Obtain Abdominal CT with IV Contrast Immediately
For a vitally stable patient with mild right upper quadrant pain following a road traffic accident, the most appropriate next step is to obtain an abdominal CT scan with IV contrast. 1
Rationale for CT Imaging
European trauma guidelines provide a Grade 1B recommendation for CT imaging in hemodynamically stable patients with suspected torso trauma or high-risk mechanism of injury. 2, 1 Road traffic accidents definitively qualify as high-risk mechanisms. 1, 3
Clinical examination alone is unreliable in blunt abdominal trauma from RTAs—up to 75% of patients have associated injuries that are not clinically apparent initially. 2, 1 The fact that this patient is "vitally stable" with only "mild" pain does not exclude serious pathology.
Right upper quadrant pain specifically raises concern for hepatobiliary injury, which occurs frequently in RTAs and can progress to life-threatening hemorrhage. 1 The liver and spleen are the most frequently injured solid organs in traffic accidents. 3
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
Why Not the Other Options?
Abdominal Ultrasound (FAST) 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 FAST is appropriate for initial triage in unstable patients, this stable patient requires definitive imaging. 2, 1
Blood Work Alone is Inadequate
Laboratory testing cannot identify the specific injuries that require intervention—only imaging can comprehensively evaluate all abdominal organs, the retroperitoneum, and detect active hemorrhage. 1
Blood work may be normal initially even with significant injuries, as hemoglobin takes time to equilibrate after acute bleeding. 1
Emergency Department Referral Without Imaging is Premature
The patient is already in a clinical setting where CT can be obtained. 1 Referring to an ED without imaging wastes critical time and simply transfers the problem without adding diagnostic value.
If this patient were seen in a primary care office without CT capability, then ED referral would be appropriate, but the question implies access to diagnostic resources. 2
Specific CT Protocol
Obtain CT abdomen/pelvis with IV contrast only—oral contrast is optional and not required for trauma evaluation. 2, 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
If CT is negative, the patient can be safely discharged with close follow-up instructions (Level B recommendation), as the negative predictive value is 99.63%. 2, 1
If solid organ injuries are identified but the patient remains hemodynamically stable, non-operative management with serial examinations may be appropriate. 1
Any free intra-abdominal fluid with subsequent hemodynamic deterioration requires urgent surgical intervention (Grade 1A recommendation). 2, 1
Critical Pitfall to Avoid
Never rely on "observation" or delayed imaging in trauma patients with abdominal pain—occult injuries can deteriorate rapidly, and delayed presentations of bowel injuries and other pathology occur in 0.2-0.5% of cases even with negative initial evaluation. 2, 1 The mild nature of current symptoms does not predict the absence of serious injury requiring intervention.