A vitally stable patient presents with mild abdominal pain, mainly in the right upper quadrant, after blunt trauma to the abdomen, what is the most appropriate initial step?

Refer the patient to the emergency department for CT imaging with IV contrast

This vitally stable patient with blunt abdominal trauma and right upper quadrant pain requires emergency department referral for definitive CT imaging, as blunt abdominal trauma mandates advanced imaging regardless of vital sign stability or mild symptoms. 1

Why Emergency Department Referral is Mandatory

• Blunt abdominal trauma requires definitive imaging even in hemodynamically stable patients with mild symptoms, as the American College of Emergency Physicians recommends that all patients with blunt abdominal trauma should be referred to the emergency department for further evaluation with CT imaging. 1

• The presence of abdominal tenderness after blunt trauma mandates advanced imaging regardless of vital sign stability, with studies showing that over one-third of "asymptomatic" patients had organ injuries, and 43% of blunt trauma patients presented with no specific complaints yet had significant injuries. 1

• Right upper quadrant pain specifically raises concern for hepatobiliary injury, which occurs frequently in blunt trauma and can progress to life-threatening hemorrhage. 2

Why Other Options Are Inadequate

Abdominal Ultrasound (Option A) is Insufficient

• Ultrasound should not be the definitive diagnostic modality in this scenario, as it has critical limitations including requiring 400-620 mL of free fluid to be detected reliably and being highly operator-dependent. 1

• FAST has high specificity but low sensitivity (56-71%) for detecting intra-abdominal injuries, meaning a negative FAST cannot exclude significant pathology. 1, 2

• Bowel injury remains one of the most commonly missed injuries on initial imaging, with 20% of bowel injuries missed even on CT. 1

Blood Work Alone (Option C) Cannot Exclude Injury

• Blood work alone cannot exclude significant pathology, such as contained hepatic injuries or developing complications, even if hemoglobin levels are normal. 2

• Never rely on clinical examination alone in blunt abdominal trauma from high-energy mechanisms, as up to 75% of patients have associated injuries that may not be clinically apparent initially. 2

Analgesics and Follow-up (Option D) is Dangerous

• 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. 2

• 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. 2

• 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. 2

The Gold Standard: CT with IV Contrast in the ED

• 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 European trauma guidelines strongly recommend CT imaging for hemodynamically stable patients with suspected torso trauma (Grade 1B recommendation). 2

• IV contrast-only CT is sufficient; oral contrast is not necessary and does not improve detection of bowel injuries. 1

• The negative predictive value of CT for need for surgical intervention is 99.63%. 2

Safe Disposition After CT

• Clinically stable patients with isolated blunt abdominal trauma can be safely discharged after negative CT with IV contrast (Level B recommendation). 3, 1

• Patients with equivocal or non-specific CT findings require admission for observation with serial clinical examinations for 3-5 days, as delayed bowel perforation from vascular injury can occur hours later. 1

Critical Pitfall to Avoid

The most dangerous error would be managing this patient in a clinic setting without definitive imaging. Physical examination is unreliable in blunt abdominal trauma, and the presence of any abdominal pain after significant trauma mandates CT evaluation in an emergency department setting where immediate surgical consultation is available if needed. 1, 2, 4