RCEM SHO Education Programme · Conquest Hospital ED

Abdominal Emergencies
in the ED

Including retroperitoneal emergencies. Pitfalls, red flags, and things never to mix up.

Dr. Igwe Joshua FRCEM 7 Sections · 40 Slides RCEM / NICE Aligned East Sussex Healthcare NHS Trust

The Acute Abdomen: A Structured ED Approach

Mortality rises with delay. ABCDE first. Always.

Clickable Abdominal Regions — Differential Diagnoses

LUQ RUQ LUQ Epigastric Umbilical /Central LIF RIF LIF R Flank L Flank Hypo- gastric Tap a region

Tap any region to see differential diagnoses

Select a region on the diagram to see differentials and red flags.

Epigastric

  • Peptic ulcer disease / perforation never miss
  • Acute pancreatitis
  • Inferior MI — up to 30% present here ECG mandatory
  • Aortic dissection type A
  • Gastritis / oesophagitis
  • Biliary colic / cholecystitis
⚠
Red Flag Rule
Get an ECG before attributing epigastric pain to any GI cause. Inferior MI + pale/diaphoretic = cardiac until proven otherwise.

Right Upper Quadrant

  • Acute cholecystitis (Murphy's sign)
  • Ascending cholangitis life threatening
  • Biliary colic
  • Hepatitis / liver abscess
  • HELLP syndrome (pregnancy)
  • Right lower lobe pneumonia (referred pain)

Left Upper Quadrant

  • Splenic rupture vascular
  • Gastric pathology
  • Pancreatitis (tail)
  • Left lower lobe pneumonia
  • Splenic infarct / abscess

Umbilical / Central

  • Early appendicitis (migrates to RIF)
  • Small bowel obstruction
  • Mesenteric ischaemia pain ÷ exam
  • AAA (pulsatile mass) vascular
  • IBD
⚠
Classic Teaching
Pain out of proportion to examination = mesenteric ischaemia until proven otherwise.

Right Iliac Fossa (RIF)

  • Acute appendicitis common
  • Ectopic pregnancy (women) beta-hCG
  • Ovarian torsion / cyst
  • Caecal volvulus
  • Inguinal hernia strangulation
  • Crohn's disease
  • Mesenteric adenitis

Left Iliac Fossa (LIF)

  • Diverticulitis (most common cause in LIF)
  • Sigmoid volvulus AXR
  • Colorectal cancer
  • Left ovarian pathology
  • Inguinal hernia
  • IBD / Crohn's

Left / Right Flank

  • Renal colic (loin to groin) USS over 50s
  • AAA rupture never miss
  • Pyelonephritis
  • Retroperitoneal haematoma
  • Psoas abscess
⚠
Rule — Over 50s
Bedside AAA ultrasound is mandatory in any patient over 50 with flank pain. Never assume renal colic without excluding AAA.

Right Flank

  • Renal colic USS over 50s
  • AAA rupture never miss
  • Ascending colon pathology
  • Retroperitoneal haematoma
  • Pyelonephritis

Hypogastric / Suprapubic

  • Urinary retention
  • Ectopic pregnancy beta-hCG
  • Uterine / bladder pathology
  • PID
  • Ovarian torsion
Quick ED Assessment — Acute Abdomen
A
ABCDE first. Identify haemodynamic compromise before detailed history. 2 large-bore IV cannulae if shocked.
B
History: SOCRATES. Onset sudden = vascular until proved otherwise. Vomiting before or after pain? LMP?
C
Examine: distension, scars, hernial orifices. Localise, peritonism, pulsatile mass. PR/vaginal where indicated.
D
Investigate: FBC, U&E, LFT, CRP, amylase, lactate, coag, G&S. Beta-hCG in all women of childbearing age. ECG.
E
Imaging: Erect CXR (free air), CT abdo/pelvis with contrast (workhorse), USS (AAA, biliary, ectopic).
⚠
Highest Risk Presentations — Act Immediately
  • Pain out of proportion to examination findings
  • Peritonism: guarding, rigidity, rebound tenderness
  • Haemodynamic instability with abdominal pain
  • Sudden onset pain = vascular until proved otherwise
🔬
Core Bloods
  • FBC, U&E, LFTs, CRP
  • Amylase / lipase
  • Lactate, coagulation, G&S
  • Troponin if cardiac in differential
  • Serum beta-hCG — all women of childbearing age. No exceptions.
📡
Imaging Strategy
  • Erect CXR: free air under diaphragm
  • AXR: obstruction, volvulus, calcified AAA
  • CT abdo/pelvis + IV contrast: gold standard
  • USS: AAA, gallstones, ectopic, ovarian
  • ECG: mandatory for epigastric / upper abdominal pain

Key Abdominal Emergencies

What to know, what never to miss. Expand each condition for full management.

Clinical Features

  • Central pain migrating to RIF (McBurney's point)
  • Anorexia, nausea, low-grade pyrexia
  • Rovsing's sign, psoas sign
  • Atypical in pregnancy, elderly, immunocompromised
  • Alvarado score guides risk stratification

Investigations

  • WBC elevated, CRP raised (not always early)
  • CT abdo/pelvis: gold standard imaging
  • USS first in children and pregnant women
  • Beta-hCG: exclude ectopic in women
Red Flags / Never Miss
  • Peritonism = perforation until proved otherwise
  • Atypical presentations in pregnancy: pain shifted superiorly
  • Elderly: minimal signs despite severe disease
ED Management
  1. NBM, IV fluids, analgesia (do not withhold opioids)
  2. Early surgical referral for Alvarado ≥7
  3. Antibiotics: NICE supports conservative Rx in uncomplicated cases
  4. Admit all with peritonism for surgical review

Small Bowel (SBO)

  • Causes: adhesions, hernia, tumour, Crohn's
  • Colicky central pain, vomiting (early), constipation (late)
  • AXR: central loops >3 cm, 'stack of coins'
  • CT confirms cause, excludes strangulation

Large Bowel (LBO)

  • Causes: colorectal cancer (60%), volvulus, diverticular
  • Distension dominant, vomiting later
  • AXR: peripheral large bowel >6 cm
  • Caecum >9 cm = impending rupture
Red Flags
  • Strangulation: fever + peritonism + raised lactate = emergency surgery
  • Caecum >9 cm: perforation imminent — urgent surgical review
Management Principles
  1. NG tube, IV fluids, catheter, NBM
  2. Early surgical referral
  3. CT confirms cause and excludes strangulation

Causes

  • Perforated peptic ulcer (most common surgical upper GI emergency)
  • Perforated diverticular disease
  • Perforated appendix, tumour
  • Boerhaave syndrome

Clinical Features

  • Sudden onset severe pain, rapid generalisation
  • Rigid abdomen, board-like guarding
  • Haemodynamic instability = peritonitis with sepsis
  • Erect CXR: subdiaphragmatic free air in 70–80%
📋
Investigation Note
If CXR negative but clinical suspicion high: CT abdomen/pelvis. CT is more sensitive than CXR for pneumoperitoneum.
ED Management
  1. IV fluids, IV antibiotics (NICE/Trust protocol)
  2. NG tube, catheter, NBM
  3. Urgent surgical referral — time-critical diagnosis

Diagnosis

  • Epigastric pain radiating to back
  • Amylase/lipase >3× upper limit of normal
  • Causes: gallstones (45%), alcohol (35%), idiopathic
  • Glasgow score ≥3 = severe (PANCREAS mnemonic)
  • Grey Turner's / Cullen's = haemorrhagic pancreatitis

Severity & Management

  • Revised Atlanta criteria: mild / moderately severe / severe
  • IV fluids: aggressive early resuscitation (Hartmann's preferred)
  • Analgesia: IV opioids, consider PCA
  • Early enteral nutrition within 24–48h if severe
  • ERCP within 24–48h if gallstone pancreatitis with cholangitis
Red Flags
  • Glasgow score ≥3: HDU/ITU and involve HPB surgery early
  • CT not indicated acutely in mild disease — CECT at 72h if not improving
  • Organ failure = severe pancreatitis: escalate immediately

Biliary Colic

  • Episodic RUQ/epigastric pain after fatty meals
  • No fever
  • USS: gallstones, normal CBD
  • Discharge with analgesia + surgical outpatient

Cholecystitis

  • Persistent RUQ pain >6h
  • Murphy's sign, fever, raised WBC/CRP
  • Tokyo guidelines grade I–III
  • IV antibiotics + surgical referral
  • Lap chole within 72h (grade I–II)

Cholangitis

  • Charcot's Triad: fever + RUQ + jaundice
  • Reynolds Pentad: + confusion + hypotension
  • Life-threatening. Do not discharge.
  • Blood cultures, IV antibiotics, IV fluids
  • Urgent ERCP or percutaneous drainage
Never Miss
  • Reynolds Pentad = septic shock. This is a surgical emergency.

Risk Stratification

  • Rockwall score (pre-endoscopy): age, shock, comorbidity
  • Glasgow-Blatchford: BUN, Hb, SBP, HR, syncope
  • Blatchford 0 = safe for outpatient endoscopy
  • HR >100, SBP <100 = haemodynamically significant

ED Management

  • 2 large-bore IV cannulae, bloods including crossmatch
  • IV PPI: omeprazole 80mg then 8mg/h
  • Transfuse: target Hb >70 (>80 if CVD)
  • Terlipressin if variceal bleeding suspected
  • Urgent OGD <24h (<12h if haemodynamically unstable)
📋
Key Pitfall
Do not assume melaena = peptic ulcer. Always exclude vascular cause. 15% of apparent LGIB is an upper GI source.
Clinical Pathway — Acute Abdominal Pain
Patient presents with acute abdominal pain
↓
ABCDE assessment — haemodynamically stable?
↓
Unstable
2× large-bore IV, resuscitate
Bedside USS for AAA
Activate surgical team
Stable
History + examination
SOCRATES, peritonism?
LMP, beta-hCG?
↓
Core bloods + ECG + Erect CXR
↓
Peritonism / free air / haemodynamic compromise?
↓
Yes
Emergency surgical referral
NBM, IV antibiotics
NG tube, catheter
No
CT abdo/pelvis + IV contrast
USS if biliary / ectopic suspected
Risk stratify and reassess

Things Never to Mix Up

High-risk diagnostic pitfalls in abdominal emergencies. These kill patients when missed.

⚠ Never Mix Up

AAA vs Renal Colic

AAA — Never Miss

  • Pulsatile abdominal mass
  • Haemodynamic instability, collapse
  • Known AAA on history
  • Age >60, male, smoker, hypertensive

Renal Colic — Reassuring

  • Haematuria present
  • Writhing in pain (not still)
  • Colicky character
  • Prior similar episodes
  • Age <50, no vascular risk
The RuleDo not assume renal colic in anyone over 60 without excluding AAA. Bedside AAA ultrasound is mandatory in any patient over 50 with flank pain. A patient with apparent renal colic who drops their BP has an AAA until proved otherwise. Do NOT send a haemodynamically unstable patient to CT without a surgeon present.
⚠ Never Mix Up

Ectopic Pregnancy vs Appendicitis

Ectopic — Suspect When

  • Woman of childbearing age
  • Positive beta-hCG
  • Haemodynamic compromise with RIF pain
  • Risk: PID, IUD, prior ectopic, IVF
  • Free fluid on TVS USS

Appendicitis — Features

  • Central pain migrating to RIF
  • Negative beta-hCG
  • Anorexia, low-grade fever
  • In pregnancy: pain shifted superiorly
  • USS first, then MRI if pregnant
The RuleBeta-hCG in every woman of childbearing age with abdominal pain. No exceptions. A positive beta-hCG + pain + haemodynamic compromise = ruptured ectopic until proved otherwise. Missed ectopic remains a leading cause of maternal death in the UK (MBRRACE report).
⚠ Never Mix Up

Mesenteric Ischaemia vs Gastroenteritis

Mesenteric Ischaemia — High Risk

  • Elderly patient
  • AF, vascular disease, recent aortic intervention
  • Pain out of proportion to examination
  • Early: soft abdomen despite severe pain
  • Late: peritonism = bowel dead
  • Raised lactate (non-specific)

Gastroenteritis — Consider Only If

  • Young patient, no vascular risk factors
  • Epidemic context, contact history
  • Normal lactate, no AF, no vascular disease
  • Pain proportionate to examination
The RuleNever diagnose gastroenteritis in a patient over 60 with vascular risk factors. AF + abdominal pain = SMA embolus until proved otherwise. CT angiography is diagnostic. Mortality 60–80% if surgery delayed beyond 12 hours from onset. Time is bowel.
⚠ Never Mix Up

Inferior MI vs Epigastric / Upper GI Pain

Inferior MI — Look For

  • Pale, diaphoretic, unwell-looking patient
  • Epigastric pain up to 30% of inferior MI presentations
  • ST elevation in II, III, aVF
  • RV MI: add V4R leads
  • Nausea, vomiting as prominent features

Aortic Dissection Type A

  • Also presents with epigastric pain
  • Tearing quality, radiation to back
  • Wide mediastinum on CXR
  • BP differential between arms
  • Never thrombolyse without ruling this out
The RuleGet an ECG before attributing epigastric pain to any GI cause. Never perform an upper GI procedure in an undiagnosed MI. Beware the patient who says 'indigestion' but looks pale and diaphoretic — that is a cardiac presentation until the ECG says otherwise.
⚠ Never Mix Up

Sigmoid / Caecal Volvulus vs Constipation

Volvulus — Features

  • Sigmoid: elderly, institutionalised, psychiatric patients
  • AXR sigmoid: 'coffee bean' / 'omega loop' sign pointing to RUQ
  • Caecal: younger patients, right-sided distension
  • Both: surgical emergencies — perforation follows delay

Management

  • Do not discharge a distended patient with laxatives without imaging
  • Sigmoid: endoscopic decompression first-line (no peritonism)
  • Caecal: surgery required in most cases
  • Surgical team aware before any management plan
The RuleNever discharge an elderly distended patient with a diagnosis of constipation without an AXR. The 'coffee bean' or 'omega loop' sign on AXR is diagnostic of sigmoid volvulus and mandates urgent surgical referral.

More Abdominal Emergencies

Hernias, gynaecological emergencies, IBD, and abdominal trauma.

Types & Risk

  • Inguinal (most common overall)
  • Femoral: highest strangulation rate, more common in women, below inguinal ligament
  • Umbilical, incisional, epigastric

Classification

  • Irreducible: cannot reduce — not necessarily compromised
  • Incarcerated: contents trapped, obstructed
  • Strangulated: vascular compromise, ischaemia = emergency
Red Flags — Strangulation
  • Tense, tender, erythematous hernia
  • Systemic features: vomiting, fever, raised WBC/lactate
  • Peritonism
Management
  1. Strangulated: emergency surgical referral. Do NOT attempt manual reduction.
  2. Reducible: safe with surgical outpatient follow-up

Ectopic Pregnancy

  • Risk: PID, IUD, prior ectopic, IVF
  • Positive beta-hCG + pain: TVS immediately
  • Haemodynamic compromise = emergency laparotomy
  • Methotrexate if stable, small, no fetal heart
  • Rhesus status: anti-D if Rh negative

Ovarian Torsion

  • Sudden onset severe unilateral lower abdominal pain
  • Nausea, vomiting, peritonism
  • Doppler USS: absence of flow not 100% sensitive
  • Normal Doppler does not exclude torsion
  • Gynaecology review urgently. Time = ovary.
Never Miss
  • PID: bilateral pelvic pain, discharge, cervical excitation, fever
  • Ovarian cyst rupture: haemoperitoneum possible if corpus luteum

Acute Severe UC (ASUC)

  • Truelove and Witts: >6 bloody stools/day + systemic upset
  • Admit all patients meeting criteria
  • IV hydrocortisone 100mg QDS (ECCO guidelines)
  • CT to exclude perforation
  • Involve gastroenterology and colorectal surgery from day one

Toxic Megacolon

  • Transverse colon >6 cm on AXR with systemic toxicity
  • Emergency surgical consultation. High mortality with delay.
  • IV fluids, steroids, broad-spectrum antibiotics, NG tube
  • Avoid antispasmodics and opioids: worsen distension
Red Flags
  • Toxic megacolon: transverse colon >6 cm = surgical emergency
  • Crohn's complications: abscess, fistula, obstruction, stricture — CT defines anatomy

Blunt Trauma

  • Spleen: most commonly injured solid organ
  • Liver: second most common; haemobilia if ductal injury
  • FAST exam: Morrison's pouch, splenorenal recess, pelvis
  • Positive FAST + haemodynamic instability = emergency laparotomy
  • Seatbelt sign: 50% association with significant intra-abdominal injury

Penetrating Trauma

  • Stab wounds: mandatory laparotomy if haemodynamically unstable
  • Gunshot wounds: all require laparotomy
  • CT indications: stable + mechanism/tenderness/distracting injury
  • Whole-body CT (NICE trauma guidelines): major trauma patients
Red Flags
  • Positive FAST + haemodynamic instability = emergency laparotomy — do not delay for CT
  • Abdominal trauma: leading cause of preventable post-injury death

Retroperitoneal Emergencies

The space behind the peritoneum: high mortality, easily missed. Physical examination is frequently unremarkable even in severe haemorrhage.

⚡
Key Principle — Retroperitoneum
Retroperitoneal bleeding does not irritate the peritoneum. Physical examination is frequently unremarkable even in severe haemorrhage. CT is the definitive diagnostic modality. Bedside ultrasound has limited retroperitoneal sensitivity. Always consider retroperitoneal pathology in undifferentiated shock.

Epidemiology & Presentation

  • 2% of all deaths in men >65 in UK. Overall mortality 80–90%.
  • Classic triad (back pain + collapse + pulsatile mass) present in <50%
  • Risk: male, age >65, smoking, hypertension, family history

ED Management

  • Permissive hypotension: target SBP 70–80 until haemostasis
  • Avoid aggressive fluids: worsens coagulopathy, dissects clot
  • Crossmatch 10 units RBC, FFP, activate MTP
  • Bedside USS: confirms aortic size
  • Do not delay surgery for CT if unstable
  • Immediate vascular surgery referral and theatre activation
Never Miss
  • Never send a haemodynamically unstable patient to CT without a surgeon present
  • EVAR vs open repair: vascular surgery decision based on anatomy and stability

Causes

  • Pelvic fracture (most common traumatic cause)
  • Aortic rupture / iliac artery injury
  • Anticoagulant-related spontaneous bleeding
  • Iatrogenic: femoral access, EVAR
  • Renal artery aneurysm rupture

ED Recognition

  • Flank/back pain, haemodynamic instability, anaemia without obvious source
  • Grey Turner's sign (flank bruising): delayed, not reliable acutely
  • Femoral neuropathy: groin and anterior thigh pain, weakness
  • CT abdo/pelvis with contrast: defines extent and active bleeding
Management
  1. Pelvic fracture haematoma: do NOT explore surgically — pack and angio-embolise
  2. Anticoagulant reversal: dabigatran (idarucizumab), DOAC (andexanet alfa), warfarin (vitamin K + PCC)
  3. Haemostatic resuscitation: activate MTP

Renal Colic

  • Colicky unilateral loin to groin pain
  • CT KUB (non-contrast): gold standard, 96% sensitivity
  • Analgesia: NSAIDs first line (diclofenac 75mg IM)
  • Admit: stone >10mm, single kidney, infection, bilateral obstruction

Obstructive Urosepsis

  • Infected hydronephrosis: high mortality without drainage
  • IV antibiotics immediately
  • Emergency nephrostomy or ureteric stent within hours
  • Urology referral urgently

Renal Infarction

  • Sudden loin pain, haematuria, AF / endocarditis history
  • CT with contrast: wedge-shaped infarct, absent nephrogram
  • Anticoagulation, nephrology review

Adrenal Crisis

  • Hypotension, hyponatraemia, hyperkalaemia, hypoglycaemia
  • Triggers: sepsis, trauma, surgery, steroid withdrawal
  • Do not wait for cortisol — give hydrocortisone 100mg IV immediately
  • IV 0.9% NaCl, glucose if hypoglycaemic

Phaeochromocytoma Crisis

  • Paroxysmal hypertension, headache, diaphoresis, palpitations
  • Do NOT give beta-blockers without prior alpha-blockade — causes hypertensive crisis
  • Phentolamine IV for acute BP control
  • Adrenal haemorrhage: CT — bilateral adrenal hyperdensity
Never Miss
  • Beta-blockers in phaeochromocytoma without alpha-blockade first = hypertensive emergency
  • Waterhouse-Friderichsen: adrenal haemorrhage in meningococcaemia — treat as adrenal crisis

Psoas Abscess

  • Insidious: back/flank pain, fever, hip flexion deformity
  • Primary: haematogenous (Staph aureus, TB)
  • Secondary: Crohn's, diverticular, spinal disease
  • CT: well-defined low-attenuation retroperitoneal collection
  • CT-guided or surgical drainage + IV antibiotics
  • Consider TB in immigrant populations and immunocompromised

Fournier's Gangrene

  • Pain out of proportion, crepitus, gas on imaging
  • CT: gas in fascial planes — pathognomonic
  • Mortality >30%. Surgical debridement within 6 hours.
  • Pip-tazo + clindamycin
  • ICU, repeated surgical washout, consider hyperbaric oxygen
  • Involves urology, colorectal, plastic surgery
Red Flag
  • Gas in fascial planes on CT = necrotising fasciitis. Surgical emergency — debridement within 6 hours.

Special Populations

Presentations differ. Thresholds for investigation and admission are lower.

Why Presentations Differ

  • Attenuated pain response: minimal pain despite serious pathology
  • Peritonism often absent even with perforation
  • Temperature may be normal in sepsis
  • Polypharmacy: NSAIDs mask pain, anticoagulants increase bleeding, steroids mask peritonism

High-Risk Diagnoses

  • AAA: always consider in over-65s with any back or abdominal pain
  • Mesenteric ischaemia: AF, vascular disease, recent MI
  • Acute cholecystitis: higher complication rate, empyema, perforation
  • Sigmoid volvulus: institutionalised, laxative-dependent
📋
ED Approach
Lower threshold for CT imaging in elderly with undifferentiated abdominal pain. Discuss with seniors early. Err on the side of admission. Social history is clinical: who is at home, falls risk, cognition baseline.

By Trimester

  • First: ectopic, miscarriage, corpus luteum cyst
  • Second/third: placental abruption, preterm labour, HELLP, appendicitis
  • Any trimester: ovarian torsion, biliary disease, appendicitis

Key Diagnoses

  • HELLP: RUQ pain + raised LFTs + thrombocytopenia + hypertension
  • Placental abruption: painful PV bleeding, uterine tenderness, fetal compromise
  • Appendicitis: pain shifted superiorly in pregnancy — USS first, MRI if unclear
Never Miss
  • HELLP: variant of severe pre-eclampsia — emergency obstetric involvement immediately
  • Rhesus status: anti-D in any bleeding or trauma in pregnancy
  • Avoid CT in first trimester where possible. USS and MRI preferred.

Who is Immunocompromised?

  • HIV/AIDS, solid organ transplant, haematological malignancy, chemotherapy
  • Long-term steroids, biologic therapy (anti-TNF, rituximab)
  • Fever may be absent even in severe sepsis
  • Peritonism may be minimal
  • Opportunistic infections and atypical organisms

Key Diagnoses

  • Neutropenic enterocolitis (typhlitis): right-sided pain, fever, diarrhoea
  • Treat with broad-spectrum IV antibiotics. Surgery if perforation.
  • CMV colitis, MAC, cryptosporidiosis in HIV
  • Post-transplant: CMV, lymphoma
⚠
ED Approach
Broad-spectrum antibiotics within 1h of triage if sepsis suspected. CT is key — do not rely on examination alone. Involve haematology / oncology / infectious diseases early.

Documentation & Safety Netting

Protect your patient. Protect your practice. Reference: RCEM Clinical Standards for Emergency Medicine.

📝
Every ED Clerking Note Must Include
  • Documented reasoning: why you reached your diagnosis
  • Relevant negatives: what you considered and excluded
  • Investigations: results reviewed and acted upon
  • Reassessment: time of re-examination if admitted
  • Escalation: who you spoke to, what was agreed
  • Disposition: rationale for discharge or admission
🛡
Safety Netting — Must Document
  • What the patient was told to look out for
  • That they understood and could act on the advice
  • Specific return criteria: severity, time window, method
  • Name of who discussed the safety net
⚠
Never Write These in an Abdominal Emergency Note
  • 'Pain not surgical' — without documented clinical examination findings
  • 'NAD' — without listing what was actually examined
  • 'Discharged home well' — without documented safety netting advice

Key Takeaways

01
Time-critical diagnoses kill when missed. Vascular always first in your differential.
02
Never attribute abdominal pain to non-organic causes until life threats are excluded.
03
Document your reasoning, your negatives, your safety net. Every time.
04
When in doubt: reassess, re-examine, and escalate early.
05
Retroperitoneal bleeding is invisible on plain imaging. CT is your tool.
06
RCEM, NICE, and EAST guidelines are your framework. Know them.
07
Beta-hCG in every woman of childbearing age with abdominal pain. No exceptions.
08
ECG before attributing epigastric pain to any GI cause. Inferior MI kills.

"Documentation protects practice. Reasoning cannot be Googled. Improvement requires honest data."

Dr. Igwe Joshua FRCEM · Conquest Hospital ED · East Sussex Healthcare NHS Trust