Free DHA Emergency Medicine mock test

Emergency Medicine sample questions with answers

10 more original exam-style Emergency Medicine questions, worked in full. They are not real or recalled exam questions, and none of them is in the diagnostic above, so sit that first if you have not.

1. Question 1 · Trauma, EMS, Prehospital and Disaster Medicine

   A 62-year-old man with a severe traumatic brain injury is intubated and ventilated. His GCS is 6, and the right pupil is now 6 mm and unreactive with new left-sided extensor posturing. Blood pressure is 150/85 mmHg and oxygen saturation is 98%. Neurosurgery is 30 minutes away. What is the most appropriate immediate management?

   1. AElevate the head of the bed to 30 degrees and give a bolus of hypertonic saline or mannitol
   2. BHyperventilate to a PaCO2 of 20-25 mmHg and continue until arrival of the neurosurgeon
   3. CAdminister intravenous dexamethasone 10 mg
   4. DAllow permissive hypotension with a target mean arterial pressure of 55 mmHg to reduce cerebral bleeding
   Show answer and explanation

   Correct answer: A. Elevate the head of the bed to 30 degrees and give a bolus of hypertonic saline or mannitol

   This is uncal (transtentorial) herniation, and the immediate temporising measures are head-up positioning with a neutral neck, adequate sedation and analgesia, and hyperosmolar therapy with hypertonic saline or mannitol while urgent neurosurgical decompression is arranged. Aggressive prophylactic hyperventilation to a PaCO2 of 25 mmHg causes cerebral vasoconstriction and ischaemia and is reserved as a brief rescue at a target of about 30-35 mmHg. Corticosteroids increase mortality in traumatic brain injury (CRASH trial), and hypotension is one of the strongest predictors of poor outcome because it lowers cerebral perfusion pressure.

   Reference: Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury, 4th edition, Neurosurgery 2017; CRASH trial, Lancet 2004

2. Question 2 · Patient Safety, Professionalism, Ethics, Evidence and ED Operations

   A single-centre study derives a new decision rule to exclude subarachnoid haemorrhage, reporting sensitivity 100% (95% CI 92-100%) and specificity 20% in 300 patients. Before this rule is adopted into routine emergency practice, what is the essential next step?

   1. AImmediate adoption, because a point estimate of 100% sensitivity guarantees no missed cases
   2. BProspective external validation in a different population and setting, followed by an impact analysis of its effect on practice and outcomes
   3. CRecalculation of the rule using the same dataset with different cut-points to improve specificity
   4. DA retrospective chart review at the same centre using the same investigators
   Show answer and explanation

   Correct answer: B. Prospective external validation in a different population and setting, followed by an impact analysis of its effect on practice and outcomes

   Methodological standards for clinical decision rules require derivation, then prospective validation in a distinct population and setting to overcome overfitting and spectrum bias, then impact analysis before broad implementation. A sensitivity point estimate of 100% with a lower confidence limit of 92% is compatible with a clinically unacceptable miss rate in a condition as lethal as subarachnoid haemorrhage, so the confidence interval, not the point estimate, drives the decision. Re-fitting on the derivation dataset or repeating the work at the same centre with the same team does not provide independent validation.

   Reference: Stiell IG, Wells GA, Methodologic standards for the development of clinical decision rules in emergency medicine, Annals of Emergency Medicine, 1999; McGinn TG et al, Users' Guides to the Medical Literature: clinical prediction rules, JAMA, 2000

3. Question 3 · Pediatric Emergencies

   A 4-month-old infant who is not yet rolling or sitting is brought in with bruising over the left cheek and pinna and a torn upper labial frenulum. The caregivers give a changing account, initially attributing the injuries to a toy dropped by an older sibling and later to a fall from a bed. What is the most appropriate management?

   1. AAdmit for a full child-protection assessment including skeletal survey and neuroimaging, and notify the statutory child protection authority
   2. BReassure the caregivers and discharge with a head injury safety-netting leaflet
   3. CPerform a coagulation screen only and discharge the infant if it is normal
   4. DArrange routine outpatient paediatric follow-up in two weeks
   Show answer and explanation

   Correct answer: A. Admit for a full child-protection assessment including skeletal survey and neuroimaging, and notify the statutory child protection authority

   Bruising in a non-ambulatory infant, injuries to the ear and cheek, a torn frenulum and an inconsistent or changing history are classic red flags for inflicted injury ('those who don't cruise rarely bruise'), and they mandate admission to a place of safety, a full evaluation including skeletal survey and neuroimaging for occult fractures and intracranial injury, and reporting to the statutory child protection body. Discharge in any form leaves the infant at risk of further and potentially fatal injury. A coagulation screen is part of the workup for a bleeding disorder but a normal result does not exclude abuse and cannot justify discharge.

   Reference: American Academy of Pediatrics Clinical Report: The Evaluation of Suspected Child Physical Abuse (2015); NICE guideline NG76: Child abuse and neglect (2017)

4. Question 4 · Neurologic and Psychiatric Emergencies

   A 61-year-old man presents with continuous vertigo, nausea and gait unsteadiness that began 6 hours ago and persists at rest. He has spontaneous left-beating horizontal nystagmus. The head impulse test is normal bilaterally, there is no skew deviation, and the nystagmus does not change direction on gaze. How should the HINTS examination be interpreted?

   1. AA normal head impulse test in acute vestibular syndrome suggests a central cause such as posterior circulation stroke
   2. BThe findings are reassuring and consistent with vestibular neuritis
   3. CThe absence of skew deviation reliably excludes a central lesion
   4. DHINTS cannot be applied and a Dix-Hallpike manoeuvre should be performed instead
   Show answer and explanation

   Correct answer: A. A normal head impulse test in acute vestibular syndrome suggests a central cause such as posterior circulation stroke

   In the acute vestibular syndrome, a normal or negative head impulse test is the worrying result, because a peripheral vestibular lesion produces an abnormal test with a corrective saccade; a normal test implies an intact vestibulo-ocular reflex and points to a central cause. Any single reassuring component such as absent skew cannot exclude stroke, as all three components must be benign. HINTS is validated only in continuous acute vestibular syndrome, not in episodic positional vertigo, so Dix-Hallpike is the wrong test here and may in fact be misleading.

   Reference: Kattah et al., HINTS to Diagnose Stroke in the Acute Vestibular Syndrome, Stroke 2009; AAN and ACEP dizziness guidance

5. Question 5 · Obstetric and Gynecologic Emergencies

   A stable 30-year-old woman has a positive pregnancy test, minimal spotting and no pain. Beta-hCG is 900 mIU/mL and transvaginal ultrasound shows no intrauterine or adnexal findings and no free fluid. She is labelled a pregnancy of unknown location. Which of the following is the most appropriate disposition plan?

   1. ADischarge with clear return precautions and a repeat beta-hCG in 48 hours arranged with early pregnancy assessment follow-up
   2. BAdmit for emergency diagnostic laparoscopy
   3. CReassure her that the low beta-hCG excludes ectopic pregnancy and arrange routine antenatal booking
   4. DGive a single dose of methotrexate now and repeat beta-hCG on day 7
   Show answer and explanation

   Correct answer: A. Discharge with clear return precautions and a repeat beta-hCG in 48 hours arranged with early pregnancy assessment follow-up

   A pregnancy of unknown location in a stable, minimally symptomatic patient is managed with serial beta-hCG at 48 hours plus explicit safety-netting and guaranteed early pregnancy unit follow-up, because the location may still prove intrauterine, ectopic or a failing pregnancy. Emergency laparoscopy is not justified without instability or diagnostic findings. A low beta-hCG does not exclude ectopic pregnancy, and empirical methotrexate before a diagnosis risks destroying a desired viable intrauterine pregnancy.

   Reference: NICE Guideline NG126 (updated 2023); ACOG Practice Bulletin No. 193 (reaffirmed 2022)

6. Question 6 · Hematologic and Oncologic Emergencies

   A 58-year-old man with a large anterior mediastinal mass has stridor at rest, orthopnoea and cannot lie flat. He is tiring and requires an airway. Which approach is safest?

   1. AStandard rapid sequence intubation with propofol and rocuronium in the supine position
   2. BImmediate needle cricothyroidotomy
   3. CTransfer to theatre for an awake technique with the patient sitting, with ENT and cardiothoracic support and rigid bronchoscopy immediately available, after dexamethasone and heliox
   4. DNon-invasive ventilation with high inspiratory pressures on the ward
   Show answer and explanation

   Correct answer: C. Transfer to theatre for an awake technique with the patient sitting, with ENT and cardiothoracic support and rigid bronchoscopy immediately available, after dexamethasone and heliox

   In critical central airway obstruction from a mediastinal mass, induction of anaesthesia and neuromuscular blockade abolish the negative intrathoracic pressure and spontaneous respiratory effort that keep the airway patent, and can cause complete, irreversible airway and cardiovascular collapse. The safe strategy is an awake, spontaneously breathing technique in the sitting position in a controlled environment with surgical rescue by rigid bronchoscopy or cardiopulmonary bypass immediately available, with dexamethasone and heliox as temporising measures. A cricothyroidotomy is useless because the obstruction is distal to the cricothyroid membrane, and non-invasive ventilation cannot overcome a fixed intrathoracic obstruction.

   Reference: Difficult Airway Society Guidelines for the Management of Unanticipated Difficult Intubation in Adults, 2015; Blank & de Souza, Anesthetic Management of Patients with an Anterior Mediastinal Mass, Canadian Journal of Anesthesia 2011

7. Question 7 · Resuscitation, Shock and Airway Management

   A 63-year-old smoker presents with a three-month history of hoarseness and now has audible inspiratory stridor at rest, tripoding but maintaining saturations of 94% on oxygen. ENT reports a large supraglottic tumour partially obstructing the laryngeal inlet. He needs a definitive airway before theatre. What is the safest airway strategy?

   1. AStandard rapid sequence induction with rocuronium and direct laryngoscopy
   2. BDeep sedation with propofol and blind nasal intubation
   3. CAwake fibreoptic or awake video-laryngoscopic intubation under topical anaesthesia with a surgeon prepared for front-of-neck access
   4. DInsertion of a laryngeal mask airway after induction as the primary technique
   Show answer and explanation

   Correct answer: C. Awake fibreoptic or awake video-laryngoscopic intubation under topical anaesthesia with a surgeon prepared for front-of-neck access

   In a patient with a known obstructing supraglottic lesion, spontaneous ventilation is the safety net; inducing anaesthesia and paralysing may collapse the airway and produce an immediate 'can't intubate, can't oxygenate' scenario that a supraglottic device cannot rescue because the obstruction is at or above the laryngeal inlet. An awake technique with topicalisation preserves ventilation while the airway is secured, with double set-up for front-of-neck access. Blind nasal intubation risks tumour trauma and haemorrhage.

   Reference: Difficult Airway Society Guidelines for awake tracheal intubation in adults, Anaesthesia 2020; Frerk C et al. DAS 2015 guidelines, British Journal of Anaesthesia 2015

8. Question 8 · Cardiovascular and Respiratory Emergencies

   A 55-year-old man with acute pulmonary embolism is normotensive (BP 128/78 mmHg) but has a raised troponin, a BNP of 480 pg/mL and an RV:LV diameter ratio of 1.2 on CT. He has no bleeding risk factors. What is the recommended initial management?

   1. ARoutine full-dose systemic thrombolysis for all such patients
   2. BDischarge on a direct oral anticoagulant with next-day follow-up
   3. CImmediate surgical embolectomy
   4. DAnticoagulation with close monitoring, reserving reperfusion for haemodynamic deterioration
   Show answer and explanation

   Correct answer: D. Anticoagulation with close monitoring, reserving reperfusion for haemodynamic deterioration

   This is intermediate-high-risk (submassive) PE: right ventricular dysfunction plus positive biomarkers but preserved blood pressure. Guidelines advise anticoagulation with monitored observation and rescue reperfusion if haemodynamic decompensation occurs, because routine systemic thrombolysis in this group reduced decompensation but caused a significant excess of major and intracranial haemorrhage in the PEITHO trial. Surgical embolectomy is reserved for high-risk patients with failed or contraindicated thrombolysis, and early discharge applies only to low-risk patients (for example sPESI 0) without RV strain.

   Reference: ESC Guidelines on Acute Pulmonary Embolism, European Heart Journal, 2019; Meyer et al., PEITHO trial, NEJM, 2014

9. Question 9 · Toxicology and Environmental Emergencies

   In the same organophosphate-poisoned worker, the team is deciding about pralidoxime. Which statement best reflects correct use of oximes?

   1. APralidoxime should be given early because it reactivates acetylcholinesterase before irreversible ageing of the enzyme occurs, and it is given alongside, not instead of, atropine
   2. BPralidoxime replaces the need for atropine once the loading dose is complete
   3. CPralidoxime is the first-line agent for carbamate poisoning and should be given before atropine
   4. DPralidoxime should be delayed for 24 hours to allow spontaneous enzyme reactivation to be assessed
   Show answer and explanation

   Correct answer: A. Pralidoxime should be given early because it reactivates acetylcholinesterase before irreversible ageing of the enzyme occurs, and it is given alongside, not instead of, atropine

   Oximes reactivate phosphorylated acetylcholinesterase only before ageing of the enzyme-inhibitor complex, so early administration matters, and pralidoxime is always an adjunct to atropine rather than a substitute because it does not reverse existing muscarinic overstimulation. Carbamates cause reversible, spontaneously hydrolysing carbamylation, so oximes are generally unnecessary and atropine remains the mainstay. Deliberate delay allows ageing to occur and forfeits any benefit.

   Reference: Goldfrank's Toxicologic Emergencies, 11th edition (2019), insecticides chapter; WHO recommendations on oxime therapy

10. Question 10 · Orthopedic and Musculoskeletal Emergencies

    A 6-year-old boy fell from monkey bars onto an extended arm. He has a swollen elbow and a displaced extension-type supracondylar humerus fracture. He cannot make the 'OK' sign (unable to flex the interphalangeal joint of the thumb and the distal interphalangeal joint of the index finger). Which nerve is most likely injured?

    1. AUlnar nerve
    2. BPosterior interosseous nerve
    3. CAnterior interosseous nerve
    4. DSuperficial radial nerve
    Show answer and explanation

    Correct answer: C. Anterior interosseous nerve

    The anterior interosseous nerve, a pure motor branch of the median nerve, is the most frequently injured nerve in extension-type (Gartland) supracondylar fractures, and its lesion produces exactly this inability to flex the thumb IP and index DIP joints with no sensory deficit. Ulnar nerve injury is more typical of flexion-type fractures and causes intrinsic weakness and small-finger sensory loss. Posterior interosseous injury causes finger drop without wrist drop, and the superficial radial nerve is purely sensory.

    Reference: Rockwood and Wilkins' Fractures in Children, 9th edition, 2019; Tintinalli's Emergency Medicine, 9th edition