What is the most appropriate next step for a patient with mild abdominal pain, mainly in the right upper quadrant, following a recent road traffic accident (RTA) and found to be vitally stable on examination?

Management of Post-RTA Abdominal Pain

This patient requires immediate CT abdomen/pelvis with IV contrast (Option A is insufficient; Option B is the correct answer). Despite hemodynamic stability, right upper quadrant pain following a road traffic accident mandates comprehensive imaging to exclude occult hepatobiliary injury, which can progress to life-threatening hemorrhage even in initially stable patients 1.

Why Emergency Department Referral is Essential

Refer this patient to the emergency department immediately for CT imaging and ongoing monitoring. Here's the algorithmic reasoning:

High-Risk Mechanism and Concerning Location

• Road traffic accidents are high-energy mechanisms that carry significant risk for delayed presentation of serious injuries including hepatic lacerations, splenic injuries, bowel perforations, and retroperitoneal hemorrhage 1
• Right upper quadrant pain specifically raises concern for hepatobiliary injury, which occurs frequently in RTAs and can progress despite initial hemodynamic stability 1
• Up to 75% of RTA patients have associated injuries that may not be clinically apparent initially 1

Why Ultrasound Alone is Inadequate

• FAST ultrasound has notably low sensitivity (56-71%) for detecting intra-abdominal injuries in blunt trauma, meaning a negative ultrasound cannot exclude significant pathology 1
• Abdominal ultrasound in the clinic setting is insufficient for trauma evaluation and may provide false reassurance 1

Why Blood Work Alone is Insufficient

• Clinical examination and laboratory tests alone cannot reliably exclude intra-abdominal injury in blunt trauma from high-energy mechanisms 1
• Hematocrit changes may not manifest immediately, and normal initial values do not exclude significant injury 2
• Delayed presentations of bowel injuries and other pathology occur in 0.2-0.5% of cases even with negative initial evaluation 1

The Definitive Diagnostic Approach

CT abdomen/pelvis with IV contrast is the gold standard for hemodynamically stable trauma patients 2, 1:

• European trauma guidelines provide a Grade 1B recommendation for CT imaging in hemodynamically stable patients with suspected torso trauma or high-risk mechanism 2, 1
• CT with IV contrast provides comprehensive evaluation of all abdominal organs, the retroperitoneum, and can detect active contrast extravasation indicating ongoing hemorrhage 1
• The negative predictive value of CT for need for surgical intervention is 99.63% 1
• IV contrast-only CT has sensitivity of 95% and specificity of 99.6% for detecting intra-abdominal injuries requiring intervention 2

Critical Time-Sensitive Considerations

Never delay imaging for "observation" in trauma patients 1:

• Occult injuries can deteriorate rapidly
• Mortality increases approximately 1% every 3 minutes when significant hemorrhage is uncontrolled 1
• Solid organ injuries may initially appear stable but can progress to hemodynamic compromise requiring urgent intervention 2

Safe Disposition After Imaging

If CT is negative 2:

• Clinically stable patients with isolated blunt abdominal trauma can be safely discharged after negative CT with IV contrast (Level B recommendation) 2
• Close follow-up and return precautions are essential, as delayed presentations can occur 2

If CT shows injury 2:

• Solid organ injuries with continued hemodynamic stability may be managed non-operatively with serial examinations 1
• Any free intra-abdominal fluid with subsequent hemodynamic deterioration requires urgent surgical intervention (Grade 1A recommendation) 2

Common Pitfalls to Avoid

• Do not rely on "vital stability" as reassurance - hemodynamic stability at presentation does not exclude significant injury that may deteriorate 1
• Do not perform outpatient ultrasound and discharge - this misses the majority of significant injuries in blunt trauma 1
• Do not order blood work alone and observe - laboratory values lag behind clinical deterioration in trauma 2
• Do not assume mild pain equals minor injury - pain severity does not correlate with injury severity in blunt abdominal trauma 2