Chronic and recurrent abdominal pains are common complaints in children and adolescents, but the evaluation in the emergency department (ED) can be challenging. We present a rare yet serious case of a 17-year-old white female who presented to the ED with a 2-day history of diffuse abdominal pain, nausea, and intractable vomiting. Abdominal examination and imaging, including computed tomography (CT), were negative during an episode 6 weeks previously. This was her fifth similar episode in a 2-month period, and she had been seen at three different hospitals and admitted on each occasion. Three days prior to presentation to our ED, she was seen at a gastroenterology clinic and diagnosed with irritable bowel syndrome and an ovarian cyst. Symptomatic therapy during the current presentation, with intravenous fluids, antiemetics, and parenteral narcotics, failed to alleviate her abdominal pain and vomiting. Emergent CT evaluation revealed a high-grade colonic obstruction with focal circumferential narrowing in the transverse colon and a lower gastrointestinal follow-through radiograph with Gastrografin enema showed a classic “apple-core” lesion. Colonic adenocarcinoma with positive regional lymph nodes was found during emergent exploratory laparotomy. Pediatric patients with recurrent, episodic abdominal pain should undergo systematic evaluation and symptomatic treatment. A previous negative workup should not dissuade emergency physicians from proceeding with a systematic and thorough evaluation of the pediatric patient presenting with abdominal pain and vomiting.

Penetrating craniofacial trauma, although uncommon, has a high potential for death or serious morbidity from injury to vital neurovascular structures. An in situ facial foreign body, particularly if large, presents significant challenges beyond safe and timely removal. Airway management, stabilization of the object, management of increased intracranial pressure, and identification of injuries to local structures are all issues that may require addressing. We present a case of penetrating facial trauma from a vice clamp, with an in situ foreign body, that illustrates several of these challenges and provides a forum for their discussion.

Pulmonary embolism (PE) is an uncommon and often overlooked cause of ST-segment elevation on the electrocardiogram (ECG). Emergent echocardiography has been cited as a means to rapidly distinguish acute myocardial infarction from PE. However, both of these conditions can present with focal wall motion abnormalities. We report a case of a 51-year-old asymptomatic male who presented to our emergency department with anterior ST-segment elevation and right-heart strain on an ECG. The clinical diagnosis of ST elevation myocardial infarction was in doubt, and an echocardiogram was obtained while the patient was in the emergency department. Although a focal area of hypokinesia was observed on echocardiography, cardiac catherization did not demonstrate any evidence of acute coronary occlusion. A computed tomographic angiogram of the chest was subsequently obtained, which demonstrated evidence of submassive pulmonary emboli. Our case highlights the limited utility of emergent echocardiography in cases of ST-segment elevation.

Carcinomatous meningitis is defined as leptomeningeal infiltration by malignant cells. A case of carcinomatous meningitis, originally diagnosed as viral meningitis, is presented here to highlight the importance of maintaining a broad differential diagnosis in patients with evidence of meningeal irritation. Clinical and laboratory clues that suggest a diagnosis of carcinomatous meningitis in a patient with meningeal irritation include the presence and type of underlying malignancy (more common with breast cancer, lung cancer, and melanoma), absence of fever, presence of radicular pain, evidence of both cranial and spinal involvement, consistent cerebrospinal fluid (CSF) findings (increased opening pressure, elevated protein concentration, decreased glucose, increased white cell count), and supportive neuroimaging. Diagnosis is based on positive CSF cytology results, which may require multiple lumbar puncture procedures to obtain. For patients with a known primary malignancy who present to the emergency department with symptoms and/or signs of meningeal irritation, carcinomatous meningitis should be included in the differential diagnosis.

The use of deep brain stimulation has become increasingly common for the treatment of movement disorders, including Parkinson disease. Although deep brain stimulation is generally very successful in alleviating the extrapyramidal symptoms of Parkinson disease, side effects can occur. This case report describes a patient presenting to the emergency department in a state of extreme aggression 3 days after a change in the parameters of his bilateral subthalamic nucleus stimulator. We review the complications of deep brain stimulation relevant to the emergency physician and provide some practical information on stimulator adjustment in an emergency.

A 36-year-old male with a history of chronic asthma presented to an emergency department with shortness of breath consistent with an asthma exacerbation. He had persistent tachypnea following inhaled bronchodilator treatment; thus, the workup and differential diagnosis were expanded. He was found to have a mixed respiratory alkalosis and metabolic acidosis with elevated serum lactate without an obvious cause and was admitted to hospital. His case was reviewed, and the lactic acidosis was thought to be caused by inhaled β2-agonist use. Emergency physicians should be aware of the potential side effects of inhaled β2-agonists as lactic acidosis may complicate clinical assessment and management of asthma exacerbations and lead to unnecessary and potentially dangerous escalations in therapy.