may improve standardization, efficiency, and care of our injured patients.

Background Research defining a Full Time Equivalent (FTE) in Acute Care Surgery (ACS) has drawn attention to the stress of ACS work, however variability of the intensity of different shifts is less understood. Study design A daily 10-point assessment measured work-intensity in 6 domains: physical, mental, temporal, effort, frustration, performance (NASA-TLX), and burnout via Single Item Burnout Question (SIBO). Results The highest levels of burnout: Emergency General Surgery (EGS), backup, and 24hr call (p < 0.01). Highest physical demand: 24hr call (13, p < 0.01); mental load: EGS (13, p < 0.01), Surgical Intensive Care Unit (13, p < 0.01), and 24hr call (13, p < 0.01); EGS demanded highest effort (13.5, p < 0.01) and temporal load (10, p < 0.01). Conclusion ACS Surgeons perceived differences in intensity of various shifts. FTE data is applicable to inform workforce planning, but a nuanced approach considering workload intensity is needed.

ABSTRACT:Reducing disparities and achieving health equity are critical goals for the trauma community. Although significant advances have been made in short-term trauma outcomes, disparities persist across various dimensions including race, sex, gender, socioeconomic status, and geographic location. This manuscript represents a distillation of a panel discussion from the 2024 Western Trauma Association meeting that examined three under-recognized categories of trauma disparities beyond traditional demographic factors. First, sex-related disparities in motor vehicle crashes stem from crash test dummies designed primarily for male physiology. Second, financial toxicity and exploring the relationship between acute trauma, financial hardship, and long-term mental and physical quality of life. Third, geographic disparities create "trauma deserts" where disadvantaged populations experience prolonged transport times and reduced access to life-saving care. The panel explored opportunities within each to improve patient outcomes at the local, regional, and national levels. ( J Trauma Acute Care Surg. 2026;101: e15-e20. Copyright© 2026 Wolters Kluwer Health, Inc. All rights reserved.).

Emergency general surgery (EGS) represents a significant portion of admissions to hospitals and overall surgical care delivery, yet comprehensive outcome tracking and quality improvement efforts have lagged behind elective surgery and trauma care. This article outlines the gap in data and provides three practical solutions to registry development: third-party registry software with dedicated registrars, leveraging existing National Surgical Quality Improvement Program (NSQIP) infrastructure through the EGS-NSQIP module, and automated data extraction from electronic medical records. Each approach offers unique advantages in addressing the dual challenges of case identification and risk-adjusted outcome measurement for both local quality improvement and national benchmarking. The aim of this white paper is to provide pragmatic, scalable data solutions for EGS leaders seeking to implement contemporary quality improvement and verification efforts.

BACKGROUND:Small bowel obstruction (SBO) is a common emergency general surgery condition frequently initially managed nonoperatively, although the optimal duration of nonoperative management (NOM) before operative intervention remains uncertain. We evaluated national variation in NOM duration and its association with clinical outcomes and healthcare use. STUDY DESIGN:We performed a retrospective cohort study using the American College of Surgeons NSQIP Emergency General Surgery Targeted Database (June 2022-December 2024). Adults with SBO who underwent an initial trial of NOM followed by surgery were included. Patients were stratified by quartiles of NOM duration after excluding high-duration outliers. Multivariable regression adjusted for demographics, comorbidities, and disease severity. A sensitivity analysis was performed in patients with adhesive SBO. RESULTS:Among 8,993 patients with SBO, 70.0% underwent initial NOM, and 1,865 ultimately required surgery. Mean NOM duration was 3.3 ± 2.4 days. Baseline demographic characteristics were similar across quartiles. Longer NOM duration was independently associated with increased postoperative and total length of stay (both p<0.001), with a significant linear trend across quartiles. After adjustment, 30-day morbidity, mortality, and readmission did not differ by NOM duration. Findings were consistent in the adhesive SBO sensitivity analysis. CONCLUSIONS:National variation in NOM duration for SBO is substantial. Among patients ultimately requiring operative intervention, prolonged NOM was associated with increased healthcare utilization without measurable improvement in short-term postoperative outcomes, supporting efforts to optimize and standardize time-limited nonoperative management.

Background:Optimal provider-to-patient (PtP) ratios in acute care surgery (ACS) remain undefined despite their importance for care quality and provider sustainability. This study aimed to understand surgeon perspectives on maximum ideal ratios across trauma, emergency general surgery (EGS) and surgical intensive care unit (SICU) services. Methods:This multicenter mixed-methods study combined quantitative surveys and semistructured interviews with ACS surgeons at level I/II trauma centers across the USA (1 August 2023-19 April 2024). Service line census data were also collected. Interviews were recorded, transcribed and qualitative analysis performed; surveys were analyzed with descriptive statistics. Results:Fifty-two interviews were completed. Survey response rate was 50.3% (212/421 eligible division leadership and faculty) from 40 centers across 24 states. The perceived maximum safe patient load for trauma and EGS was <20 patients when working independently, and up to 40 patients with full team support. SICU ratios were lower with most reporting ≤10 patients for independent coverage and ≤20 with team support. Regarding appropriate patient loads for junior residents and advanced practice providers, most respondents recommended ≤10 patients for trauma/EGS and ≤7 for SICU. For senior residents, most recommended ≤13 patients for trauma/EGS and ≤7 for SICU. Notably, 72% of centers exceeded their own leadership-recommended maximums for at least one service line. Qualitative analysis revealed patient acuity, team experience and competing demands as key workload modulators, with concerns about care quality degradation and burnout at higher ratios. Conclusions:This study establishes potential upper threshold benchmarks for ACS PtP ratios with strong agreement across institutions. Division leadership should consider developing staffing models that account for patient acuity and service complexity while implementing escalation protocols for sustained high workloads. Current practices frequently exceed maximum ideal ratios, highlighting the need for evidence-based staffing guidelines that balance financial constraints with mounting evidence linking workload intensity and density to adverse outcomes. Level of evidence:IV.

Introduction Patients recovering from severe acute exacerbations of chronic obstructive pulmonary disease (AECOPD) have a 30-day readmission rate of 20%. This study evaluated the feasibility of conducting a randomised controlled trial to evaluate clinical, patient-reported and physiological effects of home high-flow therapy (HFT) in addition to usual medical therapy, in eucapnic patients recovering from AECOPD to support the design of a phase 3 trial.Methods A mixed-methods feasibility randomised controlled trial (quantitative primacy, concurrently embedded qualitative evaluation) (ISRCTN15949009) recruiting consecutive non-obese patients hospitalised with AECOPD not requiring acute non-invasive ventilation. Participants were randomised to receive usual care or usual care and home HFT (37°C, 30 L/min) with weekly home-based follow-up for 4 weeks to collect data on: device usage, breathlessness (modified Borg scale, visual analogue scale, Multidimensional Dyspnoea Profile), health-related quality of life (COPD Assessment Test (CAT), Clinical COPD Questionnaire), pulse oximetry, spirometry and inspiratory capacity, parasternal electromyography and actigraphy. Semistructured interviews were conducted in week 4. Trial progression criteria were: ≥40% of eligible patients randomised, ≤20% attrition, ≥70% complete data, and no device-related serious adverse events (SAE).Results 18 of 45 eligible patients were randomised (age 69±5 years, 44% female, body mass index 23±5 kg/m2, forced expiratory volume in 1 second 32±12%). One withdrew following non-respiratory hospitalisation. Complete outcome measures were collected in >90% of home assessments. There were no device-related SAE. Daily HFT usage was 2.7±2.2 hours in week 1, falling to 2.3±1.4 hours by week 4. Temperature and flow settings were modified for comfort in 6 cases. Higher HFT usage was associated with lower symptom burden (CAT p=0.01). Interviews highlighted ease of device use, reduced salbutamol usage, and improved sputum production and clearance.Conclusions The data from this feasibility study support the progression to a phase 3 randomised clinical trial investigating the effect of home (HFT) on admission-free survival in COPD patients recovering from a severe exacerbation.Trial registration number The study received ethical approval (REC19/LO/0194) and was prospectively registered (ISRCTN15949009).

BACKGROUND:The benefit of transfusion of fresh frozen plasma (FFP) and platelets in a 1:1 ratio with packed red blood cells (PRBCs) is well established; however, the benefit of a particular ratio of cryoprecipitate to PRBC is not. The Joint Trauma System updated its 2019 Damage Control Resuscitation Guideline by recommending empiric 1:1 cryoprecipitate/PRBCs. We hypothesized that patients receiving product within the cryoprecipitate/PRBC guideline range (high ratio) would have an associated reduction in mortality. METHODS:We included adult patients in the Trauma Quality Improvement Program data registry (2013-2021) who received at least 5 U of PRBCs and 1 U of FFP within 4 hours. Death within 30 minutes, nonsurvivable injury patterns, preexisting coagulopathy, advanced directives, transfers, and burns were excluded. Patients were partitioned into high (≥1:1), medium (≥1:2 to <1:1), and low (<1:2) cryoprecipitate/PRBC ratios. Treatment effects were estimated with propensity score-weighted risk adjustment models, clustering by center. The primary outcome was 6-hour mortality. Secondary outcomes included 24-hour and inpatient mortality. Adjusting for FFP, platelets, and whole blood was included as a sensitivity analysis. RESULTS:A total of 49,301 patients (high, 5,284; medium, 3,630; low, 40,387) were included. The mean age was 39, 79% were male, 58% suffered blunt trauma, and the mean Injury Severity Score was 29. Unadjusted 6-hour mortality was 11.8%, 18.8%, and 21.3% for high, medium, and low ratios. High ratio was protective as compared with low at 6 hour (adjusted odds ratio [aOR], 0.52; 95% confidence interval [CI], 0.45-0.58) and 24 hours (aOR, 0.74; 95% CI, 0.67-0.82), and medium ratio was protective as compared with low ratio at 6 hours (aOR, 0.78; 95% CI, 0.70-0.87). Blood product sensitivity analysis demonstrated that high and medium ratios were protective of 6-hour, 24-hour, and inpatient mortality. CONCLUSION:High cryoprecipitate ratios were independently associated with decreased mortality in massively transfused civilian trauma patients during the first 24 hours. Future prospective multicenter randomized trials are warranted. LEVEL OF EVIDENCE:Prognostic and Epidemiological; Level III.

Background Fibrinogen levels can drastically increase from inflammation, trauma, or surgery, which increases risk of venous thromboembolism (VTE). We developed small interfering RNA (siFibrinogen) that decreased fibrinogen production and thrombosis in rodent models, which became effective hours after administration and knockdown lasted over a week. Here, we tested whether knockdown of fibrinogen was feasible and safe in a preclinical large animal model. We hypothesized that fibrinogen could be controllably knocked down to levels that still enable hemostasis and avoid limitations of the current standard of care agent, low-molecular-weight heparin (LMWH). Objectives This study evaluated the preclinical safety and feasibility of a novel therapy for VTE prophylaxis for complications in trauma and surgical patients. Methods Female Yorkshire/cross swine (7-15 kg) were infused with small interfering RNA targeting fibrinogen (siFibrinogen), LMWH, or a vehicle control. Hemostasis was assessed in an established model of hemorrhagic shock. Reversibility was evaluated by administering fibrinogen concentrate. Results Circulating fibrinogen concentrations decreased in swine in a dose-dependent manner, lasting over a week from 1 injection of siFibrinogen. Fibrinogen reduction to levels > 0.4 g/L did not impair hemostasis during hemorrhagic shock when compared with LMWH or vehicle control. The effects of siFibrinogen were reversed by the administration of fibrinogen concentrate. No infusion-related reactions or toxicity was observed. Conclusion siFibrinogen represents a promising novel approach for VTE prophylaxis, avoiding limitations of LMWH. siFibrinogen administered early in patient care could decrease fibrinogen in a sustained and predictable manner to prevent thrombosis while preserving hemostasis.

BACKGROUND:There is a lack of high-quality evidence regarding the most appropriate pharmacologic venous thromboembolism chemoprophylaxis (VTEp) agent in traumatic brain injury (TBI). Low-Molecular Weight Heparin (LMWH) is presumed to reduce VTE events; however, concerns of worsening intracranial hemorrhage (ICH) persist. The aim of the present study is to compare the efficacy and safety of LWMH versus Unfractionated Heparin (UFH) in patients with non-operative TBI. METHODS:We performed a single-center retrospective review of all adult TBI patients (age ≥18years) admitted to a Level I trauma center (2015-2022). Exclusion criteria included neurosurgical intervention prior to VTEp, absence of VTEp, worsened ICH prior to VTEp initiation, and death or discharge within 48 ​h of admission. The study population was stratified into those who received LMWH versus UFH as VTEp. The primary outcome of interest was VTE events. Secondary outcomes included worsening ICH, transfusion requirements, and in-hospital mortality. RESULTS:A total of 2176 patients met inclusion criteria (median age 62 years and 64 ​% male) of whom 68 ​% received UFH while 32 ​% received LMWH. Overall, there was no significant difference in demographics, injury characteristics, and time to VTEp initiation; however, compared to patients who received UFH, those who received LMWH were younger (51 vs 68 years p ​< ​0.001) and less likely to present with a subdural hematoma (59 ​% vs 65 ​% p ​= ​0.02). The LMWH cohort had a lower rate of VTE events (1.4 ​% vs 3.0 ​%; p ​= ​0.03) and in-hospital mortality (1.4 ​% vs 3.9 ​%; p ​< ​0.01). No significant differences in worsening ICH (2.8 ​% vs 3.3 ​%; p ​= ​0.2) or transfusion requirements (7.7 ​% vs 8.2 ​%; p ​= ​0.6) were detected. After controlling for age, ISS, BMI, and presence of SDH, LMWH was associated with lower odds of VTE events (AOR: 0.47, 95 %CI: 0.30-0.86) but not mortality (AOR: 0.65, 95%CI: 0.47-1.22). CONCLUSION:Compared to UFH, LMWH is a safe and effective chemoprophylactic agent in patients with non-operative stable TBI. LEVEL OF EVIDENCE:Level III, Therapeutic/Care Management.

BackgroundEmergency general surgery (EGS) patients who undergo interfacility transfer (IFT) experience higher rates of complications and mortality compared to those directly admitted (DA) to a hospital. However, their failure-to-rescue (FTR) rates-defined as mortality following a major complication-remain less studied. Given the increased burden of adverse outcomes in this population, we hypothesized that IFT patients would have higher risk-adjusted FTR rates than DA patients.MethodsWe performed a 5-year (2016-2020) retrospective analysis using the National Surgical Quality Improvement Program (NSQIP) database, focusing on patients aged 18 years and older undergoing high-risk EGS procedures, including enterectomy, colectomy, peptic ulcer surgery, and laparotomy. To assess the impact of IFT, we employed multivariable logistic regression models, adjusting for demographic factors, comorbidities, and procedure type.ResultsAmong 70 028 patients (52% female, 66% white, median age 66), 15 032 (21.4%) underwent IFT. After risk adjustment, IFT patients demonstrated significantly higher odds of major complications (OR 1.09, 95% CI 1.04-1.14), mortality (OR 1.23, 95% CI 1.16-1.31), and FTR (OR 1.12, 95% CI 1.04-1.19), suggesting that transferred patients are at a distinct disadvantage compared to DA patients.Discussion: Interfacility transfer is independently associated with worse outcomes in EGS patients, including higher FTR rates. These findings identify a vulnerable subpopulation of EGS patients that are readily identified by clinicians and highlights the need for future research to identify modifiable risk factors contributing to this disparity.

Importance:Perforated peptic ulcer disease (PUD) affects 4 million people annually worldwide, with a lifetime prevalence of 5% to 10%. Of those affected, 5% will progress to the point of perforation. Despite advances in the understanding and treatment, perforated PUD continues to have a high rate of morbidity (48.5%) and mortality (9.3%). This review summarizes the current evidence on management of perforated PUD, including management of failed repairs. Observations:Approaches for repair include primary closure and omental patch closure. Omental patch may be most useful in large perforations with friable tissue. Minimally invasive surgery is the preferred approach in perforated PUD, with improved outcomes compared with open techniques. Leak from the ulcer after repair is seen in approximately 12% to 17% of cases. Approaches to releak include expectant management, radiologic and/or endoscopic intervention, and repeat surgery. Morbidity and mortality after releak are especially high, and complete healing of the leak may take time. Conclusions and Relevance:Despite advances in medical management and surgical techniques, perforated PUD continues to have a relatively high rate of morbidity and mortality. Minimally invasive surgery is the current preferred treatment approach.

BACKGROUND:The use of tranexamic acid in trauma patients at risk for hemorrhage remains controversial. This guideline evaluates the use of tranexamic acid in two clinical settings, the prehospital environment and the inpatient setting. In addition, this PMG evaluates the use TXA in specific populations and at different dosages and evaluates the potential risks associated with its use. METHODS:Using the Grading of Recommendations Assessment, Development and Evaluation methodology, an EAST working group conducted a systematic review using MEDLINE, EMBASE, and COCHRANE CENTRAL. Articles in English from 2000 through 2023 were considered in evaluating four PICO questions relevant to the use of TXA in injured trauma patients at risk of hemorrhage (defined as patients with a systolic blood pressure (SBP) ≤90 mm Hg or a heart rate ≥110/min or suspicion for active hemorrhage). RESULTS:Thirty studies were identified for qualitative analysis, of which 24 met criteria for meta-analysis. TXA was associated with a significant reduction in 24-hour mortality in both prehospital (log risk ratio, -0.29; 95% confidence interval, -0.53 to -0.05; p = 0.02) and in-hospital settings (-0.38[-0.69, -0.06]; p = 0.02). A similar benefit was observed at 30-days across both settings (prehospital: -0.18[-0.35, -0.00]; p = 0.05, in-hospital: -0.24[-0.40, -0.07]; p = 0.01). In patients with SBP ≤75 mm Hg, TXA reduced mortality, but this was not found to be significant (-0.18 [-0.46, 0.09]; p = 0.20). The incidence of vaso-occlusive events did not differ between groups in either setting. Moreover, a large heterogeneity regarding TXA dosing regimens and comparison groups across studies was observed. CONCLUSION:Based on current available evidence, we conditionally recommend for the routine use of TXA in the prehospital and in-hospital settings. We cannot recommend for or against the use of an initial higher dose of bolus TXA. Finally, we conditionally recommend for the routine use of TXA in patients with severe hypotension. LEVEL OF EVIDENCE:Systematic Review/Meta-Analyses; Level III.

Background: Mechanical insufflation-exsufflation (MI-E) is used to augment secretion clearance in neuromuscular patients with weakened cough strength. Cough peak flow (CPF) is a measure of cough function that is used to assess a patient's ability to clear secretions, with thresholds set that categorize cough as effective, ineffective or severely ineffective. MI-E is prescribed according to these thresholds, and CPF is used to assess titration of MI-E settings. The Clearway2 (Breas Medical, Stratford-upon-Avon, United Kingdom) displays a real-time CPF, measured by an internal pneumotachograph. This study sought to assess the agreement and repeatability of this displayed CPF, against the reference CPF measurement by a calibrated pneumotachograph. Methods: This study consisted of two phases (1) lung model (Group A) and (2) acutely unwell individuals with neuromuscular conditions (Group B) and clinically stable individuals with neuromuscular conditions (Group C). Simultaneous CPF measurements were recorded from the MI-E device (CPFMI-E) and a calibrated pneumotachograph (CPF), which was inserted into the MI-E circuit. Bland-Altman analysis was used to assess agreement between methods of measurement, and repeatability was assessed using a repeated measures analysis of variance. Results: During phase 1, 805 simulated coughs were evaluated with the Clearway2. The mean bias toward CPFMI-E was 33 L/min (95% limits of agreement 6-60 L/min). During phase 2, the mean bias increased to 66 L/min (95% limits of agreement 13-119 L/min). CPFMI-E and CPF both had good repeatability in all groups. Conclusions: The Clearway2 MI-E device provided a real-time CPF measurement that was repeatable and systematically higher than CPF. It may therefore be a useful tool to measure change longitudinally, or in response to changes in MI-E settings, in an individual patient. Caution is advised if using the CPFMI-E to assess cough efficacy against clinical thresholds.

Background: Recurrent pneumothorax (rPTX) is a common complication following thoracostomy tube (TT) removal in chest trauma patients. While chest X-ray (CXR) is most commonly used to detect a rPTX, bedside ultraportable ultrasound (UPUS) is a feasible, low cost, and radiation free alternative. No consensus exists with regards to the optimal timing of diagnostic imaging to assess for rPTX post-TT removal. Accordingly, we sought to identify an ideal UPUS timing to detect a rPTX Methods: We conducted a single center prospective study of adult (>= 18years) patients admitted with a chest trauma. UPUS examinations were performed using the Butterfly iQ+TM ultrasound. Three intercostal spaces (ICS) were evaluated (2nd through 4th). Post-TT UPUS examinations were performed at different timepoints following tube removal (1-6 h). A rPTX on UPUS was defined as the absence of lung-sliding in one or more intercostal spaces, and was considered a clinically concerning rPTX if lung-sliding was absent in >= 2 ICS. UPUS findings were compared to CXR. Results: Ninety-two patients (97 hemi-thoraces) were included in the analysis. A total of 58 patients had a post-TT removal rPTX of which 11 were either clinically concerning or expanding. Comparing UPUS findings to CXR, the 3-hour post-TT removal ultrasound examinations were associated with the highest sensitivity. By hour 4, no rPTX showed expansion in size. Three patients required an intervention for a clinically concerning rPTX, all of whom were detected on UPUS 3-hour post-TT removal. Conclusion: Bedside UPUS performed at 3-hour post-TT removal has the highest sensitivity in detecting clinically concerning rPTX. Size of rPTX appears to stabilize by hour 4. In the absence of clinical symptoms, repeat imaging or observation of non-significant rPTX beyond 4 h may not provide added clinical benefit. Level of Evidence: Level II, Diagnostic Tests or Criteria