Management of Vitally Stable Patient with Mild RUQ Pain After RTA
This patient requires immediate referral to an emergency department for CT imaging with IV contrast, not outpatient ultrasound or isolated blood work. 1
Why Emergency Department Referral is Mandatory
The presence of any abdominal pain following blunt trauma from a road traffic accident mandates advanced imaging in an emergency setting, regardless of vital sign stability. 1 European trauma guidelines explicitly state that hemodynamically stable patients with suspected torso trauma or high-risk mechanism of injury (which RTAs definitively are) must undergo further assessment using CT imaging (Grade 1B recommendation). 2
Critical Evidence Supporting ED Referral:
Over one-third of "asymptomatic" blunt trauma patients had organ injuries, and 43% with no specific complaints had significant injuries on imaging. 1
Right upper quadrant pain specifically raises concern for hepatobiliary injury, which occurs frequently in RTAs and can progress to life-threatening hemorrhage even with initial hemodynamic stability. 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. 3
Up to 75% of RTA patients have associated injuries that may not be clinically apparent initially. 3
Why Outpatient Ultrasound is Inadequate
FAST ultrasound has high specificity but critically low sensitivity (56-71%) for detecting intra-abdominal injuries in blunt trauma, meaning a negative FAST cannot exclude significant pathology. 3 Additional limitations include:
Requires 400-620 mL of free fluid to be detected reliably and is highly operator-dependent. 1
Bowel injury remains one of the most commonly missed injuries, with 20% missed even on CT. 1 Ultrasound performs far worse for this indication.
Cannot adequately assess the retroperitoneum, where hemorrhage may be occult. 4
Why Blood Work Alone is Insufficient
Blood work cannot exclude significant pathology such as contained hepatic injuries or developing complications, even if hemoglobin levels are normal. 3 Hemorrhage may be contained initially, and laboratory values lag behind clinical deterioration. 2
The Required Diagnostic Approach
CT scan with intravenous contrast is the gold standard for evaluating blunt abdominal trauma in hemodynamically stable patients, with sensitivity of 95-97% and specificity of 94-95% for detecting intra-abdominal injuries. 1 The negative predictive value for need for surgical intervention is 99.63%. 3
ED Management Protocol:
Establish large-bore IV access during imaging preparation. 3
Perform CT abdomen/pelvis with IV contrast (oral contrast is not necessary). 3, 1
Monitor vital signs continuously during imaging. 3
Never 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. 3
Common 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 negative initial evaluation. 3 The case literature documents deaths from isolated jejunal tears that were missed by conservative management without proper imaging. 5
Answer: B - Refer patient to an emergency department for further evaluation (specifically for CT imaging with IV contrast).