A 32-year-old man is brought to the emergency department following a high-speed motor vehicle collision. On arrival, he is alert and oriented, blood pressure 110/72 mmHg, heart rate 98/min, respiratory rate 20/min. Primary survey reveals no airway obstruction, bilateral breath sounds present, and no external bleeding. During secondary survey, the trauma surgeon palpates the abdomen and notes mild tenderness in the left upper quadrant without guarding or rigidity. The patient denies pain elsewhere. What is the most appropriate next step in the management of this patient?

Explanation

## Clinical Assessment and Management Approach **Key Point:** In a haemodynamically stable trauma patient with a positive secondary survey finding (LUQ tenderness), the next step is imaging with CT scan of the abdomen and pelvis with IV contrast, which is the gold standard for evaluating solid organ injuries in stable patients. ### ATLS Protocol for Abdominal Trauma The management of abdominal trauma depends critically on the patient's haemodynamic status: | Haemodynamic Status | Physical Exam Finding | Next Step | |---|---|---| | Stable | Positive abdominal exam | CT abdomen/pelvis with IV contrast | | Stable | Negative abdominal exam | Observation + serial exams | | Unstable | Any positive finding | Diagnostic peritoneal lavage or FAST ± laparotomy | | Unstable | Equivocal exam | FAST or DPL | **High-Yield:** This patient is haemodynamically stable (BP 110/72, HR 98) with a positive secondary survey finding (LUQ tenderness). CT imaging is indicated to characterize the injury and guide non-operative management versus operative intervention. ### Why CT is Superior in Stable Patients 1. **Sensitivity and specificity:** CT detects solid organ injuries, free fluid, and retroperitoneal bleeding with >95% accuracy 2. **Grading of injury:** Allows classification of splenic/hepatic injuries (Grade I–V) to guide conservative management 3. **Non-operative management:** Enables selective non-operative management (NOM) with ICU observation for Grade I–III injuries in compliant, stable patients **Clinical Pearl:** Diagnostic peritoneal lavage (DPL) is now reserved for unstable patients without access to FAST or CT, as it cannot grade solid organ injuries and has a high false-positive rate (free fluid ≠ operative injury in stable patients). **Mnemonic — FAST Indications:** **F**ocused **A**ssessment with **S**onography for **T**rauma — used in unstable patients or when CT unavailable; not the first-line in stable patients. [cite:ATLS 10th Edition, Chapter 5: Initial Assessment and Management]