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Acute abdominal pain is a medical challenge for emergency physician due to the variety of possible diagnosis, lack of diagnostic and treatment standard in emergency department and the need of a rapid patient management. It is of paramount importance to quickly rule out or diagnose life threatening clinical conditions as acute myocardial infarction or aortic abdominal aneurism rupture. A few more time is allowed to confirm other diseases that lead to major complications if left untreated as acute appendicitis, testicular torsion and acute pyelonefritis. While acute abdominal pain in the elderly reflect often surgical conditions, it has a benign origin in the majority of young patients who can be generally managed as out patient, after a short clinical observation, with a diagnosis at discharge of non specific abdominal pain. The reason for the development of practical clinical pathways for patient with acute abdominal pain is to facilitate physician in differentiating patient who need hospital admission or a short intensive observation from those who can be safely discharged home.

Acute abdominal pain is a medical challenge for emergency physician due to the variety of possible diagnosis, lack of diagnostic and treatment standard in emergency department and the need of a rapid patient management. It is of paramount importance to quickly rule out or diagnose life threatening clinical conditions as acute myocardial infarction or aortic abdominal aneurism rupture. A few more time is allowed to confirm other diseases that lead to major complications if left untreated as acute appendicitis, testicular torsion and acute pyelonefritis. While acute abdominal pain in the elderly reflect often surgical conditions, it has a benign origin in the majority of young patients who can be generally managed as out patient, after a short clinical observation, with a diagnosis at discharge of non specific abdominal pain. The reason for the development of practical clinical pathways for patient with acute abdominal pain is to facilitate physician in differentiating patient who need hospital admission or a short intensive observation from those who can be safely discharged home.

In the vast majority of cases, palpitations are a symptom of little clinical importance that does not warrant any particular diagnostic investigations other than a careful medical history, physical examination and standard 12-lead ECG. However, it should not be underestimated as it can be the only important symptom preceding a sudden death (sometimes in young subjects). It is not always possible to evaluate these cases swiftly. However, it requires all the physician’s skill to weigh up the medical history, clinical and electrocardiographic elements that constitute warning signs. We have observed that a history of palpitations or valve disease, fainting, especially due to exertion and poorly tolerated paroxysmal palpitations are all alarm elements. In the early weeks of life, we observed that certain subgroup of patients is at very high risk of sudden death and is unfortunately not diagnosed properly for slight and relatively unknown ECG alterations (Brugada syndrome, ARVD, long QT syndrome, idiopathic ventricular tachycardia) and the underestimation of warning signs (palpitations caused by exertion, unexplained episodes of fainting). The aim of this short work is to provide elements for guiding the identification of this very generic, misleading and complex symptom.

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Crowding adversely affects the performance of emergency departments (EDs) by worsening efficiency, timeliness of care, clinical outcomes and patients’ satisfaction. We describe in this study our attempt at improving crowding by modifying the roles and workflow of the ED physicians. The observation unit physician was given the additional duty of prioritizing admissions and managing unclear, complex cases, which were previously under the responsibility of front line emergency physicians. We analyzed two corresponding periods, both before the intervention (9897 ED attendances) in 2012 and after the intervention (10,297 attendances) in 2013. Most of the crowding indices improved significantly, including timeliness of triage, of first medical contact, access to resus area, and overall length of stay in ED. Also, emergency hospital admissions, average specialist consultations and imaging studies per patient decreased significantly. The observation unit workload increased. There was no significant excess of adverse events.

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