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Arab Board EM Final Written study materials
Arab Board EM Final Written study resources

Arab Board EM Final Written practice questions

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Question 1Resuscitation and Cardiovascular Emergencies

A 58-year-old man collapses in the emergency department waiting room. He is unresponsive, not breathing normally, and has no palpable carotid pulse. According to current adult basic life support guidelines, which compression rate and depth should be delivered?

  1. 60 to 80 per minute with a depth of 2 to 3 cm
  2. 80 to 100 per minute with a depth of 4 to 5 cm
  3. 120 to 140 per minute with a depth of 6 to 7 cm
  4. 100 to 120 per minute with a depth of 5 to 6 cm Correct answer.

Explanation

High-quality adult chest compressions are delivered at 100 to 120 per minute with a depth of at least 5 cm but not more than 6 cm, allowing full chest recoil. Rates and depths outside this range reduce coronary perfusion and increase injury.

Question 2Resuscitation and Cardiovascular Emergencies

A 70-year-old woman with a history of hypertension presents with sudden-onset palpitations. Her ECG shows a regular narrow-complex tachycardia at 190 beats per minute. She is alert with a blood pressure of 128/76 mmHg and no chest pain or heart failure signs. Which is the most appropriate initial management?

  1. Immediate synchronised cardioversion at 100 J
  2. Intravenous metoprolol followed by oral anticoagulation
  3. Intravenous amiodarone infusion over 24 hours
  4. Vagal manoeuvres followed by intravenous adenosine if unsuccessful Correct answer.

Explanation

In a haemodynamically stable patient with a regular narrow-complex tachycardia, vagal manoeuvres are the first step, followed by adenosine if these fail. Synchronised cardioversion is reserved for instability or refractory cases.

Question 3Resuscitation and Cardiovascular Emergencies

A 24-year-old man is brought in after a witnessed out-of-hospital cardiac arrest with bystander CPR. On arrival the rhythm is ventricular fibrillation. After the first defibrillation and two minutes of CPR, the rhythm remains ventricular fibrillation. Which intervention has the strongest evidence to improve survival when given during resuscitation?

  1. Routine sodium bicarbonate
  2. Early defibrillation of a shockable rhythm Correct answer.
  3. Intravenous calcium chloride
  4. High-dose adrenaline (5 mg)

Explanation

Early defibrillation is the single most effective intervention for ventricular fibrillation cardiac arrest, with survival falling with each minute of delay. Adrenaline is given after the second shock but does not replace timely defibrillation.

Question 4Resuscitation and Cardiovascular Emergencies

A 62-year-old man presents with crushing central chest pain of 40 minutes' duration. His ECG shows ST elevation of 3 mm in leads V2 to V4. The nearest primary percutaneous coronary intervention centre is 90 minutes away by transfer, and a fibrinolytic-capable emergency department is on site. Which reperfusion strategy is preferred?

  1. Transfer for primary PCI regardless of time
  2. Await serial troponins before deciding
  3. Immediate fibrinolysis with tenecteplase Correct answer.
  4. Urgent coronary artery bypass grafting

Explanation

When primary PCI cannot be delivered within 120 minutes of first medical contact, fibrinolysis should be given promptly if there are no contraindications, ideally within 30 minutes of arrival. Transfer for PCI remains an option if it can be achieved within the time window.

Question 5Resuscitation and Cardiovascular Emergencies

A 30-year-old woman is found unresponsive with pinpoint pupils and a respiratory rate of 4 per minute. After securing the airway and providing ventilation, which antidote is indicated?

  1. Naloxone Correct answer.
  2. Flumazenil
  3. Atropine
  4. N-acetylcysteine

Explanation

Pinpoint pupils with respiratory depression strongly suggest opioid toxicity, for which naloxone is the specific competitive antagonist. Ventilation should be supported while the antidote is titrated to restore adequate respiration.

Question 6Resuscitation and Cardiovascular Emergencies

A 55-year-old woman is admitted with a large anterior STEMI and develops acute pulmonary oedema with a blood pressure of 86/54 mmHg and cool peripheries. Which finding best indicates that she has cardiogenic shock rather than a simple distributive process?

  1. Warm flushed skin with wide pulse pressure
  2. Elevated jugular venous pressure with cool clammy extremities Correct answer.
  3. Isolated tachycardia with normal lactate
  4. Bounding peripheral pulses with a low diastolic pressure

Explanation

Cardiogenic shock is characterised by inadequate cardiac output with elevated filling pressures (raised JVP) and signs of poor peripheral perfusion such as cool, clammy skin and raised lactate. This contrasts with the warm vasodilated picture of distributive shock.

Question 7Resuscitation and Cardiovascular Emergencies

A 68-year-old man is resuscitated from cardiac arrest and remains comatose after return of spontaneous circulation. Which post-arrest intervention has been shown to improve neurological outcome?

  1. Routine corticosteroids
  2. Immediate extubation to assess neurological status
  3. Targeted temperature management with avoidance of hyperthermia Correct answer.
  4. Routine prophylactic antibiotics

Explanation

After cardiac arrest, targeted temperature management and strict avoidance of hyperthermia improve neurological outcomes. Sedation, controlled ventilation, and haemodynamic support are also part of the post-arrest care bundle.

Question 8Resuscitation and Cardiovascular Emergencies

A 45-year-old man with no known cardiac disease has a witnessed collapse and is found in ventricular fibrillation. Which electrolyte abnormality most commonly predisposes to this arrhythmia in an otherwise structurally normal heart?

  1. Hyperchloraemia
  2. Hypernatraemia
  3. Hypokalaemia Correct answer.
  4. Hypercalcaemia

Explanation

Hypokalaemia prolongs repolarisation and predisposes to ventricular arrhythmias, particularly in the presence of digoxin, ischaemia, or QT-prolonging drugs. Hypernatraemia, hypercalcaemia, and hyperchloraemia are not typical precipitants of ventricular fibrillation.

Question 9Resuscitation and Cardiovascular Emergencies

A 72-year-old man presents with a regular wide-complex tachycardia at 160 beats per minute. He is haemodynamically stable. Which feature most reliably supports a ventricular rather than a supraventricular origin?

  1. Presence of atrioventricular dissociation Correct answer.
  2. A history of hypertension
  3. QRS duration of 130 ms
  4. Absence of visible P waves

Explanation

Atrioventricular dissociation, with P waves independent of the QRS complexes, is a highly specific marker of ventricular tachycardia. Other features such as extreme axis deviation, capture beats, and fusion beats also support a ventricular origin.

Question 10Resuscitation and Cardiovascular Emergencies

A 66-year-old woman with a history of inferior STEMI now has a heart rate of 38 per minute, a blood pressure of 78/42 mmHg, and cool skin. The ECG shows third-degree atrioventricular block with a wide QRS escape rhythm. Which is the most appropriate next step?

  1. Transcutaneous pacing while arranging transvenous pacing Correct answer.
  2. Intravenous adenosine 6 mg
  3. Atropine 0.5 mg intravenously and reassess
  4. Observation with repeat ECG in one hour

Explanation

Third-degree AV block with a wide QRS escape rhythm and haemodynamic compromise is an indication for immediate pacing, starting with transcutaneous pacing while transvenous access is arranged. Atropine is unlikely to be effective in infranodal block.

Question 11Resuscitation and Cardiovascular Emergencies

A 60-year-old man with a history of heart failure presents with a heart rate of 130 per minute, irregularly irregular, and a blood pressure of 88/60 mmHg. He is confused and has cool peripheries. Which is the most appropriate immediate management?

  1. Adenosine 6 mg intravenous push
  2. Intravenous digoxin loading
  3. Oral anticoagulation and observation
  4. Synchronised DC cardioversion Correct answer.

Explanation

An irregularly irregular tachycardia with haemodynamic instability indicates unstable atrial fibrillation, for which emergency synchronised cardioversion is indicated. Rate-control drugs are used in stable patients.

Question 12Resuscitation and Cardiovascular Emergencies

A 50-year-old man is resuscitated from ventricular fibrillation. His ECG shows a prolonged QT interval. Which electrolyte correction is most important in preventing recurrence?

  1. Correction of hypomagnesaemia and hypokalaemia Correct answer.
  2. Correction of hyperphosphataemia
  3. Correction of hypernatraemia
  4. Correction of hypercalcaemia

Explanation

Hypokalaemia and hypomagnesaemia prolong the QT interval and predispose to torsades de pointes and ventricular fibrillation. Correcting these electrolytes is essential in secondary prevention.

Question 13Resuscitation and Cardiovascular Emergencies

A 34-year-old woman is brought in after a bee sting with stridor, wheeze, and a blood pressure of 76/40 mmHg. Which is the most appropriate first-line drug?

  1. Intravenous chlorphenamine 10 mg
  2. Intravenous hydrocortisone 200 mg
  3. Intramuscular adrenaline 0.5 mg into the anterolateral thigh Correct answer.
  4. Nebulised salbutamol alone

Explanation

Intramuscular adrenaline into the anterolateral thigh is the first-line treatment for anaphylaxis, reversing vasodilation and airway oedema. Antihistamines and corticosteroids are adjuncts and do not treat the acute airway or circulatory compromise.

Question 14Resuscitation and Cardiovascular Emergencies

A 78-year-old woman is found unresponsive with a blood pressure of 210/110 mmHg and a heart rate of 52 per minute. She has a Glasgow Coma Scale of 6. Which is the most appropriate immediate step?

  1. Oral nifedipine to lower blood pressure rapidly
  2. Immediate intravenous labetalol bolus to normalise blood pressure
  3. Sublingual captopril
  4. Controlled airway management with cautious blood pressure reduction Correct answer.

Explanation

In hypertensive emergencies with impaired consciousness, airway protection and controlled reduction of blood pressure (typically by 20 to 25 percent in the first hour) are priorities. Overly rapid reduction risks cerebral and coronary hypoperfusion.

Question 15Resuscitation and Cardiovascular Emergencies

A 64-year-old man presents with sudden severe tearing chest pain radiating to the back. His blood pressure is 190/100 mmHg in the right arm and 150/80 mmHg in the left arm. Which finding on imaging is diagnostic of a Stanford type A aortic dissection?

  1. Pericardial effusion alone
  2. Intimal flap in the ascending aorta Correct answer.
  3. Left ventricular hypertrophy
  4. Dilated descending aorta without a flap

Explanation

The presence of an intimal flap involving the ascending aorta defines a Stanford type A dissection, which is a surgical emergency. Interarm blood pressure difference and tearing pain are classic clinical clues.

Question 16Resuscitation and Cardiovascular Emergencies

A 48-year-old man with a history of alcohol misuse presents with palpitations. His ECG shows a narrow-complex tachycardia at 180 beats per minute with a regular rhythm. He is hypotensive at 82/50 mmHg. Which is the most appropriate immediate management?

  1. Intravenous adenosine
  2. Vagal manoeuvres
  3. Oral bisoprolol
  4. Synchronised DC cardioversion Correct answer.

Explanation

Haemodynamic instability with a tachyarrhythmia is an indication for immediate synchronised cardioversion. Adenosine and vagal manoeuvres are reserved for stable patients.

Question 17Resuscitation and Cardiovascular Emergencies

A 58-year-old man is in cardiac arrest with pulseless electrical activity. Which of the following is the most important initial step in management?

  1. Administration of calcium chloride
  2. Identification and correction of reversible causes Correct answer.
  3. Administration of atropine
  4. Immediate defibrillation

Explanation

Pulseless electrical activity is managed with high-quality CPR and systematic identification and correction of reversible causes such as hypovolaemia, hypoxia, acidosis, and tamponade. Defibrillation is not indicated because the rhythm is not shockable.

Question 18Resuscitation and Cardiovascular Emergencies

A 32-year-old woman presents with a heart rate of 150 per minute, a regular narrow-complex tachycardia, and a blood pressure of 118/70 mmHg. Her ECG shows a short RP tachycardia with retrograde P waves. Which is the most likely diagnosis?

  1. Atrial flutter with variable block
  2. Atrioventricular nodal reentrant tachycardia Correct answer.
  3. Ventricular tachycardia
  4. Sinus tachycardia

Explanation

A regular narrow-complex tachycardia with a short RP interval and retrograde P waves is characteristic of atrioventricular nodal reentrant tachycardia, the most common paroxysmal supraventricular tachycardia. It typically responds to vagal manoeuvres or adenosine.

Question 19Resuscitation and Cardiovascular Emergencies

A 70-year-old man with a history of ischaemic heart disease develops bradycardia at 40 per minute with a blood pressure of 90/60 mmHg after receiving a beta-blocker overdose. Which is the most appropriate initial therapy?

  1. Synchronised cardioversion
  2. Intravenous glucagon Correct answer.
  3. Intravenous adenosine
  4. Intravenous amiodarone

Explanation

Beta-blocker toxicity causing symptomatic bradycardia and hypotension is treated with intravenous glucagon, which bypasses the beta-receptor blockade by activating adenylate cyclase. High-dose insulin and pacing may also be used in refractory cases.

Question 20Resuscitation and Cardiovascular Emergencies

A 26-year-old man is brought in after a high-voltage electrical injury with cardiac arrest. He is resuscitated, and the ECG shows ST elevation in the anterior leads. Which is the most likely mechanism of myocardial injury?

  1. Pulmonary embolism
  2. Direct thermal and electrical injury to the myocardium Correct answer.
  3. Coronary atherosclerosis
  4. Pericardial tamponade

Explanation

High-voltage electrical injury can cause direct myocardial damage, arrhythmias, and coronary spasm, producing ischaemic ECG changes in a young patient without atherosclerotic disease. Careful monitoring for arrhythmias is required.

Question 21Resuscitation and Cardiovascular Emergencies

A 58-year-old woman with a history of mitral stenosis presents with palpitations and a heart rate of 140 per minute. She is haemodynamically stable. Her ECG shows a narrow-complex irregular tachycardia. Which of the following is the most appropriate initial management?

  1. Immediate electrical cardioversion
  2. Rate control with a beta-blocker or calcium channel blocker Correct answer.
  3. Amiodarone loading
  4. Intravenous adenosine

Explanation

In stable atrial fibrillation, rate control with a beta-blocker or non-dihydropyridine calcium channel blocker is the initial approach. In mitral stenosis, rate control is particularly important because tachycardia reduces diastolic filling time and worsens pulmonary congestion.

Question 22Resuscitation and Cardiovascular Emergencies

A 66-year-old man with a history of hypertension is found unresponsive. His blood pressure is 200/110 mmHg and his pupils are unequal. Which of the following is the most important initial consideration in management?

  1. Rapid reduction of blood pressure to normal within minutes
  2. Immediate lumbar puncture
  3. Immediate thrombolysis
  4. Securing the airway and imaging the brain while controlling blood pressure Correct answer.

Explanation

An unresponsive hypertensive patient with unequal pupils may have an intracerebral haemorrhage or other intracranial catastrophe. Airway protection, urgent neuroimaging, and controlled blood pressure reduction are priorities; thrombolysis is contraindicated in haemorrhage.

Question 23Resuscitation and Cardiovascular Emergencies

A 55-year-old man with a history of dilated cardiomyopathy presents with a heart rate of 180 per minute, a wide-complex regular tachycardia, and a blood pressure of 100/65 mmHg. He is alert. Which is the most appropriate management?

  1. Intravenous adenosine
  2. Observation
  3. Intravenous verapamil
  4. Intravenous amiodarone or synchronised cardioversion Correct answer.

Explanation

A regular wide-complex tachycardia in a patient with structural heart disease should be treated as ventricular tachycardia. In a stable patient, intravenous amiodarone or synchronised cardioversion is appropriate; verapamil is contraindicated.

Question 24Resuscitation and Cardiovascular Emergencies

A 40-year-old woman develops sudden severe dyspnoea and pleuritic chest pain two days after caesarean delivery. Her heart rate is 120 per minute, blood pressure 100/70 mmHg, and oxygen saturation 88 percent on room air. Which is the most appropriate initial management?

  1. Anticoagulation with low-molecular-weight heparin while awaiting CT pulmonary angiography Correct answer.
  2. Immediate thrombolysis
  3. Observation with repeat saturation in two hours
  4. Oral aspirin

Explanation

In a haemodynamically stable patient with suspected pulmonary embolism, prompt therapeutic anticoagulation is started while confirmatory imaging is arranged. Thrombolysis is reserved for haemodynamic instability.

Question 25Resuscitation and Cardiovascular Emergencies

A 60-year-old man is in cardiac arrest with ventricular fibrillation refractory to three shocks, adrenaline, and amiodarone. Which of the following should be considered next?

  1. Termination of resuscitation
  2. Immediate defibrillation with a higher energy and treatment of reversible causes Correct answer.
  3. Administration of atropine
  4. Administration of calcium chloride

Explanation

Refractory ventricular fibrillation requires continued high-quality CPR, defibrillation at maximum energy, and treatment of reversible causes such as electrolyte disturbance, ischaemia, and hypothermia. Resuscitation should not be terminated while reversible causes may still be addressed.

Question 26Resuscitation and Cardiovascular Emergencies

During CPR in an adult, what is the recommended compression-to-ventilation ratio for a single rescuer?

  1. 5:1
  2. 50:2
  3. 30:2 Correct answer.
  4. 15:2

Explanation

Current resuscitation guidelines recommend a compression-to-ventilation ratio of 30:2 for adult CPR to minimize interruptions in chest compressions and maintain adequate coronary perfusion pressure.

Question 27Resuscitation and Cardiovascular Emergencies

A 62-year-old man with no known cardiac history collapses suddenly. Bystanders start CPR. The AED arrives and advises a shock. What is the correct sequence of actions immediately after the shock is delivered?

  1. Resume chest compressions immediately Correct answer.
  2. Give two rescue breaths, then check pulse
  3. Reanalyse the rhythm with the AED
  4. Check the rhythm, then give adrenaline

Explanation

After a shock, chest compressions should be resumed immediately without checking the rhythm or pulse, as this minimizes interruptions in compressions and improves survival.

Question 28Resuscitation and Cardiovascular Emergencies

A 70-year-old woman presents with a heart rate of 32 bpm, blood pressure 80/50 mmHg, and cool extremities. ECG shows third-degree AV block. Intravenous atropine 1 mg is given with no effect. What is the most appropriate next step in management?

  1. Transcutaneous pacing Correct answer.
  2. Isoprenaline infusion
  3. Adenosine 6 mg IV push
  4. Synchronized cardioversion

Explanation

Transcutaneous pacing is indicated for symptomatic bradycardia unresponsive to atropine, especially in high-degree AV block, to maintain adequate heart rate and perfusion.

Question 29Resuscitation and Cardiovascular Emergencies

A 58-year-old man with a history of myocardial infarction presents with a regular narrow-complex tachycardia at 180 bpm. He is alert but has a blood pressure of 100/70 mmHg and no chest pain. Vagal maneuvers and adenosine have failed to convert the rhythm. What is the most appropriate next step?

  1. Intravenous amiodarone
  2. Observation and reassessment
  3. Synchronized cardioversion
  4. Intravenous metoprolol Correct answer.

Explanation

For stable narrow-complex tachycardia unresponsive to adenosine, intravenous beta-blockers such as metoprolol are recommended to slow the ventricular rate and attempt conversion.

Question 30Resuscitation and Cardiovascular Emergencies

A 45-year-old man is resuscitated from cardiac arrest. His ECG shows a prolonged QT interval (QTc 520 ms). Which electrolyte abnormality is most likely to contribute to this finding?

  1. Hypernatraemia
  2. Hypochloraemia
  3. Hypercalcaemia
  4. Hypokalaemia Correct answer.

Explanation

Hypokalaemia prolongs the QT interval by delaying ventricular repolarization, increasing the risk of torsades de pointes and cardiac arrest.

Question 31Respiratory and Thoracic Emergencies

A 24-year-old man develops sudden right-sided pleuritic chest pain and breathlessness while at rest. He is tall and thin. He is tachycardic with reduced breath sounds and hyperresonance on the right. What is the most appropriate immediate next step in management?

  1. Portable chest radiograph in the emergency department Correct answer.
  2. Urgent needle decompression of the right chest
  3. Bedside echocardiography
  4. CT pulmonary angiography

Explanation

The presentation suggests a primary spontaneous pneumothorax in a stable patient; in the haemodynamically stable patient, imaging (usually erect chest radiograph) confirms the diagnosis before any drainage procedure. Needle decompression is reserved for tension physiology or haemodynamic compromise. CT pulmonary angiography is for suspected pulmonary embolism, not first-line here.

Question 32Respiratory and Thoracic Emergencies

Which finding is most characteristic of a tension pneumothorax on clinical examination?

  1. Ipsilateral reduced breath sounds with hypotension and distended neck veins Correct answer.
  2. Tracheal deviation toward the affected side
  3. Bilateral crackles with a raised oxygen saturation
  4. Dullness to percussion with bronchial breathing

Explanation

Tension pneumothorax causes ipsilateral absent breath sounds, hyperresonance, hypotension and raised jugular venous pressure from impaired venous return. Tracheal deviation is away from the affected side and is a late sign. Dullness with bronchial breathing suggests consolidation, not air in the pleural space.

Question 33Respiratory and Thoracic Emergencies

A 68-year-old smoker presents with a large right pleural effusion. Thoracentesis yields turbid fluid with a pH of 7.05, glucose of 1.5 mmol/L and visible pus. What is the most appropriate definitive management?

  1. Insertion of a chest drain with ongoing drainage Correct answer.
  2. Chest tube drainage with intrapleural fibrinolytics only
  3. Observation with serial radiographs
  4. Repeated aspiration with oral antibiotics as an outpatient

Explanation

Frank pus, a pH below 7.2 and low glucose define an empyema, which requires prompt tube thoracostomy and antibiotics; intrapleural fibrinolytics are adjunctive, not a substitute for drainage. Observation or outpatient aspiration risks sepsis and loculation.

Question 34Respiratory and Thoracic Emergencies

Which arterial blood gas pattern is most consistent with acute severe asthma?

  1. Metabolic acidosis with a high PaO2
  2. Respiratory acidosis with a normal PaO2
  3. Metabolic alkalosis with hypercapnia
  4. Respiratory alkalosis with hypoxaemia Correct answer.

Explanation

Early acute severe asthma produces hyperventilation with a low PaCO2 and respiratory alkalosis, together with hypoxaemia from ventilation-perfusion mismatch. A normal or rising PaCO2 in a tiring asthmatic signals impending respiratory failure. Metabolic patterns are not typical of uncomplicated asthma.

Question 35Respiratory and Thoracic Emergencies

A 30-year-old woman with asthma is drowsy, has a silent chest and a PaCO2 of 7.5 kPa. What is the most appropriate immediate action?

  1. Nebulised salbutamol and discharge after observation
  2. Urgent tracheal intubation and mechanical ventilation Correct answer.
  3. Oral prednisolone and a peak flow recheck in one hour
  4. Intravenous antibiotics and chest physiotherapy

Explanation

A silent chest, drowsiness and rising PaCO2 indicate life-threatening asthma with impending respiratory failure, requiring urgent intubation and ventilatory support. Oral therapy or discharge is unsafe, and antibiotics have no role in an asthma attack.

Question 36Respiratory and Thoracic Emergencies

Which single measurement best predicts the severity of an acute exacerbation of COPD at presentation?

  1. Arterial pH Correct answer.
  2. Respiratory rate alone
  3. Peak expiratory flow rate
  4. Sputum colour

Explanation

Arterial pH, together with PaCO2, is the strongest predictor of outcome and need for ventilatory support in acute COPD exacerbation; acidaemia indicates respiratory failure. Sputum colour and isolated respiratory rate are less discriminating.

Question 37Respiratory and Thoracic Emergencies

In a patient with an acute COPD exacerbation, which finding best indicates the need for non-invasive ventilation?

  1. Oxygen saturation of 94% on air
  2. Purulent sputum production
  3. A raised white cell count
  4. Persistent hypercapnic respiratory acidosis despite optimal medical therapy Correct answer.

Explanation

Non-invasive ventilation is indicated for persistent respiratory acidosis (pH below 7.35 with hypercapnia) despite maximal bronchodilators, steroids and controlled oxygen. Saturation, white cell count and sputum character do not by themselves indicate NIV.

Question 38Respiratory and Thoracic Emergencies

A 55-year-old man is immobilised after a femoral fracture. He becomes suddenly breathless and tachycardic with pleuritic chest pain and a clear chest radiograph. What is the most appropriate first-line investigation?

  1. CT pulmonary angiography Correct answer.
  2. D-dimer assay
  3. Ventilation-perfusion scan
  4. Transthoracic echocardiography

Explanation

CT pulmonary angiography is the investigation of choice for suspected pulmonary embolism in a haemodynamically stable patient with a clear chest radiograph. D-dimer is useful only to rule out PE in low-probability patients and is unhelpful in high-probability cases. Echocardiography is reserved for unstable patients.

Question 39Respiratory and Thoracic Emergencies

A 60-year-old woman with a large pulmonary embolism is hypotensive and hypoxic. Thrombolysis is contraindicated because of recent intracranial surgery. What is the most appropriate management?

  1. Catheter-directed therapy or surgical embolectomy discussion Correct answer.
  2. Systemic anticoagulation alone with observation
  3. Surgical pulmonary embolectomy referral
  4. Inferior vena cava filter insertion alone

Explanation

In high-risk PE with contraindications to thrombolysis, catheter-directed therapy or surgical embolectomy should be considered alongside anticoagulation. Anticoagulation alone is insufficient for shock, and an IVC filter does not treat the obstructing clot.

Question 40Respiratory and Thoracic Emergencies

Which statement about community-acquired pneumonia severity assessment using the CURB-65 score is correct?

  1. A score of 3 indicates low mortality risk
  2. A score of 2 mandates intensive care admission
  3. The score includes oxygen saturation
  4. A score of 0 to 1 generally allows outpatient management Correct answer.

Explanation

CURB-65 scores 0 to 1 are usually suitable for outpatient care, 2 suggests short inpatient admission, and 3 or more indicates severe pneumonia with high mortality. The score uses confusion, urea, respiratory rate, blood pressure and age, not oxygen saturation.

Question 41Respiratory and Thoracic Emergencies

A 45-year-old man with pneumonia develops rapidly worsening hypoxia, bilateral infiltrates and a normal cardiac silhouette on chest radiograph. Which feature most supports a diagnosis of acute respiratory distress syndrome?

  1. Unilateral lobar consolidation with air bronchograms
  2. A pulmonary artery wedge pressure above 18 mmHg
  3. Bilateral opacities not fully explained by cardiac failure, with a PaO2/FiO2 ratio below 300 Correct answer.
  4. A normal chest radiograph with isolated hypoxaemia

Explanation

ARDS is defined by acute onset, bilateral opacities not fully explained by cardiac failure, and hypoxaemia with a PaO2/FiO2 ratio of 300 or less. A high wedge pressure points to cardiogenic oedema, and lobar consolidation suggests pneumonia without ARDS.

Question 42Respiratory and Thoracic Emergencies

A 70-year-old man sustains blunt chest trauma after a road traffic collision. He is hypoxic, and examination shows paradoxical inward movement of a segment of the chest wall during inspiration. What is the immediate priority?

  1. Chest wall strapping to stabilise the segment
  2. Immediate surgical fixation of the ribs
  3. Adequate analgesia, oxygenation and ventilatory support Correct answer.
  4. Prophylactic antibiotics for all rib fractures

Explanation

Flail chest is managed primarily with analgesia, oxygen and ventilatory support to overcome the underlying pulmonary contusion; surgical fixation is considered in selected cases. Strapping restricts ventilation and increases atelectasis, and antibiotics are not routinely indicated.

Question 43Respiratory and Thoracic Emergencies

Which finding is most suggestive of a massive haemothorax after penetrating chest trauma?

  1. Dullness to percussion with hypotension and absent breath sounds Correct answer.
  2. Tracheal deviation toward the affected side
  3. Hyperresonance to percussion on the affected side
  4. Subcutaneous emphysema over the chest wall

Explanation

A massive haemothorax produces dullness to percussion, reduced or absent breath sounds and haemodynamic compromise from blood loss. Hyperresonance suggests air, not blood, and tracheal shift is away from the affected side when it occurs.

Question 44Respiratory and Thoracic Emergencies

A 35-year-old woman has a witnessed generalised seizure followed 30 minutes later by fever, tachycardia, hypoxia and bilateral pulmonary infiltrates. What is the most likely diagnosis?

  1. Acute severe asthma
  2. Neurogenic pulmonary oedema Correct answer.
  3. Pulmonary embolism
  4. Aspiration pneumonia

Explanation

Neurogenic pulmonary oedema follows a sudden central nervous system insult such as a seizure or head injury and presents with rapid-onset hypoxaemia and bilateral infiltrates. Aspiration pneumonia usually evolves over hours to days with focal changes, and PE or asthma do not fit this postictal sequence.

Question 45Respiratory and Thoracic Emergencies

A 28-year-old woman presents with recurrent pneumothoraces, and examination reveals a small stature and a distinctive facial appearance. Which underlying diagnosis should be considered?

  1. Marfan syndrome Correct answer.
  2. Cystic fibrosis
  3. Bronchiectasis
  4. Alpha-1 antitrypsin deficiency

Explanation

Marfan syndrome is a connective tissue disorder associated with tall stature, arachnodactyly and apical blebs that predispose to spontaneous pneumothorax. The other conditions cause chronic airway disease or emphysema rather than recurrent pneumothorax with a Marfanoid habitus.

Question 46Respiratory and Thoracic Emergencies

A patient with a suspected tension pneumothorax becomes profoundly hypotensive during transfer. Which immediate action is most appropriate?

  1. Administer intravenous fluids and await senior review
  2. Obtain a portable chest radiograph before any intervention
  3. Perform immediate needle decompression of the affected hemithorax Correct answer.
  4. Start non-invasive ventilation

Explanation

Tension pneumothorax with haemodynamic compromise is a clinical diagnosis requiring immediate needle decompression without waiting for imaging. Non-invasive ventilation would worsen the air trapping, and fluids alone do not relieve the obstructive shock.

Question 47Respiratory and Thoracic Emergencies

A 62-year-old man with known COPD has an acute deterioration with a raised D-dimer, but CT pulmonary angiography is contraindicated because of severe renal impairment. Which investigation is most appropriate?

  1. Transthoracic echocardiography
  2. Chest radiograph alone
  3. Repeat D-dimer measurement
  4. Ventilation-perfusion lung scan Correct answer.

Explanation

When CT pulmonary angiography is contraindicated, a ventilation-perfusion scan is the usual alternative for suspected PE. Repeating a D-dimer adds nothing, a chest radiograph cannot diagnose PE, and echocardiography is reserved for unstable patients.

Question 48Respiratory and Thoracic Emergencies

Which physiological change is most responsible for hypoxaemia in acute pulmonary embolism?

  1. Diffusion impairment alone
  2. Increased alveolar ventilation
  3. Ventilation-perfusion mismatch Correct answer.
  4. Reduced oxygen carriage by haemoglobin

Explanation

Pulmonary embolism causes hypoxaemia chiefly through ventilation-perfusion mismatch from obstructed perfusion to ventilated lung regions. Diffusion impairment alone and altered haemoglobin carriage are not the principal mechanisms. Increased ventilation would tend to raise, not lower, oxygenation.

Question 49Respiratory and Thoracic Emergencies

A 40-year-old man has a witnessed aspiration of gastric contents and develops cough and hypoxaemia within two hours. Which management step is most appropriate initially?

  1. Immediate bronchoscopy to remove all aspirated material
  2. Supportive oxygen therapy and airway protection with reassessment Correct answer.
  3. Routine antibiotics for all patients regardless of findings
  4. Prophylactic high-dose corticosteroids

Explanation

Initial management of aspiration is supportive, with oxygen, airway protection and observation for evolving pneumonitis or pneumonia. Routine bronchoscopy, steroids and universal antibiotics are not indicated; antibiotics are reserved for established infection.

Question 50Respiratory and Thoracic Emergencies

A 19-year-old with sickle cell disease presents with fever, chest pain, breathlessness and a new pulmonary infiltrate. What is the most important early intervention?

  1. Broad-spectrum antibiotics and urgent haematology input with oxygen and hydration Correct answer.
  2. Nebulised bronchodilators alone
  3. Chest physiotherapy alone
  4. Immediate exchange transfusion for all patients

Explanation

Acute chest syndrome requires prompt broad-spectrum antibiotics, oxygen, hydration and analgesia, with urgent haematology input for possible transfusion. Exchange transfusion is reserved for severe or deteriorating cases, and bronchodilators or physiotherapy alone are insufficient.