What is the next step in management for a 27-year-old patient with a stable condition and a deep stab wound in the right upper quadrant (RUQ) of the lower chest?

Management of Stable Patient with RUQ Lower Chest Stab Wound

CT scan with IV contrast of the chest and abdomen is the next appropriate step in management for a stable 27-year-old patient with a deep stab wound to the right upper quadrant lower chest. 1, 2

Rationale for CT Imaging

The American College of Radiology (ACR) guidelines strongly recommend CT imaging for hemodynamically stable patients with penetrating torso trauma 1. This approach is supported by:

• CT is optimal for identifying the trajectory of penetrating injuries and predicting which organs may be involved
• Single-acquisition whole-torso imaging is preferred over segmental imaging to follow the complete tract of the injury
• CT with IV contrast provides visualization of potential vascular injuries, solid organ damage, and diaphragmatic injuries

Imaging Protocol

• Place radiodense markers at the entry wound site to aid in determining trajectory 1
• Perform CT chest, abdomen, and pelvis with IV contrast as a single acquisition 1
• This allows evaluation of:
  • Diaphragmatic injury (sensitivity 14-82%, specificity 87%) 1
  • Thoracic injuries (pneumothorax, hemothorax)
  • Solid organ injuries
  • Vascular injuries
  • Hollow viscus injuries

Why Not Immediate Laparotomy?

While laparotomy was traditionally performed for all penetrating torso trauma, recent evidence supports "selective conservatism" for stable patients 1. Unnecessary laparotomies can be avoided with appropriate imaging, as:

• More than 80% of thoracic injuries can be managed non-operatively 2
• CT can identify patients who can be safely managed without surgery 3
• Negative CT findings in stable patients can reliably exclude significant injuries requiring intervention

Why Not Just Observation?

Simple observation without imaging is inadequate because:

• RUQ lower chest wounds can involve both thoracic and abdominal structures
• The diaphragm position varies with respiration, making injury assessment challenging
• Small diaphragmatic injuries may not be immediately symptomatic but can lead to delayed herniation
• The World Journal of Emergency Surgery recommends diagnostic imaging for stable patients with suspected diaphragmatic hernia 1

Pitfalls to Avoid

1. Relying solely on physical examination: A study by Berardoni et al. found that 8.7% of patients with negative CT scans still had injuries requiring therapeutic intervention 4

2. Missing diaphragmatic injuries: These can be subtle on imaging and may lead to delayed herniation if missed

3. Inadequate contrast timing: Proper IV contrast timing is essential to evaluate both arterial and venous phases for potential vascular injuries 1

4. Overlooking trajectory: The path of penetrating injuries can be unpredictable, requiring evaluation of adjacent body regions even when entry wounds appear localized 2

Follow-up Management

After CT imaging:

• If significant injuries are identified: Proceed with appropriate surgical intervention based on specific findings
• If no significant injuries are found: Admission for observation is still warranted for 24-48 hours to monitor for delayed presentations 5
• Serial clinical examinations and laboratory studies should be performed during observation

By following this evidence-based approach, you can accurately identify injuries requiring intervention while avoiding unnecessary surgical procedures in this stable patient with a deep RUQ lower chest stab wound.