What is the most appropriate next step for a vitally stable patient with mild abdominal pain after a recent road traffic accident (RTA)?

Management of Vitally Stable Patient with Mild RUQ Pain After RTA

Obtain an abdominal CT scan with IV contrast immediately—do not rely on clinical stability alone or delay imaging with observation, as high-energy mechanisms like RTAs carry significant risk for occult injuries that may not manifest with immediate hemodynamic instability. 1

Why CT is the Appropriate Next Step

• European trauma guidelines strongly recommend CT imaging for hemodynamically stable patients with suspected torso trauma or high-risk mechanism of injury (Grade 1B recommendation). 2, 1 This is the highest-quality guideline evidence available and directly addresses your clinical scenario.

• Right upper quadrant pain specifically raises concern for hepatobiliary injury, which occurs frequently in RTAs and can progress to life-threatening hemorrhage. 1 The anatomic location of pain makes this a high-risk presentation that requires definitive imaging.

• 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 Up to 75% of RTA patients have associated injuries not clinically apparent initially. 1

Why NOT Ultrasound Alone

• FAST ultrasound has high specificity but 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 identify free fluid rapidly, it will miss many clinically significant injuries in this high-risk mechanism.

• CT with IV contrast provides comprehensive evaluation of all abdominal organs, the retroperitoneum, and can detect active extravasation of contrast indicating ongoing hemorrhage. 1 This is the definitive test, not a screening tool.

Why NOT Bloodwork Alone

• Blood work alone cannot exclude significant pathology, such as contained hepatic injuries or developing complications, even if hemoglobin levels are normal. 1 Laboratory values lag behind actual injury and provide false reassurance in the acute setting.

Why NOT Immediate ED Referral Without Imaging

• Hemodynamically stable patients warrant further assessment using CT (Grade 1B recommendation). 2 The patient's vital stability allows time for definitive imaging before transfer, which provides critical information for the receiving team.

• The negative predictive value of CT for need for surgical intervention is 99.63%. 1 This means if CT is negative, you can safely discharge or observe; if positive, you have actionable information for appropriate referral.

Clinical Algorithm

1. Establish large-bore IV access during imaging preparation 1
2. Obtain abdominal CT with IV contrast (oral contrast is optional and not required for trauma evaluation) 2, 1
3. Monitor vital signs continuously during the imaging process 1

Based on CT Results:

• If CT shows free intra-abdominal fluid with subsequent hemodynamic deterioration: urgent surgical intervention required (Grade 1A recommendation) 2, 1

• If CT shows solid organ injuries with maintained hemodynamic stability: non-operative management with serial examinations and repeat imaging 1

• If CT is negative: hemodynamically stable patients with isolated blunt abdominal trauma can be safely discharged after negative CT with IV contrast (Level B recommendation) 2, 1

Critical Pitfall to Avoid

Never rely on clinical examination alone in blunt abdominal trauma from high-energy mechanisms like RTAs—occult injuries can deteriorate rapidly, and mortality increases approximately 1% every 3 minutes when significant hemorrhage is uncontrolled. 1 The patient's current vital stability does not exclude life-threatening injury; it simply provides a window for definitive imaging before potential deterioration.