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Iraqi Board Emergency Medicine study materials
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Iraqi Board Emergency Medicine practice questions

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Question 1Resuscitation and Cardiovascular Emergencies

A 58-year-old man collapses in the emergency department waiting area. He is unresponsive, not breathing normally, and has no palpable carotid pulse. A defibrillator is attached and shows a disorganized chaotic waveform without discernible QRS complexes. What is the single most appropriate immediate action?

  1. Perform synchronized cardioversion at 100 J
  2. Deliver an unsynchronized shock at maximum energy
  3. Give epinephrine 1 mg IV push before any shock
  4. Start high-quality chest compressions at 100-120/min Correct answer.

Explanation

The rhythm described is ventricular fibrillation, and the top priority in VF cardiac arrest is immediate high-quality chest compressions with minimal interruption, followed by early defibrillation as soon as the device is charged and ready. Compressions are started first because they maintain coronary and cerebral perfusion while the defibrillator is prepared.

Question 2Resuscitation and Cardiovascular Emergencies

During adult CPR in the emergency department, which compression parameter best reflects high-quality chest compressions according to current resuscitation guidelines?

  1. Depth of 5 to 6 cm with full recoil at 100 to 120 per minute Correct answer.
  2. Depth of 5 to 6 cm with a compression-to-ventilation ratio of 15:2
  3. Depth of 2 to 3 cm at 80 per minute
  4. Depth of at least 7 cm at 140 per minute

Explanation

High-quality CPR in adults requires compressions of 5 to 6 cm depth, a rate of 100 to 120 per minute, complete chest recoil, and minimal interruptions. These parameters optimize intrathoracic pressure generation and coronary perfusion pressure while limiting injury.

Question 3Resuscitation and Cardiovascular Emergencies

A 24-year-old man is brought in after a high-voltage electrical injury. He is unresponsive with gasping respirations and a weak pulse. The monitor shows a wide, regular rhythm at 180 per minute with a palpable but faint radial pulse and a systolic blood pressure of 70 mmHg. He has an IV in place. What is the most appropriate next step?

  1. Synchronized cardioversion under sedation Correct answer.
  2. Amiodarone 300 mg IV bolus
  3. Immediate unsynchronized defibrillation
  4. Adenosine 6 mg rapid IV push

Explanation

A regular wide-complex tachycardia with a pulse and hemodynamic instability (hypotension with signs of poor perfusion) is treated with urgent synchronized cardioversion. Sedation is used when feasible, but hemodynamic instability takes priority over complete sedation.

Question 4Resuscitation and Cardiovascular Emergencies

A 70-year-old woman presents with palpitations and lightheadedness. The ECG shows an irregularly irregular narrow-complex tachycardia at 150 per minute with no discernible P waves. Blood pressure is 128/76 mmHg and she is alert. Which management is most appropriate?

  1. IV amiodarone 150 mg over 10 minutes
  2. Rate control with an intravenous beta-blocker or calcium channel blocker Correct answer.
  3. IV adenosine 6 mg rapid push
  4. Immediate synchronized cardioversion at 200 J

Explanation

The rhythm is atrial fibrillation with rapid ventricular response in a hemodynamically stable patient, so the initial priority is rate control using a beta-blocker or a non-dihydropyridine calcium channel blocker. Synchronized cardioversion is reserved for instability or after adequate anticoagulation and rate control.

Question 5Resuscitation and Cardiovascular Emergencies

A 62-year-old man with crushing chest pain has an ECG showing 3 mm ST elevation in leads II, III, and aVF. He is 40 minutes from a hospital with primary PCI capability but has no contraindications to fibrinolysis. Which strategy best fits current reperfusion guidance?

  1. Give aspirin alone and admit for observation
  2. Immediate transfer for primary PCI regardless of time delay
  3. Fibrinolysis now if PCI cannot be achieved within 120 minutes of first medical contact Correct answer.
  4. Wait for troponin results before any reperfusion decision

Explanation

For ST-elevation myocardial infarction, primary PCI is preferred when it can be delivered within 120 minutes of first medical contact. When that target cannot be met and there are no contraindications, prompt fibrinolysis is indicated, followed by transfer for angiography.

Question 6Resuscitation and Cardiovascular Emergencies

A 55-year-old woman with acute inferior STEMI develops bradycardia at 38 per minute, hypotension of 78/50 mmHg, and cool clammy skin. The ECG shows sinus bradycardia with no heart block. She has received aspirin and morphine. Which intervention is most appropriate first?

  1. Atropine 1 mg IV, repeated as needed Correct answer.
  2. Transcutaneous pacing at 80 per minute
  3. Isoproterenol infusion
  4. Synchronized cardioversion at 50 J

Explanation

Symptomatic sinus bradycardia with hypotension and poor perfusion from an inferior infarct is initially treated with atropine, which antagonizes vagal tone and often corrects the bradycardia. Pacing is reserved for atropine-refractory cases or high-grade block.

Question 7Resuscitation and Cardiovascular Emergencies

A 30-year-old man is resuscitated after drowning. He remains unresponsive and apneic but has a palpable pulse of 60 per minute. Which ventilation approach is most appropriate?

  1. Passive oxygen only with no positive pressure
  2. Chest compressions at 100 per minute with no ventilations
  3. Compressions and ventilations at 30:2
  4. Rescue breaths every 6 seconds with compressions withheld Correct answer.

Explanation

In a patient with a pulse but inadequate spontaneous breathing, rescue breathing alone is provided at approximately one breath every 6 seconds (10 per minute), and chest compressions are withheld because a pulse is present. Hypoxia is the primary insult in drowning, so oxygenation is prioritized.

Question 8Resuscitation and Cardiovascular Emergencies

A 68-year-old man presents with sudden severe dyspnea and pleuritic chest pain. He is tachycardic at 118 per minute, hypotensive at 82/54 mmHg, and hypoxic. Bedside echocardiography shows a dilated right ventricle with septal flattening. Which immediate treatment most directly addresses the underlying pathophysiology?

  1. Systemic thrombolysis Correct answer.
  2. A 500 mL normal saline bolus
  3. Intravenous furosemide 80 mg
  4. High-dose norepinephrine alone

Explanation

The findings suggest a high-risk pulmonary embolism with right ventricular strain causing obstructive shock. In hemodynamically unstable PE, systemic thrombolysis is the treatment that relieves the pulmonary arterial obstruction and improves right ventricular function.

Question 9Resuscitation and Cardiovascular Emergencies

A 45-year-old man is found unresponsive after a suspected opioid overdose. He has a weak pulse of 50 per minute and agonal respirations. Naloxone is administered, but he remains apneic and pulseless 30 seconds later. What is the correct sequence?

  1. Begin bag-mask ventilation alone without compressions
  2. Continue naloxone only and reassess in 2 minutes
  3. Start chest compressions and follow the cardiac arrest algorithm Correct answer.
  4. Give flumazenil and observe

Explanation

Once a patient becomes pulseless, standard cardiac arrest management with high-quality chest compressions and the ACLS algorithm is required. Naloxone reverses opioid-induced respiratory depression but does not treat cardiac arrest, so CPR must begin immediately.

Question 10Resuscitation and Cardiovascular Emergencies

A 72-year-old woman on warfarin presents with a large intracerebral hemorrhage and an INR of 3.8. Which agent most rapidly and completely reverses the coagulopathy?

  1. Fresh frozen plasma 2 units
  2. Prothrombin complex concentrate plus vitamin K Correct answer.
  3. Platelet transfusion
  4. Vitamin K 10 mg IV

Explanation

For urgent warfarin reversal in intracranial hemorrhage, four-factor prothrombin complex concentrate provides rapid replacement of the vitamin K-dependent factors, and vitamin K is added to ensure sustained reversal. This combination achieves faster and more complete correction than plasma alone.

Question 11Resuscitation and Cardiovascular Emergencies

A 60-year-old man with a history of hypertension presents with tearing chest pain radiating to the back. He is hypertensive at 180/100 mmHg and has a pulse deficit between arms. Which initial pharmacologic approach is most appropriate?

  1. Immediate vasopressor infusion
  2. Intravenous beta-blocker followed by a vasodilator Correct answer.
  3. Aggressive fluid loading
  4. Intravenous thrombolytic therapy

Explanation

Acute aortic dissection requires reduction of the heart rate and blood pressure to limit shear stress on the aorta. A beta-blocker is given first to control heart rate and dP/dt, followed by a vasodilator such as nitroprusside to achieve the target blood pressure.

Question 12Resuscitation and Cardiovascular Emergencies

A 34-year-old woman with a known history of Wolff-Parkinson-White syndrome presents with a regular narrow-complex tachycardia at 190 per minute and is hemodynamically stable. Which agent is contraindicated because it may preferentially block the AV node and promote conduction down the accessory pathway?

  1. Amiodarone
  2. Adenosine Correct answer.
  3. Procainamide
  4. Synchronized cardioversion

Explanation

In pre-excited tachyarrhythmias, AV nodal blocking agents such as adenosine, verapamil, diltiazem, and digoxin can increase antegrade conduction over the accessory pathway and precipitate ventricular fibrillation. Procainamide is a preferred agent for stable pre-excited atrial fibrillation, and cardioversion is used if unstable.

Question 13Resuscitation and Cardiovascular Emergencies

A 19-year-old athlete collapses during a football match and is in cardiac arrest. Bystanders report a blow to the chest just before collapse. Which mechanism best explains the likely cause of arrest?

  1. Commotio cordis causing ventricular fibrillation during the vulnerable repolarization period Correct answer.
  2. Commotio cordis causing complete heart block
  3. Tension pneumothorax from rib fracture
  4. Aortic transection

Explanation

Commotio cordis is sudden cardiac arrest from a blunt precordial impact occurring during the vulnerable period of repolarization, which triggers ventricular fibrillation. Prompt defibrillation is the key to survival because the myocardium is otherwise structurally normal.

Question 14Resuscitation and Cardiovascular Emergencies

A 65-year-old man is in cardiac arrest with an initial rhythm of asystole. After 2 minutes of CPR, the rhythm remains asystole. Which intervention is indicated at this point in the algorithm?

  1. Atropine 3 mg IV
  2. Immediate defibrillation at 200 J
  3. Synchronized cardioversion at 100 J
  4. Epinephrine 1 mg IV every 3 to 5 minutes Correct answer.

Explanation

In non-shockable rhythms, epinephrine 1 mg IV is given as soon as feasible and repeated every 3 to 5 minutes while CPR continues. Defibrillation and cardioversion have no role in asystole.

Question 15Resuscitation and Cardiovascular Emergencies

A 50-year-old woman is resuscitated from cardiac arrest and achieves return of spontaneous circulation. She remains comatose with a blood pressure of 85/50 mmHg and a temperature of 36.5°C. Which post-arrest measure is most strongly supported to improve neurologic outcome?

  1. Routine corticosteroids
  2. Immediate extubation
  3. Prophylactic antibiotics
  4. Targeted temperature management with avoidance of fever Correct answer.

Explanation

Post-arrest care that improves neurologic outcomes includes targeted temperature management with strict avoidance of fever, along with hemodynamic optimization and treatment of the precipitating cause. Fever worsens cerebral injury and should be actively prevented.

Question 16Resuscitation and Cardiovascular Emergencies

A 28-year-old man is brought in after a stab wound to the left chest. He is hypotensive at 70/40 mmHg with distended neck veins and muffled heart sounds. Bedside ultrasound shows pericardial fluid with right ventricular collapse in diastole. What is the definitive management?

  1. Pericardiocentesis with catheter drainage alone
  2. Emergency thoracotomy or sternotomy for surgical repair Correct answer.
  3. Aggressive fluid resuscitation and observation
  4. Pericardial window in the operating room

Explanation

This is cardiac tamponade from penetrating trauma, and the definitive treatment is surgical decompression and repair of the injury. Needle pericardiocentesis is a temporizing measure at best and may be inadequate when blood is clotted.

Question 17Resuscitation and Cardiovascular Emergencies

A 40-year-old man with no prior cardiac history presents with palpitations. The ECG shows a regular narrow-complex tachycardia at 170 per minute. He is stable. Vagal maneuvers fail. Which medication is the recommended first-line pharmacologic therapy?

  1. Lidocaine 1 mg/kg IV
  2. Adenosine 6 mg rapid IV push Correct answer.
  3. Digoxin 0.5 mg IV
  4. Amiodarone 150 mg IV

Explanation

For stable regular narrow-complex supraventricular tachycardia, adenosine 6 mg rapid IV push followed by a saline flush is the first-line drug after vagal maneuvers fail. It transiently blocks the AV node and terminates reentrant SVT.

Question 18Resuscitation and Cardiovascular Emergencies

A 58-year-old man with crushing chest pain has an ECG showing ST elevation in leads V1 to V4. He has no contraindications to fibrinolysis. Which coronary artery is most likely occluded?

  1. Right coronary artery
  2. Left main coronary artery
  3. Left anterior descending artery Correct answer.
  4. Left circumflex artery

Explanation

ST elevation in the precordial leads V1 to V4 indicates an anterior myocardial infarction, which is typically caused by occlusion of the left anterior descending artery. Recognition of the territory guides urgency and prognosis.

Question 19Resuscitation and Cardiovascular Emergencies

A 75-year-old woman presents with syncope. The ECG shows complete heart block with a wide QRS ventricular escape rhythm at 30 per minute. She is confused and hypotensive. Which intervention is most appropriate?

  1. Atropine 1 mg IV and observe
  2. Transcutaneous pacing while preparing for transvenous pacing Correct answer.
  3. Isoproterenol infusion as definitive therapy
  4. Synchronized cardioversion

Explanation

Symptomatic high-grade or complete AV block, especially with a wide-complex escape rhythm, responds poorly to atropine and requires transcutaneous pacing as a bridge to transvenous pacing. Pacing restores an adequate rate and perfusion.

Question 20Resuscitation and Cardiovascular Emergencies

A 66-year-old man is admitted with acute decompensated heart failure. He is dyspneic at rest, has bibasilar crackles, and an oxygen saturation of 88% on room air. Blood pressure is 150/90 mmHg. Which initial therapy is most appropriate?

  1. Intravenous beta-blocker bolus
  2. Immediate pericardiocentesis
  3. Noninvasive positive pressure ventilation plus intravenous nitroglycerin Correct answer.
  4. Large-volume fluid resuscitation

Explanation

Hypertensive acute pulmonary edema with hypoxemia is treated with noninvasive positive pressure ventilation to improve oxygenation and reduce work of breathing, along with afterload reduction using intravenous nitrates. This combination rapidly improves respiratory status.

Question 21Resuscitation and Cardiovascular Emergencies

A 48-year-old man presents with a wide-complex tachycardia at 160 per minute. He is alert with a blood pressure of 118/72 mmHg. He has a history of ischemic cardiomyopathy. Which agent is the preferred first-line antiarrhythmic for stable monomorphic ventricular tachycardia?

  1. Digoxin
  2. Adenosine
  3. Diltiazem
  4. Procainamide or amiodarone Correct answer.

Explanation

For stable monomorphic ventricular tachycardia, intravenous procainamide or amiodarone is recommended, and synchronized cardioversion is used if the patient becomes unstable. AV nodal blockers such as diltiazem are contraindicated because they can cause hemodynamic collapse.

Question 22Resuscitation and Cardiovascular Emergencies

A 22-year-old man is brought in after a motor vehicle collision with a pelvic fracture. He is tachycardic at 130 per minute and hypotensive at 80/50 mmHg, and he remains hypotensive despite 2 liters of crystalloid. Which blood product strategy is most appropriate?

  1. Albumin infusion
  2. Fresh frozen plasma alone
  3. Balanced transfusion of packed red cells, plasma, and platelets in a massive transfusion protocol Correct answer.
  4. Continue crystalloid until blood pressure normalizes

Explanation

Hemorrhagic shock that persists despite initial crystalloid requires activation of a massive transfusion protocol with balanced ratios of red cells, plasma, and platelets to restore volume and clotting factors while minimizing dilutional coagulopathy.

Question 23Resuscitation and Cardiovascular Emergencies

A 60-year-old woman with a history of hypertension presents with tearing chest pain radiating to the back. She is hypertensive and has a pulse deficit between arms. Which diagnostic study is most appropriate to confirm the diagnosis?

  1. Transthoracic echocardiography
  2. Computed tomography angiography of the aorta Correct answer.
  3. Chest radiograph
  4. Troponin level

Explanation

Computed tomography angiography of the aorta is the diagnostic study of choice for suspected aortic dissection because it visualizes the intimal flap and defines the extent of involvement. It is rapid and highly sensitive in stable patients.

Question 24Resuscitation and Cardiovascular Emergencies

A 55-year-old man is in cardiac arrest with ventricular fibrillation. After two shocks and 2 minutes of CPR, the rhythm remains VF. Epinephrine has been given. Which medication is indicated at this point?

  1. Calcium chloride 1 g IV
  2. Sodium bicarbonate 1 mEq/kg
  3. Amiodarone 300 mg IV bolus Correct answer.
  4. Atropine 1 mg IV

Explanation

For refractory VF or pulseless VT after shocks and epinephrine, amiodarone 300 mg IV bolus is recommended, with a second dose of 150 mg if needed. It is an adjunct to defibrillation and CPR, not a replacement for them.

Question 25Resuscitation and Cardiovascular Emergencies

A 70-year-old man with a history of heart failure presents with fatigue and palpitations. The ECG shows a wide-complex rhythm at 40 per minute with a regular P wave preceding each QRS at a rate of 75 per minute, but the PR interval is variable and there is no consistent relationship. He is hypotensive. Which rhythm best explains this?

  1. Second-degree AV block type I
  2. Junctional rhythm with retrograde P waves
  3. Third-degree AV block with an escape rhythm Correct answer.
  4. Sinus bradycardia with first-degree AV block

Explanation

Complete (third-degree) AV block is characterized by AV dissociation, with atrial and ventricular rates independent of each other and no consistent PR relationship. A slow wide-complex escape rhythm with hypotension indicates a symptomatic high-grade block requiring pacing.

Question 26Resuscitation and Cardiovascular Emergencies

A 62-year-old man collapses in the emergency department waiting room. Cardiopulmonary resuscitation is started and the monitor shows a disorganized, chaotic baseline without identifiable QRS complexes. According to current adult advanced life support guidance, which rhythm classification and initial defibrillation decision apply?

  1. Ventricular fibrillation, which is a shockable rhythm requiring immediate defibrillation Correct answer.
  2. Asystole, which is a non-shockable rhythm requiring continued CPR only
  3. Sinus arrest with escape beats, which is non-shockable and requires transcutaneous pacing
  4. Pulseless electrical activity, which is non-shockable and requires a search for reversible causes

Explanation

A chaotic, disorganized baseline with no identifiable QRS complexes defines ventricular fibrillation, which is one of the two shockable arrest rhythms. Defibrillation should be delivered as soon as possible, with CPR resumed immediately after each shock. The distinction matters because shockable rhythms have better survival when defibrillated early.

Question 27Resuscitation and Cardiovascular Emergencies

A 58-year-old woman is admitted with a non-ST-elevation acute coronary syndrome. She has ongoing chest pain, dynamic ST depression, and hemodynamic instability with a blood pressure of 84/56 mmHg. Which management strategy is most appropriate?

  1. Discharge with outpatient stress testing within two weeks
  2. Urgent invasive coronary angiography with intent to revascularize Correct answer.
  3. Fibrinolytic therapy followed by a watchful waiting period
  4. Observation with serial troponins for 24 hours before any decision

Explanation

Refractory ischemia, dynamic ST changes, and hemodynamic instability are very high-risk features that place a non-ST-elevation acute coronary syndrome patient in the urgent invasive strategy group. Coronary angiography with revascularization should be performed within about two hours rather than delayed. Fibrinolysis is not indicated in non-ST-elevation acute coronary syndrome.

Question 28Resuscitation and Cardiovascular Emergencies

A 47-year-old man presents with sudden-onset palpitations. The ECG shows a regular narrow-complex tachycardia at 190 per minute with no visible P waves. He is alert, his blood pressure is 124/78 mmHg, and he has no chest pain or heart failure signs. Intravenous adenosine fails to terminate the rhythm. Which next step is most appropriate?

  1. Intravenous diltiazem or verapamil for rate control Correct answer.
  2. Vagal maneuvers repeated while awaiting another drug
  3. Intravenous amiodarone bolus followed by infusion
  4. Immediate synchronized cardioversion at 200 J

Explanation

In a stable patient with a regular narrow-complex supraventricular tachycardia that persists after adenosine, a rate-controlling calcium channel blocker such as diltiazem or verapamil is a reasonable next pharmacologic step. Synchronized cardioversion is reserved for instability or failure of drug therapy. Amiodarone is not first-line for stable re-entrant supraventricular tachycardia.

Question 29Resuscitation and Cardiovascular Emergencies

A 71-year-old woman with a permanent pacemaker is brought in after a collapse. The ECG shows a bradycardic rhythm at 40 per minute with a pacing spike before each QRS complex, but no capture. She is confused and her blood pressure is 82/50 mmHg. Which action should be taken first?

  1. Apply transcutaneous pacing while arranging definitive pacing support Correct answer.
  2. Start an isoproterenol infusion as the sole therapy
  3. Give intravenous atropine 1 mg and reassess in five minutes
  4. Reprogram the pacemaker with a magnet to an asynchronous mode

Explanation

Failure to capture with pacing spikes and symptomatic bradycardia requires immediate transcutaneous pacing as a bridge while definitive pacing is arranged. Transcutaneous pacing is the fastest available method to secure a perfusing rate in this unstable patient. Magnet application and drug therapy do not reliably correct a lead or capture failure.

Question 30Resuscitation and Cardiovascular Emergencies

A 64-year-old man with severe aortic stenosis is admitted with acute decompensated heart failure. He is hypotensive at 86/54 mmHg with cold extremities, bibasilar crackles, and a lactate of 4.2 mmol/L. Which initial pharmacologic approach is most appropriate?

  1. Rapid bolus of 1 L normal saline to improve preload
  2. High-dose intravenous nitroglycerin infusion to reduce afterload
  3. Intravenous vasopressor support with careful monitoring rather than aggressive vasodilation Correct answer.
  4. Intravenous furosemide as the sole initial therapy

Explanation

In severe aortic stenosis, the fixed outflow obstruction means cardiac output depends heavily on preload and afterload; aggressive vasodilation can precipitate profound hypotension. In this hypotensive, low-output state, vasopressor support with cautious monitoring is preferred over vasodilators. Fluid boluses risk pulmonary edema in a patient with crackles.

Question 31Respiratory and Thoracic Emergencies

A 24-year-old man with acute asthma presents with silent chest, drowsiness, and a PaCO2 of 58 mmHg. What is the most appropriate immediate interpretation of the rising PaCO2?

  1. A sign of impending respiratory failure requiring urgent ventilatory support Correct answer.
  2. Evidence that the bronchospasm has resolved and therapy can be reduced
  3. An artefact of overbreathing that should be repeated after nebulisation
  4. An expected finding in severe asthma that requires no change in management

Explanation

In acute severe asthma the PaCO2 is typically low because of hyperventilation; a normal or rising PaCO2 indicates fatigue and impending ventilatory failure. Combined with a silent chest and altered consciousness, this mandates immediate escalation, including preparation for intubation and mechanical ventilation. It should never be read as improvement.

Question 32Respiratory and Thoracic Emergencies

Which finding best defines a tension pneumothorax requiring immediate needle decompression before imaging?

  1. Tracheal deviation with hypotension and distended neck veins Correct answer.
  2. Subcutaneous emphysema over the chest wall with normal saturations
  3. Reduced breath sounds with a dry cough and normal blood pressure
  4. Unilateral pleuritic pain with a small apical radiolucency

Explanation

Tension pneumothorax is a clinical diagnosis of obstructive shock: haemodynamic compromise plus signs of mediastinal shift such as tracheal deviation and distended neck veins. Decompression must not be delayed for radiography. Stable patients with lesser findings can be imaged first.

Question 33Respiratory and Thoracic Emergencies

A 68-year-old woman with a recent hip replacement develops sudden pleuritic chest pain, tachycardia, and hypoxaemia. Bedside echocardiography shows a dilated right ventricle. What is the most appropriate immediate management?

  1. Observation with repeat D-dimer in six hours
  2. Therapeutic anticoagulation with unfractionated heparin Correct answer.
  3. Chest physiotherapy and incentive spirometry
  4. Intravenous thrombolysis regardless of haemodynamic status

Explanation

This presentation is high-risk pulmonary embolism with right ventricular strain but without sustained hypotension, so therapeutic parenteral anticoagulation is the immediate priority while risk stratification continues. Thrombolysis is reserved for haemodynamic instability or refractory deterioration.

Question 34Respiratory and Thoracic Emergencies

Which arterial blood gas pattern is most characteristic of acute exacerbation of COPD with chronic CO2 retention?

  1. pH 7.46, PaCO2 48 mmHg, HCO3 26 mmol/L
  2. pH 7.50, PaCO2 28 mmHg, HCO3 22 mmol/L
  3. pH 7.24, PaCO2 70 mmHg, HCO3 32 mmol/L Correct answer.
  4. pH 7.38, PaCO2 40 mmHg, HCO3 24 mmol/L

Explanation

Acute-on-chronic hypercapnic respiratory failure shows an elevated PaCO2 with a raised bicarbonate reflecting metabolic compensation, but the pH remains acidotic because compensation is incomplete. A normal bicarbonate with hypercapnia suggests an acute uncompensated state rather than chronic retention.

Question 35Respiratory and Thoracic Emergencies

A patient with a large spontaneous pneumothorax is being treated with a chest drain. Which sign most specifically indicates drain blockage rather than re-expansion?

  1. Mild pleuritic pain at the insertion site
  2. Absent swinging of the fluid column with worsening respiratory distress Correct answer.
  3. Gradual reduction in drained air over 24 hours
  4. Continuous bubbling in the water seal chamber

Explanation

Loss of swinging (tidalling) of the water-seal fluid column, especially with clinical deterioration, suggests the drain is blocked, kinked, or displaced. Continuous bubbling indicates an ongoing air leak rather than obstruction.

Question 36Respiratory and Thoracic Emergencies

Which single measurement is the most reliable bedside indicator of severity in a patient with suspected acute respiratory distress syndrome?

  1. PaO2/FiO2 ratio Correct answer.
  2. Respiratory rate alone
  3. Peak expiratory flow rate
  4. Sputum colour

Explanation

The PaO2/FiO2 ratio quantifies the degree of hypoxaemia relative to delivered oxygen and forms the basis of ARDS severity classification. Peak flow assesses airflow obstruction, and sputum colour or respiratory rate alone do not grade oxygenation failure.

Question 37Respiratory and Thoracic Emergencies

A 30-year-old presents after a stab wound to the right chest with hypotension, distended neck veins, and muffled heart sounds. What is the most appropriate immediate action?

  1. Pericardiocentesis after transthoracic echocardiography
  2. Urgent pericardiocentesis or surgical decompression Correct answer.
  3. CT angiography of the chest
  4. Insertion of a chest drain on the right side

Explanation

The triad of hypotension, distended neck veins, and muffled heart sounds after penetrating chest trauma suggests cardiac tamponade, which is a clinical diagnosis requiring emergency drainage or thoracotomy. Waiting for imaging risks cardiac arrest.

Question 38Respiratory and Thoracic Emergencies

Which feature most strongly suggests that a patient with community-acquired pneumonia requires admission rather than outpatient therapy?

  1. Productive cough with green sputum
  2. CURB-65 score of 2 or more Correct answer.
  3. Temperature of 37.8°C
  4. A single episode of vomiting

Explanation

CURB-65 (confusion, urea, respiratory rate, blood pressure, age 65) stratifies mortality risk; a score of 2 or more generally warrants hospital assessment or admission. Individual symptoms such as mild fever, sputum colour, or isolated vomiting are poor discriminators.

Question 39Respiratory and Thoracic Emergencies

A patient with a tracheostomy becomes acutely dyspnoeic and hypoxic, and suctioning fails to pass beyond the tube tip. What is the most appropriate next step?

  1. Attach to non-invasive ventilation over the tracheostomy
  2. Deflate the cuff and assess for upper airway patency before removal Correct answer.
  3. Nebulise saline and reassess in 15 minutes
  4. Increase the suction pressure and repeat attempts

Explanation

Failure to pass a suction catheter suggests an obstructed tracheostomy tube. The cuff should be deflated to allow airflow around the tube and to assess whether the patient can breathe through the upper airway, with removal of the tube if obstruction is confirmed.

Question 40Respiratory and Thoracic Emergencies

Which radiographic finding is most typical of a large left-sided pleural effusion?

  1. Air bronchograms within a lobar consolidation
  2. Bilateral hilar lymphadenopathy
  3. Blunting of the costophrenic angle with a meniscus Correct answer.
  4. Hyperinflation with flattened hemidiaphragms

Explanation

Pleural fluid collects dependently, obliterating the costophrenic angle and producing a meniscus-shaped upper border on an erect film. Hyperinflation suggests obstructive disease, air bronchograms suggest consolidation, and hilar lymphadenopathy suggests another process.

Question 41Respiratory and Thoracic Emergencies

A 55-year-old with COPD has a pH of 7.18 and PaCO2 of 80 mmHg despite controlled oxygen and nebulised bronchodilators. What is the most appropriate next step?

  1. Non-invasive ventilation with bilevel positive airway pressure Correct answer.
  2. Immediate endotracheal intubation
  3. Intravenous sodium bicarbonate
  4. Increasing the inspired oxygen concentration

Explanation

Acute hypercapnic respiratory acidosis in COPD is the classic indication for non-invasive ventilation, which reduces intubation rates and mortality when the pH is below 7.35. Intubation is reserved for failure of NIV or contraindications.

Question 42Respiratory and Thoracic Emergencies

Which finding most reliably distinguishes massive haemoptysis from minor bleeding in a patient presenting with blood-streaked sputum?

  1. Associated pleuritic chest pain
  2. Presence of clots in the sputum
  3. Blood mixed with frothy sputum
  4. Volume of blood exceeding about 600 mL in 24 hours Correct answer.

Explanation

Massive haemoptysis is generally defined by the volume of blood expectorated, with thresholds around 600 mL in 24 hours or bleeding causing airway compromise. Clots, pain, or frothiness do not quantify severity.

Question 43Respiratory and Thoracic Emergencies

A patient develops sudden-onset dyspnoea, tachycardia, and hypoxaemia after a long-haul flight. Which investigation is most appropriate as the first-line diagnostic test in a haemodynamically stable patient?

  1. Troponin measurement
  2. CT pulmonary angiography
  3. D-dimer with clinical probability assessment Correct answer.
  4. Chest radiograph alone

Explanation

In a stable patient with a plausible clinical probability, D-dimer is used to rule out pulmonary embolism when the result is negative. A positive result or high pre-test probability leads to CT pulmonary angiography.

Question 44Respiratory and Thoracic Emergencies

Which mechanism best explains hypoxaemia in a patient with a large right-to-left intrapulmonary shunt?

  1. Blood bypasses ventilated alveoli and is not oxygenated Correct answer.
  2. Alveolar oxygen tension falls because of hypoventilation
  3. Diffusion distance increases because of fibrosis
  4. Ventilation exceeds perfusion in the affected lung units

Explanation

In a true shunt, deoxygenated blood passes through the pulmonary circulation without contacting ventilated alveoli, so supplemental oxygen has limited effect. Hypoventilation, diffusion impairment, and dead-space ventilation produce different patterns.

Question 45Respiratory and Thoracic Emergencies

A patient with suspected oesophageal rupture after forceful vomiting presents with severe chest pain and subcutaneous emphysema. What is the most appropriate initial investigation?

  1. Contrast oesophagography with water-soluble contrast Correct answer.
  2. Transthoracic echocardiography
  3. Spirometry
  4. Immediate bronchoscopy

Explanation

Boerhaave syndrome is suspected clinically with Mackler's triad of vomiting, chest pain, and subcutaneous emphysema. Water-soluble contrast oesophagography is the initial confirmatory study before surgical management.

Question 46Respiratory and Thoracic Emergencies

Which parameter is most important to monitor when initiating non-invasive ventilation in a patient with acute respiratory failure?

  1. Urine output and serum creatinine
  2. Peak expiratory flow rate
  3. Level of consciousness and arterial blood gases Correct answer.
  4. Daily weight and fluid balance

Explanation

Response to NIV is judged by clinical status, work of breathing, and serial arterial blood gases; failure to improve within one to two hours indicates the need for intubation. Renal and fluid parameters are secondary in the acute phase.

Question 47Respiratory and Thoracic Emergencies

A patient with a tension pneumothorax has undergone needle decompression with improvement, but 20 minutes later becomes hypotensive again. What is the most appropriate next step?

  1. Administer intravenous fluids and observe
  2. Repeat needle decompression at the same site
  3. Obtain a chest radiograph before further intervention
  4. Insert a definitive chest drain Correct answer.

Explanation

Needle decompression is a temporising measure; recurrence of instability indicates that the tension has reaccumulated or the needle has become blocked or displaced. A definitive intercostal chest drain must be placed urgently.

Question 48Respiratory and Thoracic Emergencies

Which feature is most consistent with a diagnosis of acute epiglottitis rather than viral croup?

  1. Gradual onset over several days
  2. Prominent rhinorrhoea and conjunctivitis
  3. Drooling, muffled voice, and rapid onset of high fever Correct answer.
  4. Barking cough and inspiratory stridor

Explanation

Acute epiglottitis presents with the rapid onset of high fever, drooling, and a muffled voice due to supraglottic inflammation. Croup is characterised by a barking cough and gradual onset, and viral illnesses cause prominent coryzal symptoms.

Question 49Respiratory and Thoracic Emergencies

A patient with a known large bulla develops sudden pleuritic pain and breathlessness. Which finding on auscultation is most consistent with a pneumothorax?

  1. Reduced breath sounds and hyper-resonance on the affected side Correct answer.
  2. Coarse crepitations at both bases
  3. Pleural rub with inspiratory wheeze
  4. Bronchial breath sounds with crackles

Explanation

Air in the pleural space diminishes transmission of breath sounds and produces hyper-resonance to percussion on the affected side. Bronchial breathing and crackles indicate consolidation, and a pleural rub suggests pleurisy.

Question 50Respiratory and Thoracic Emergencies

Which intervention is most likely to reduce mortality in a patient with acute respiratory distress syndrome who is mechanically ventilated?

  1. Prophylactic corticosteroids in all cases
  2. Immediate tracheostomy within 24 hours
  3. Routine high tidal volume to improve oxygenation
  4. Low tidal volume ventilation targeting plateau pressures below 30 cmH2O Correct answer.

Explanation

Lung-protective ventilation with low tidal volumes (about 6 mL/kg predicted body weight) and plateau pressure limitation reduces ventilator-induced lung injury and mortality. High tidal volumes worsen injury, and routine steroids or early tracheostomy have not shown consistent benefit.