Management of Blunt Abdominal Trauma After RTA
This vitally stable patient with right upper quadrant pain following a road traffic accident requires immediate CT imaging with IV contrast, not discharge or simple observation with blood work alone. 1
Why CT Imaging is Essential
Blunt abdominal trauma from motor vehicle accidents carries significant risk for delayed presentation of serious injuries, including hepatic lacerations, splenic injuries, bowel perforations, and retroperitoneal hemorrhage that may not manifest immediately with hemodynamic instability. 1
Right upper quadrant pain specifically raises concern for hepatobiliary injury, which occurs frequently in RTAs and can progress to life-threatening hemorrhage. 1
Clinical examination alone is unreliable in blunt abdominal trauma from high-energy mechanisms like RTAs, as up to 75% of patients have associated injuries that may not be clinically apparent initially. 1
European trauma guidelines strongly recommend CT imaging for hemodynamically stable patients with suspected torso trauma or high-risk mechanism of injury (Grade 1B recommendation). 1
Why Other Options Are Inadequate
Abdominal Ultrasound Alone is Insufficient
FAST ultrasound has notably low sensitivity (56-71%) for detecting intra-abdominal injuries in blunt trauma, meaning a negative FAST cannot exclude significant pathology. 1
While ultrasound can detect free fluid, it cannot adequately evaluate solid organ injuries, retroperitoneal structures, or the full extent of hepatobiliary trauma that RUQ pain suggests. 1
Blood Work Alone is Dangerous
Never rely on laboratory values alone or delay imaging for "observation" in trauma patients—occult injuries can deteriorate rapidly, and mortality increases approximately 1% every 3 minutes when significant hemorrhage is uncontrolled. 1
Initial hemoglobin may be falsely reassuring before equilibration occurs, and delayed presentations of bowel injuries and other pathology occur in 0.2-0.5% of cases even with negative initial evaluation. 1
Emergency Department Referral May Be Unnecessary
This patient is already presenting for medical evaluation and is vitally stable, making them an ideal candidate for outpatient CT imaging if available at the current facility. 2
Clinically stable patients with isolated blunt abdominal trauma can be safely discharged after negative CT with IV contrast (Level B recommendation), but they cannot be safely discharged without imaging. 2, 1
Recommended Diagnostic Algorithm
Obtain abdominal CT with IV contrast immediately (oral contrast is optional and not required for trauma evaluation). 1
CT with IV contrast provides comprehensive evaluation of all abdominal organs, the retroperitoneum, and can detect active extravasation of contrast indicating ongoing hemorrhage. 1
Ensure large-bore IV access is established during imaging preparation. 1
Monitor vital signs continuously during the imaging process. 1
Management Based on CT Results
The negative predictive value of CT for need for surgical intervention is 99.63%, allowing safe discharge if negative. 1
Patients with solid organ injuries and hemodynamic stability may be managed non-operatively with serial examinations and repeat imaging. 1
Any free intra-abdominal fluid with subsequent hemodynamic deterioration requires urgent surgical intervention (Grade 1A recommendation). 1
Critical Pitfall to Avoid
Do not discharge patients without imaging when there is any abdominal pain following significant trauma, as delayed presentations of bowel injuries and other pathology occur even with initially reassuring clinical presentations. 1 The correct answer is A - Abdominal ultrasound only if CT is unavailable, but CT with IV contrast is the definitive appropriate next step for this clinical scenario.