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ACEM Fellowship Written practice questions

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Question 1Emergency Medicine (content domains not enumerated in source)

A 4-year-old child is brought in after a generalised tonic-clonic seizure that lasted 2 minutes and has now stopped. The child is alert and afebrile with a normal neurological examination. According to paediatric status epilepticus guidance, what is the most appropriate next step in management?

  1. Observe and investigate for the cause without giving antiseizure medication Correct answer.
  2. Give intravenous levetiracetam immediately
  3. Give rectal diazepam as first-line therapy
  4. Perform an urgent lumbar puncture before any other intervention

Explanation

A brief self-terminating seizure in a child who has returned to baseline does not require antiseizure medication; management focuses on identifying the cause and parental education. Routine lumbar puncture is not indicated in an alert child with a normal examination and no meningism. Escalation drugs such as levetiracetam are reserved for ongoing or recurrent seizures.

Question 2Emergency Medicine (content domains not enumerated in source)

Which intravenous fluid is recommended as the initial resuscitation fluid for a hypotensive adult trauma patient?

  1. 5% dextrose
  2. 20% albumin
  3. 0.45% sodium chloride
  4. 0.9% sodium chloride Correct answer.

Explanation

Isotonic crystalloid, typically 0.9% sodium chloride or a balanced crystalloid, is used for initial volume resuscitation in haemorrhagic shock while blood products are arranged. Hypotonic fluids such as 0.45% sodium chloride do not stay in the intravascular space effectively. Dextrose solutions provide free water and do not expand plasma volume.

Question 3Emergency Medicine (content domains not enumerated in source)

A patient presents with sudden painless loss of vision in one eye described as a curtain descending. Fundoscopy shows a pale retina with a cherry-red spot at the macula. What is the most likely diagnosis?

  1. Central retinal artery occlusion Correct answer.
  2. Acute angle-closure glaucoma
  3. Retinal detachment
  4. Vitreous haemorrhage

Explanation

Central retinal artery occlusion classically produces sudden painless monocular visual loss with a pale, oedematous retina and a cherry-red spot at the fovea where the choroidal circulation shows through. It is an ocular emergency because retinal infarction occurs within hours. Immediate measures aim to dislodge or reduce the obstruction while the underlying cause is investigated.

Question 4Emergency Medicine (content domains not enumerated in source)

Which of the following is the most appropriate initial airway manoeuvre in an unresponsive adult with suspected cervical spine injury and no obvious facial trauma?

  1. Head tilt-chin lift
  2. Insertion of a nasopharyngeal airway without lubrication
  3. Blind digital intubation
  4. Jaw thrust with manual in-line stabilisation Correct answer.

Explanation

In suspected cervical spine injury, the jaw thrust with manual in-line stabilisation opens the airway while minimising movement of the cervical spine. The head tilt-chin lift extends the neck and may aggravate an unstable injury. Blind techniques are unsafe and obsolete in modern emergency airway management.

Question 5Emergency Medicine (content domains not enumerated in source)

A 28-year-old woman presents with a painful swollen calf after a long-haul flight. Which clinical decision rule is most appropriate to guide further investigation for deep vein thrombosis?

  1. CURB-65 score
  2. Glasgow Coma Scale
  3. CHA2DS2-VASc score
  4. Wells score Correct answer.

Explanation

The Wells score stratifies the pretest probability of deep vein thrombosis and guides whether D-dimer testing or compression ultrasound is the appropriate next step. The other listed scores address consciousness, stroke risk in atrial fibrillation, and pneumonia severity respectively. Applying them here would not inform the diagnosis of venous thromboembolism.

Question 6Emergency Medicine (content domains not enumerated in source)

Which of the following is a recognised early complication of severe acute pancreatitis?

  1. Pancreatic pseudocyst
  2. Chronic pancreatitis
  3. Hypocalcaemia Correct answer.
  4. Pancreatic adenocarcinoma

Explanation

Hypocalcaemia arises early in severe acute pancreatitis due to saponification of calcium in areas of fat necrosis and is a marker of severity. Pseudocysts typically develop weeks after the acute episode. Chronic pancreatitis and malignancy are long-term sequelae rather than early complications.

Question 7Emergency Medicine (content domains not enumerated in source)

A patient has a blood pressure of 210/120 mmHg with headache and blurred vision but no focal neurological deficit or evidence of acute end-organ damage. What is the most appropriate management?

  1. Sublingual nifedipine for rapid reduction
  2. No treatment and discharge with outpatient review
  3. Immediate intravenous nitroprusside to normalise blood pressure within minutes
  4. Gradual oral blood pressure reduction in a monitored setting Correct answer.

Explanation

Severe asymptomatic hypertension without acute end-organ damage should be lowered gradually over hours to days, usually with oral agents, to avoid precipitating ischaemia. Rapid parenteral reduction is reserved for hypertensive emergencies with end-organ injury. Sublingual nifedipine causes unpredictable precipitous falls in pressure and is not recommended.

Question 8Emergency Medicine (content domains not enumerated in source)

Which of the following best describes the first-line vasopressor for septic shock in adults?

  1. Noradrenaline Correct answer.
  2. Adrenaline
  3. Vasopressin
  4. Dobutamine

Explanation

Noradrenaline is the recommended first-line vasopressor in septic shock because it raises mean arterial pressure with fewer arrhythmias than adrenaline. Dobutamine is an inotrope used for low cardiac output rather than as a primary vasopressor. Vasopressin is generally added as a second agent to reduce noradrenaline requirements.

Question 9Emergency Medicine (content domains not enumerated in source)

A 60-year-old man has a witnessed cardiac arrest with an initial rhythm of ventricular fibrillation. After two shocks and two cycles of CPR, what is the recommended first intravenous medication?

  1. Calcium chloride 10 mL
  2. Sodium bicarbonate 8.4%
  3. Atropine 3 mg
  4. Adrenaline 1 mg Correct answer.

Explanation

In shockable cardiac arrest, adrenaline 1 mg intravenously is given after the second unsuccessful shock and repeated every three to five cycles. Atropine has no role in ventricular fibrillation arrest. Routine buffer and calcium administration are not recommended in cardiac arrest outside specific indications such as hyperkalaemia.

Question 10Emergency Medicine (content domains not enumerated in source)

A patient presents with a wide-complex tachycardia and is haemodynamically unstable with a systolic blood pressure of 70 mmHg and altered consciousness. What is the most appropriate immediate management?

  1. Observation with serial ECGs
  2. Intravenous adenosine
  3. Synchronised electrical cardioversion Correct answer.
  4. Oral beta-blocker

Explanation

Any unstable tachycardia, whether narrow or wide complex, is treated with synchronised electrical cardioversion. Adenosine is diagnostic and therapeutic for stable regular narrow-complex tachycardia but is not appropriate in unstable wide-complex rhythms. Oral therapy and observation would delay definitive treatment in a peri-arrest patient.

Question 11Emergency Medicine (content domains not enumerated in source)

A young adult is found with pinpoint pupils, a respiratory rate of 6 per minute, and depressed consciousness. Which antidote should be administered?

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

Explanation

The triad of pinpoint pupils, respiratory depression, and reduced consciousness suggests opioid toxicity, for which naloxone is the specific antagonist. Flumazenil reverses benzodiazepines but can precipitate seizures in mixed overdose. N-acetylcysteine treats paracetamol toxicity and atropine treats organophosphate or carbamate poisoning.

Question 12Emergency Medicine (content domains not enumerated in source)

A patient with a known abdominal aortic aneurysm presents with sudden severe abdominal and back pain and is hypotensive. Which finding on examination is most suggestive of a ruptured aneurysm?

  1. A pulsatile expansile abdominal mass Correct answer.
  2. Rebound tenderness in the right lower quadrant
  3. Absent bowel sounds alone
  4. A positive Murphy sign

Explanation

A pulsatile expansile abdominal mass in a hypotensive patient with back pain strongly suggests a leaking or ruptured abdominal aortic aneurysm. Murphy sign indicates cholecystitis and right lower quadrant rebound suggests appendicitis or another localised inflammatory process. Absent bowel sounds are non-specific and may occur in many acute abdominal conditions.

Question 13Emergency Medicine (content domains not enumerated in source)

A 70-year-old woman presents with sudden-onset severe headache described as the worst of her life. Non-contrast CT of the head is normal. What is the most appropriate next investigation?

  1. EEG
  2. Lumbar puncture for xanthochromia Correct answer.
  3. MRI of the cervical spine
  4. Carotid Doppler ultrasound

Explanation

A thunderclap headache with a normal non-contrast CT still requires lumbar puncture to detect xanthochromia from subarachnoid haemorrhage, ideally after 12 hours from onset. CT sensitivity is highest in the first six hours and falls thereafter. The other investigations do not assess for subarachnoid blood.

Question 14Emergency Medicine (content domains not enumerated in source)

Which of the following best describes the immediate management of a patient with an acute dystonic reaction to an antipsychotic medication?

  1. Intravenous or intramuscular benztropine or procyclidine Correct answer.
  2. Intravenous haloperidol
  3. Oral levodopa
  4. Intravenous flumazenil

Explanation

Acute dystonia is a common extrapyramidal reaction to dopamine-blocking drugs and responds rapidly to anticholinergic agents such as benztropine or procyclidine. Further antipsychotic dosing may worsen the reaction. Levodopa is used for Parkinson disease and flumazenil reverses benzodiazepines, neither of which addresses acute dystonia.

Question 15Emergency Medicine (content domains not enumerated in source)

A patient with known asthma presents with a silent chest, exhaustion, and a rising PaCO2. What does the rising PaCO2 indicate?

  1. Improving bronchospasm
  2. Adequate response to bronchodilators
  3. Development of a pneumothorax
  4. Impending respiratory failure Correct answer.

Explanation

In acute severe asthma, PaCO2 is usually low because of hyperventilation; a normal or rising PaCO2 signals fatigue and impending respiratory failure. A silent chest reflects such poor airflow that wheeze cannot be generated. This is a pre-arrest situation requiring urgent escalation of therapy and consideration of ventilatory support.

Question 16Emergency Medicine (content domains not enumerated in source)

A patient is bitten by a snake and develops ptosis, bulbar weakness, and progressive descending flaccid paralysis. Which mechanism best explains these findings?

  1. Central nervous system depression
  2. Excessive acetylcholine accumulation at muscarinic receptors
  3. Direct destruction of motor neurons in the spinal cord
  4. Presynaptic blockade of acetylcholine release at the neuromuscular junction Correct answer.

Explanation

Many elapid venoms contain neurotoxins that block neuromuscular transmission, producing descending flaccid paralysis with ptosis and bulbar weakness. This is a postsynaptic or presynaptic blockade rather than destruction of motor neurons. Excessive cholinergic activity would produce a different picture with secretions, bradycardia, and fasciculations.

Question 17Emergency Medicine (content domains not enumerated in source)

A 3-week-old infant is brought in with poor feeding, lethargy, and a temperature of 38.2°C. What is the most appropriate initial management?

  1. Antipyretics alone with observation at home
  2. Discharge with advice to return if feeding worsens
  3. Full sepsis screen with empirical intravenous antibiotics and admission Correct answer.
  4. Oral amoxicillin and outpatient review in 48 hours

Explanation

Fever in a neonate under 28 days is a red flag for serious bacterial infection, and current guidance recommends a full sepsis evaluation with empirical intravenous antibiotics and admission. Young infants may mount a poor inflammatory response and deteriorate rapidly. Outpatient management is inappropriate at this age.

Question 18Emergency Medicine (content domains not enumerated in source)

A patient presents with a painful, swollen, erythematous leg with a clearly demarcated border and systemic features of fever and rigors. Which organism is the most common cause of this presentation?

  1. Staphylococcus epidermidis
  2. Pseudomonas aeruginosa
  3. Beta-haemolytic streptococci Correct answer.
  4. Clostridioides difficile

Explanation

Cellulitis with a well-demarcated border and systemic upset is most often caused by beta-haemolytic streptococci, though Staphylococcus aureus may also be involved. S. epidermidis is a skin commensal and an uncommon cause of community-acquired cellulitis. Pseudomonas and C. difficile cause unrelated clinical syndromes.

Question 19Emergency Medicine (content domains not enumerated in source)

Which of the following is the most appropriate initial management of a patient with suspected tension pneumothorax who is hypotensive and hypoxic?

  1. Immediate needle decompression without waiting for imaging Correct answer.
  2. Observation with supplemental oxygen alone
  3. Urgent chest radiograph before any intervention
  4. Needle aspiration of the pericardium

Explanation

Tension pneumothorax is a clinical diagnosis and requires immediate decompression, either by needle thoracostomy or finger thoracostomy, before imaging. Waiting for a chest radiograph can be fatal in an unstable patient. Pericardial aspiration addresses tamponade, not pneumothorax.

Question 20Emergency Medicine (content domains not enumerated in source)

A patient presents with acute confusion, fever, and neck stiffness. Which finding on cerebrospinal fluid analysis is most consistent with bacterial meningitis?

  1. Lymphocyte predominance with normal glucose
  2. Eosinophil predominance with normal glucose
  3. Normal cell count with normal protein
  4. Neutrophil predominance with low glucose and high protein Correct answer.

Explanation

Bacterial meningitis typically produces a neutrophilic pleocytosis with low cerebrospinal fluid glucose and elevated protein. Viral meningitis more often shows lymphocyte predominance with normal glucose. Normal cell counts and eosinophilic patterns are not characteristic of acute bacterial infection.

Question 21Emergency Medicine (content domains not enumerated in source)

A patient with a history of alcohol use disorder presents with confusion and ataxia. Which of the following is the most appropriate initial treatment for suspected Wernicke encephalopathy?

  1. Intravenous thiamine before or alongside glucose administration Correct answer.
  2. Intravenous glucose alone
  3. Oral folate alone
  4. Intravenous naloxone

Explanation

Wernicke encephalopathy is a medical emergency, and thiamine should be given parenterally before or with glucose to prevent precipitation or worsening of the syndrome. Glucose alone can precipitate the condition in a thiamine-deficient patient. Folate and naloxone do not address thiamine deficiency.

Question 22Emergency Medicine (content domains not enumerated in source)

A morbidly obese patient requires emergent airway management. Which of the following is the most appropriate preoxygenation strategy?

  1. Rapid sequence induction without preoxygenation
  2. Nasal cannula at 2 L per minute alone
  3. Supine positioning with a simple face mask
  4. Head-up positioning with non-invasive positive pressure preoxygenation Correct answer.

Explanation

In obese patients, preoxygenation is enhanced by head-up or ramped positioning and the use of non-invasive positive pressure ventilation to overcome reduced functional residual capacity. A simple face mask or nasal cannula alone provides inadequate oxygen reserve for a potentially difficult airway. Preoxygenation should never be omitted before rapid sequence induction.

Question 23Emergency Medicine (content domains not enumerated in source)

A patient presents with severe hyponatraemia of 108 mmol/L and generalised seizures. What is the most appropriate initial management?

  1. Hypertonic 3% saline given in small boluses with careful monitoring Correct answer.
  2. Fluid restriction only
  3. Normal saline infusion at 1 L per hour
  4. Rapid correction to 135 mmol/L within 6 hours

Explanation

Symptomatic severe hyponatraemia with seizures requires urgent but controlled correction with hypertonic saline, typically in small boluses, aiming to raise sodium by a limited amount in the first hours. Overly rapid correction risks osmotic demyelination. Fluid restriction alone is too slow for an actively seizing patient, and normal saline may worsen dilutional hyponatraemia.

Question 24Emergency Medicine (content domains not enumerated in source)

A patient presents with a suspected cauda equina syndrome. Which feature most strongly supports urgent imaging and surgical referral?

  1. Saddle anaesthesia with urinary retention Correct answer.
  2. Bilateral calf cramps
  3. Unilateral radicular pain alone
  4. A history of chronic low back pain

Explanation

Saddle anaesthesia with urinary retention or incontinence indicates cauda equina syndrome and mandates urgent MRI and neurosurgical referral to prevent permanent deficit. Unilateral radicular pain and chronic back pain are common and non-specific. Calf cramps do not suggest cauda equina compression.

Question 25Emergency Medicine (content domains not enumerated in source)

A patient with a known ventricular septal defect presents with fever and a new murmur. Which of the following is the most appropriate initial step in management?

  1. Immediate surgery without investigation
  2. Blood cultures before starting empirical antibiotics Correct answer.
  3. Observation for 48 hours before cultures
  4. Oral paracetamol alone

Explanation

Fever with a new murmur in a patient with congenital heart disease raises concern for infective endocarditis, and blood cultures should be taken before empirical antibiotics to maximise yield. Delay in obtaining cultures reduces diagnostic sensitivity. Immediate surgery and simple observation are inappropriate in this setting.

Question 26Emergency Medicine (content domains not enumerated in source)

A patient presents with sudden painless loss of vision in one eye described as a curtain descending over the visual field. Which artery is most likely occluded?

  1. Posterior ciliary artery
  2. Central retinal artery Correct answer.
  3. Ophthalmic artery
  4. Central retinal vein

Explanation

Amaurosis fugax and curtain-like visual loss reflect transient or permanent retinal ischaemia, most often embolic to the central retinal artery from a carotid or cardiac source. Fundoscopy typically shows a pale retina with a cherry-red spot at the macula. Urgent assessment for stroke risk and carotid disease is required.

Question 27Emergency Medicine (content domains not enumerated in source)

A patient has a suspected acute compartment syndrome of the lower leg after a tibial fracture. Which finding is the most reliable early indicator?

  1. Pain out of proportion to injury, worsened by passive stretch Correct answer.
  2. Absent distal pulses
  3. Paralysis of the foot
  4. Pallor of the limb

Explanation

Compartment syndrome is a clinical diagnosis; pain out of proportion and pain on passive stretch of the compartment muscles are the earliest and most reliable signs. Pulses are typically preserved because arterial pressure exceeds compartment pressure until very late. Pallor, paraesthesia and paralysis are late features and should not be awaited.

Question 28Emergency Medicine (content domains not enumerated in source)

Which of the following is the most appropriate first-line treatment for a patient with symptomatic bradycardia and haemodynamic instability that persists despite atropine?

  1. Transcutaneous pacing Correct answer.
  2. Adenosine bolus
  3. Synchronised cardioversion
  4. Intravenous amiodarone

Explanation

For symptomatic bradycardia unresponsive to atropine, transcutaneous pacing is the recommended next step, alongside consideration of chronotropic agents such as adrenaline or dopamine infusion. Pacing should be started without delaying other resuscitation measures. Sedation or analgesia may be required if the patient is conscious.

Question 29Emergency Medicine (content domains not enumerated in source)

A patient presents with a painful, swollen, erythematous leg with a clearly demarcated border and systemic features of fever. What is the most likely diagnosis?

  1. Necrotising fasciitis
  2. Erysipelas Correct answer.
  3. Cellulitis
  4. Deep vein thrombosis

Explanation

Erysipelas is a superficial bacterial skin infection characterised by a raised, sharply demarcated erythematous plaque, usually on the face or leg, with systemic upset. Cellulitis is deeper and typically has less clearly defined margins. Necrotising fasciitis presents with severe pain, rapid progression, systemic toxicity and crepitus.

Question 30Emergency Medicine (content domains not enumerated in source)

Which of the following is the most appropriate initial management for a patient with suspected tension pneumothorax who is haemodynamically unstable?

  1. Urgent chest X-ray before intervention
  2. Chest tube insertion after CT confirmation
  3. Observation with supplemental oxygen
  4. Needle decompression without waiting for imaging Correct answer.

Explanation

Tension pneumothorax with haemodynamic instability is a clinical diagnosis requiring immediate needle decompression without waiting for imaging. Delay risks cardiovascular collapse. A definitive chest drain should follow.

Question 31Emergency Medicine (content domains not enumerated in source)

A patient presents with acute confusion, fever, and neck stiffness. Which cerebrospinal fluid finding is most consistent with bacterial meningitis?

  1. Normal cell count with raised protein
  2. Lymphocyte predominance with normal glucose
  3. Neutrophil predominance with low glucose and high protein Correct answer.
  4. Eosinophil predominance with normal glucose

Explanation

Bacterial meningitis typically produces a neutrophilic pleocytosis with low glucose and elevated protein. Viral meningitis usually shows lymphocyte predominance with normal glucose. Tuberculous and fungal meningitis often show lymphocyte predominance with low glucose.

Question 32Emergency Medicine (content domains not enumerated in source)

Which of the following is the most appropriate initial management for a patient with an acute dystonic reaction to an antipsychotic?

  1. Intravenous haloperidol
  2. Intravenous procyclidine or benztropine Correct answer.
  3. Oral fluoxetine
  4. Intravenous flumazenil

Explanation

Acute dystonia is a extrapyramidal reaction treated with anticholinergic agents such as procyclidine or benztropine, given intravenously or intramuscularly. Symptoms usually resolve rapidly. Antipsychotics should not be continued without review.

Question 33Emergency Medicine (content domains not enumerated in source)

A 3-week-old infant is brought in with poor feeding, lethargy, and a temperature of 38.2°C. What is the most appropriate management?

  1. Discharge with safety netting
  2. Full septic screen and empirical intravenous antibiotics Correct answer.
  3. Oral amoxicillin and outpatient review
  4. Reassurance and observation at home

Explanation

Fever in a neonate under 28 days is a red flag for serious bacterial infection. Current guidance recommends a full septic screen including blood, urine and cerebrospinal fluid cultures, and empirical intravenous antibiotics with admission. Discharge or outpatient management is unsafe at this age.

Question 34Emergency Medicine (content domains not enumerated in source)

A patient is bitten by a snake and develops ptosis, bulbar weakness, and progressive descending flaccid paralysis. Which antivenom is most appropriate?

  1. Black widow spider antivenom
  2. Scorpion antivenom
  3. Snake antivenom with neurotoxic activity Correct answer.
  4. Bee sting immunotherapy

Explanation

Descending flaccid paralysis with ptosis and bulbar weakness after a snake bite suggests neurotoxic envenomation, such as from elapid snakes. The appropriate treatment is the specific neurotoxic snake antivenom, together with supportive care and monitoring of respiratory function. Black widow and scorpion antivenoms are irrelevant.

Question 35Emergency Medicine (content domains not enumerated in source)

A patient with a known abdominal aortic aneurysm presents with sudden severe abdominal and back pain and is hypotensive. What is the most appropriate immediate action?

  1. Oral antihypertensives and outpatient review
  2. Discharge with analgesia
  3. Urgent CT angiography and vascular surgical referral Correct answer.
  4. Reassurance and observation

Explanation

The presentation suggests a leaking or ruptured abdominal aortic aneurysm, which is a surgical emergency. Urgent CT angiography (if stable enough) and immediate vascular surgical referral are required, alongside resuscitation with blood products. Delay is associated with high mortality.

Question 36Emergency Medicine (content domains not enumerated in source)

A 70-year-old woman presents with sudden-onset severe headache described as the worst of her life. Non-contrast CT of the brain is normal. What is the most appropriate next step?

  1. Immediate discharge
  2. Lumbar puncture after 12 hours Correct answer.
  3. MRI brain in 6 weeks
  4. Reassurance and analgesia

Explanation

A normal non-contrast CT does not exclude subarachnoid haemorrhage, particularly if performed early or in a patient with a suggestive history. Lumbar puncture for xanthochromia should be performed at least 12 hours after symptom onset, or CT angiography can be considered. Discharge without further investigation is unsafe.

Question 37Emergency Medicine (content domains not enumerated in source)

A patient presents with a wide-complex tachycardia and is haemodynamically unstable with a systolic blood pressure of 70 mmHg. What is the most appropriate immediate management?

  1. Oral beta-blocker
  2. Synchronised cardioversion Correct answer.
  3. Intravenous adenosine
  4. Observation

Explanation

An unstable wide-complex tachycardia requires immediate synchronised cardioversion. Adenosine is used for stable regular narrow-complex tachycardia and is not first-line here. Sedation should be given if the patient is conscious.

Question 38Emergency Medicine (content domains not enumerated in source)

A patient has a blood pressure of 210/120 mmHg with headache and blurred vision but no focal neurological deficit or evidence of end-organ damage. What is the most appropriate management?

  1. No treatment and routine follow-up
  2. Immediate intravenous labetalol to normalise blood pressure
  3. Sublingual nifedipine for rapid reduction
  4. Gradual oral antihypertensive therapy with close monitoring Correct answer.

Explanation

This presentation is hypertensive urgency without acute end-organ damage; blood pressure should be lowered gradually, usually with oral agents. Rapid normalisation risks cerebral, coronary and renal hypoperfusion. Intravenous therapy is reserved for hypertensive emergencies with end-organ damage.

Question 39Emergency Medicine (content domains not enumerated in source)

A 60-year-old man has a witnessed cardiac arrest with an initial rhythm of ventricular fibrillation. After two shocks and adrenaline, the rhythm remains ventricular fibrillation. What is the next most appropriate intervention?

  1. Give sodium bicarbonate
  2. Give atropine
  3. Stop resuscitation
  4. Give amiodarone and continue CPR with further shocks Correct answer.

Explanation

In refractory ventricular fibrillation after shocks and adrenaline, amiodarone is recommended along with continued high-quality CPR and further defibrillation attempts. Atropine is not indicated in cardiac arrest with ventricular fibrillation. Sodium bicarbonate is not routinely recommended.

Question 40Emergency Medicine (content domains not enumerated in source)

A patient with a history of alcohol use disorder presents with confusion and ataxia. Which of the following is the most appropriate initial treatment?

  1. Oral lorazepam
  2. Intravenous glucose alone
  3. Intravenous naloxone
  4. Intravenous thiamine Correct answer.

Explanation

Confusion and ataxia in a patient with alcohol use disorder suggest Wernicke encephalopathy, which requires urgent parenteral thiamine. Glucose should be given with thiamine, not alone, to avoid precipitating or worsening the condition. Untreated Wernicke encephalopathy can progress to Korsakoff syndrome.

Question 41Emergency Medicine (content domains not enumerated in source)

A patient with a known ventricular septal defect presents with fever and a new murmur. Which of the following is the most appropriate initial investigation?

  1. Electrocardiogram
  2. Echocardiography before cultures
  3. Chest X-ray
  4. Blood cultures before antibiotics Correct answer.

Explanation

Fever and a new murmur in a patient with congenital heart disease suggest infective endocarditis. Blood cultures should be taken before starting antibiotics to maximise yield, followed by echocardiography. Delay in antibiotics is acceptable only briefly to obtain cultures in a stable patient.

Question 42Emergency Medicine (content domains not enumerated in source)

A patient presents with a painful, swollen, erythematous leg with a clearly demarcated border and systemic features of fever. Which of the following is the most appropriate initial management?

  1. Elevation, analgesia and appropriate antibiotics Correct answer.
  2. Observation without treatment
  3. Immediate surgical debridement
  4. Anticoagulation with low-molecular-weight heparin

Explanation

The presentation suggests erysipelas or cellulitis, which is managed with elevation, analgesia and antibiotics covering streptococci and staphylococci. Systemic features warrant prompt treatment. Surgical debridement is reserved for necrotising infection.

Question 43Emergency Medicine (content domains not enumerated in source)

A patient with a suspected opioid overdose has pinpoint pupils, a respiratory rate of 6 per minute, and depressed consciousness. Which antidote is most appropriate?

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

Explanation

The triad of pinpoint pupils, respiratory depression and depressed consciousness suggests opioid toxicity, which is reversed with naloxone. Naloxone may need to be repeated or infused because its half-life is shorter than many opioids. Flumazenil is for benzodiazepines and can precipitate seizures.

Question 44Emergency Medicine (content domains not enumerated in source)

A patient presents with a suspected acute coronary syndrome and ST elevation on the electrocardiogram. Which of the following is the most appropriate immediate management?

  1. Observation with serial troponins
  2. Primary percutaneous coronary intervention Correct answer.
  3. Oral aspirin alone
  4. Exercise stress testing

Explanation

ST-elevation myocardial infarction requires urgent reperfusion, with primary percutaneous coronary intervention being the preferred strategy when available within the appropriate time frame. Aspirin should be given but is not sufficient alone. Observation and stress testing are inappropriate.

Question 45Emergency Medicine (content domains not enumerated in source)

A patient presents with a suspected acute aortic dissection and is hypertensive. Which of the following is the most appropriate initial pharmacological management?

  1. Oral aspirin and discharge
  2. Intravenous thrombolysis
  3. Fluid restriction
  4. Intravenous beta-blocker to reduce heart rate and blood pressure Correct answer.

Explanation

In acute aortic dissection, the priority is to reduce aortic wall stress by lowering heart rate and blood pressure, typically with intravenous beta-blockade, followed by vasodilators if needed. Thrombolysis is contraindicated because of the risk of catastrophic haemorrhage. Urgent surgical or cardiothoracic referral is required.

Question 46Emergency Medicine (content domains not enumerated in source)

A patient presents with a suspected tension pneumothorax and is haemodynamically unstable. Which of the following is the most appropriate immediate management?

  1. Needle decompression followed by chest drain Correct answer.
  2. Bronchodilators and steroids
  3. Chest X-ray before treatment
  4. Observation with oxygen

Explanation

Tension pneumothorax with haemodynamic instability requires immediate needle decompression without waiting for imaging, followed by definitive chest drain insertion. Delay can lead to cardiac arrest. Bronchodilators and steroids are for asthma or COPD.

Question 47Emergency Medicine (content domains not enumerated in source)

A patient presents with a suspected acute stroke and a last-known-well time of 2 hours ago. Which of the following is the most appropriate immediate investigation before thrombolysis?

  1. Carotid ultrasound
  2. Lumbar puncture
  3. Non-contrast CT head Correct answer.
  4. MRI brain in 24 hours

Explanation

Immediate non-contrast CT head is required to exclude intracranial haemorrhage before thrombolysis. Lumbar puncture is contraindicated in suspected stroke and is not used acutely. MRI and carotid ultrasound are not the first-line investigation in the hyperacute setting.

Question 48Emergency Medicine (content domains not enumerated in source)

A patient presents with a suspected severe acute pancreatitis and develops hypotension and hypoxaemia. Which of the following is the most appropriate initial management?

  1. Immediate surgery
  2. Intravenous antibiotics routinely
  3. Immediate oral feeding
  4. Aggressive intravenous fluid resuscitation and oxygen therapy Correct answer.

Explanation

Severe acute pancreatitis requires aggressive intravenous fluid resuscitation, oxygen therapy and close monitoring, often in a high-dependency setting. Routine antibiotics are not recommended unless there is proven infected necrosis. Surgery is reserved for specific complications.

Question 49Emergency Medicine (content domains not enumerated in source)

A patient is brought to the emergency department after a fall from a height. Which cervical spine imaging decision rule is used to determine whether imaging is required in an alert, stable patient?

  1. Wells score
  2. PERC rule
  3. Canadian C-Spine Rule Correct answer.
  4. Ottawa Ankle Rules

Explanation

The Canadian C-Spine Rule is a validated clinical decision tool that identifies alert, haemodynamically stable trauma patients at low risk of cervical spine injury in whom imaging can be safely omitted. It incorporates high-risk features, low-risk features permitting range of motion, and the ability to rotate the neck.

Question 50Emergency Medicine (content domains not enumerated in source)

Which finding on a 12-lead ECG is most characteristic of hyperkalaemia in a patient with acute kidney injury?

  1. Diffuse ST elevation with PR depression
  2. Sawtooth baseline with absent P waves
  3. Prolonged QT interval with U waves
  4. Peaked T waves with a widened QRS Correct answer.

Explanation

Hyperkalaemia classically produces tall, narrow-based peaked T waves and, as potassium rises further, QRS widening that can progress to a sine wave pattern and cardiac arrest. These changes reflect slowed myocardial conduction from elevated extracellular potassium.