Multidetector CT Findings in the Abdomen and Pelvis after Damage Control Surgery for Acute Traumatic Injuries

Abstract

After experiencing blunt or penetrating trauma, patients in unstable condition who are more likely to die of uncorrected shock than of incomplete injury repairs undergo emergency limited exploratory laparotomy, which is also known as damage control surgery (DCS). This surgery is part of a series of resuscitation steps, with the goal of stabilizing the patient's condition, with rapid surgical control of hemorrhage followed by supportive measures in the intensive care unit before definitive repair of injuries. These patients often are imaged with multidetector CT within 24-48 hours of the initial surgery. Knowledge of this treatment plan is critical to CT interpretation, because there are anatomic derangements and foreign bodies that would not be present in patients undergoing surgery for other reasons. Patients may have injuries beyond the surgical field that are only identified at imaging, which can alter the care plan. Abnormalities related to the resuscitation period such as the CT hypoperfusion complex and ongoing hemorrhage can be recognized at CT. Familiarity with these imaging and clinical findings is important, because they can be seen not only in trauma patients after DCS but also in other patients in the critical care setting. The interpretation of imaging studies can be helped by an understanding of the diagnostic challenges of grading organ injuries with surgical materials in place and the awareness of potential artifacts on images in these patients.

Changes in Approach to Solid Organ Injury: What the Radiologist Needs to Know

“…An efficient multidisciplinary team approach is required as the standard care in blunt and penetrating trauma, allowing quick rational decisions to be made with a thorough understanding of the spectrum of injuries possible and the natural history and pathophysiology of shock. 7 Optimal management of trauma patients requires well-coordinated liaison between the trauma surgeon and the radiologist to ensure timely and accurate diagnosis and management. After detecting potentially treatable lethal injuries that require immediate intervention, the evaluation should be focused on rapid detection and treatment of catastrophic bleeding.…”

“…After detecting potentially treatable lethal injuries that require immediate intervention, the evaluation should be focused on rapid detection and treatment of catastrophic bleeding. 7,8 Nonspecific clinical signs of blunt intra-abdominal injury include tachycardia, which may be due to hypovolemia caused by vascular injury or can merely be secondary to pain response. Signs of hemorrhagic shock such as systolic blood pressure less than 80 mm Hg increase the index of suspicion for a major vascular injury.…”

“…Possible indications for CT in the early postoperative period include (1) determination of solid organ injury extent, (2) identification of vascular injury for a potential angiographic procedure, (3) evaluation for traumatic injury in regions of the abdomen and pelvis that were not surgically explored, (4) evaluation for traumatic injuries that may have been missed during initial surgery, (5) definition of a penetrating injury trajectory, especially across anatomic compartments, (6) evaluation of effective surgical repair, (7) evaluation for foreign bodies that may have been missed during the initial surgery, and (8) assistance in planning definitive surgery. 7,60,62,63 Persistent hemodynamic instability despite resuscitation or worsening coagulopathy is also indications for CT to assess for uncontrolled active hemorrhage or failure of surgical repair.…”

“…In hypoperfusion states, the kidneys demonstrate initial increased enhancement when compared with normal appearances, though it may progress to nonenhancement in cases of prolonged shock. 7 Renal collecting system or ureteric injury will often be better detected on CT than during initial laparotomy, best demonstrated on delayed imaging post-contrast administration. 62,69 These injuries can often be treated with temporary measures such as ureteral stent placement or diverting nephrostomy to temporize to definitive repair.…”

“…In the absence of interventions to the specific organ, the radiologist should report the AAST grade for hepatic, splenic, and renal injuries on the basis of imaging appearance regardless of any available surgical description. 7 Direct communication with the surgical team and review of imaging with them, if necessary, is encouraged. In cases where an injured solid organ has undergone repair prior to imaging, the AAST OIS grading may not reflect the imaging appearances, and the radiologist may instead use the AAST OIS scale descriptors but opt not to assign a grade.…”