What is the most appropriate next step for a patient with mild abdominal pain, mainly in the right upper quadrant, after a recent road traffic accident (RTA) who is vitally stable?

Management of Post-RTA Abdominal Pain

Refer this patient to an emergency department for CT imaging with IV contrast immediately. Despite hemodynamic stability, blunt abdominal trauma from a road traffic accident with persistent right upper quadrant pain requires definitive imaging to exclude life-threatening injuries that may not manifest with immediate vital sign changes 1.

Why Emergency Department Referral 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.

Critical Evidence Supporting Immediate Referral

• 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
• Never rely on clinical examination alone 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
• Do not 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

Why Other Options Are Inadequate

Abdominal Ultrasound (Option A) - Insufficient

• 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 or solid organ injuries, it cannot comprehensively evaluate the retroperitoneum or detect active hemorrhage 1
• Ultrasound may miss critical injuries that CT would identify, potentially delaying life-saving intervention 1

Blood Work Alone (Option C) - Dangerously Inadequate

• Blood work alone cannot exclude significant pathology, such as contained hepatic injuries or developing complications, even if hemoglobin levels are normal 1
• Hemoglobin may remain normal in the acute phase despite significant ongoing bleeding 1
• Laboratory values lag behind clinical deterioration in trauma patients 1

What Should Happen in the Emergency Department

Immediate Actions Upon Arrival

• CT abdomen and pelvis with IV contrast (oral contrast is optional and not required for trauma evaluation) 1
• Ensure large-bore IV access is established during imaging preparation 1
• Monitor vital signs continuously during the imaging process 1

CT Protocol Specifics

• CT with IV contrast provides comprehensive evaluation of all abdominal organs, the retroperitoneum, and can detect active extravasation of contrast indicating ongoing hemorrhage 1
• The negative predictive value of CT for need for surgical intervention is 99.63% 1

Management Based on CT Results

• 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
• Hemodynamically stable patients with isolated blunt abdominal trauma can be safely discharged after negative CT with IV contrast (Level B recommendation) 1

Critical Pitfalls to Avoid

• Avoid discharging patients without imaging when there is any abdominal pain following significant trauma, as delayed presentations of bowel injuries and other pathology occur in 0.2-0.5% of cases even with negative initial evaluation 1
• Do not assume vital stability equals absence of serious injury—hepatic lacerations and other solid organ injuries can present with delayed hemorrhage 1
• Do not perform outpatient ultrasound as the initial step in trauma patients, as this delays definitive diagnosis and appropriate triage 1