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Background
CT with IV contrast is the standard of care for diagnosing and characterizing internal injuries in the hospital trauma bay setting. Trauma surgeons and their specialist colleagues rely on the initial CT scan findings to guide decisions in terms of operative vs nonoperative management, timeliness of intervention, operative planning, medical management of trauma and prognostication. With increasing reliance on this diagnostic tool, stewardship and proper utilization of CT becomes increasingly important. Unnecessary CT scans expose the patient to a significant dose of ionizing radiation, and improper CT protocols can result in failure to diagnose serious injuries. It is therefore critically important for radiologists to optimize trauma CT protocols for injury detection, understand the advantages and limitations of each protocol, and make appropriate decisions for what phase(s) of contrast a CT of the chest, abdomen, and pelvis (CT CAP) should be obtained in.

Educational Goals / Teaching Points
The primary goal of this presentation is to provide a framework for CT CAP protocol optimization in the setting of trauma. While all institutions need not use the exact same decision-making tree and CT protocols, a review of the available literature can provide a set of guidelines for how radiologists and surgeons can optimize the diagnostic yield of trauma CT scans. This will prevent patients from undergoing unnecessarily high doses of ionizing radiation. This can be achieved by tailoring the CT protocol to the patient being scanned, appropriately choosing the phase(s) of CT contrast to obtain, optimizing patient positioning and contrast injection techniques, and avoiding common pitfalls. This presentation also provides a review of the available literature regarding how multiphase CT should be used to characterize vascular injuries, active bleeding, and renal collecting system/ureteral injuries in the setting of both blunt and penetrating trauma to the chest, abdomen, and pelvis.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
In the setting of severe trauma, it is critically important to assess for arterial vascular injuries and the presence of active arterial bleeding which requires an arterial phase CT scan. However, it is also important to detect and characterize solid organ lacerations and assess for venous bleeding which are best seen on a venous phase scan. It may be necessary to obtain both arterial and venous phase scans to distinguish active bleeding from vascular pseudoaneurysm. Split-bolus contrast injection techniques can offer a way of optimizing injury detection without the need for multiple CT scans in some cases. Renal collecting system and ureter injuries may require a renal excretory phase CT scan to be confidently diagnosed and characterized.

Conclusion
This presentation provides an overview of literature regarding the appropriate use of single and multiphasic CT CAP protocols in the setting of both blunt and penetrating trauma to the chest, abdomen, and pelvis. This includes a discussion of vascular, renal, and ureteral injury characterization using multiphasic CT.