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Question 1. Which of the following best describes the pathophysiologic mechanism of an ST-segment elevation myocardial infarction (STEMI)? A) Subendocardial ischemia without full-thickness necrosis B) Complete occlusion of a coronary artery leading to transmural necrosis C) Coronary vasospasm without plaque rupture D) Microvascular obstruction without epicardial artery blockage Answer: B Explanation: STEMI results from an abrupt, usually thrombotic, occlusion of an epicardial coronary artery, producing transmural (full-thickness) myocardial necrosis, which manifests as ST-segment elevation on the ECG. Question 2. On a 12-lead ECG, which pattern is most characteristic of an inferior STEMI? A) ST elevation in leads V1-V B) ST elevation in leads II, III, aVF C) ST depression in leads I, aVL D) Tall R waves in V1-V Answer: B Explanation: Inferior myocardial infarctions involve the right coronary artery territory and produce ST-segment elevation in the inferior leads II, III, and aVF. Question 3. The first-line antiplatelet agent administered in the pre-hospital setting for suspected acute coronary syndrome is: A) Clopidogrel B) Prasugrel C) Aspirin D) Ticagrelor Answer: C Explanation: Aspirin irreversibly inhibits platelet COX-1, reducing thromboxane A2 production, and is the cornerstone of early antiplatelet therapy for ACS.
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Question 4. Which anticoagulant is preferred for immediate anticoagulation in a patient undergoing primary PCI for STEMI? A) Warfarin B) Heparin (unfractionated) C) Enoxaparin (LMWH) D) Fondaparinux Answer: B Explanation: Unfractionated heparin allows rapid titration and reversal, making it the anticoagulant of choice during primary percutaneous coronary intervention. Question 5. In the setting of cardiogenic shock, the hemodynamic parameter most indicative of low cardiac output is: A) Central venous pressure >12 mm Hg B) Pulmonary capillary wedge pressure >18 mm Hg C) Cardiac index <2.2 L/min/m² D) Systemic vascular resistance >2000 dyn·s·cm⁻⁵ Answer: C Explanation: A reduced cardiac index directly reflects inadequate forward flow and is a key diagnostic criterion for cardiogenic shock. Question 6. Which of the following is the most appropriate immediate treatment for ventricular fibrillation (VF) in the emergency department? A) Intravenous amiodarone 300 mg bolus B) Synchronized cardioversion at 100 J C) Immediate unsynchronized defibrillation at 200 J D) High-dose atropine 1 mg IV Answer: C Explanation: VF is a chaotic rhythm requiring immediate unsynchronized shock (defibrillation) to restore organized electrical activity.
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Question 10. Which medication is contraindicated in hypertensive emergencies due to risk of reflex tachycardia and increased intracranial pressure? A) Labetalol B) Nicardipine C) Sodium nitroprusside D) Fenoldopam Answer: C Explanation: Sodium nitroprusside can cause rapid vasodilation, reflex tachycardia, and increase intracranial pressure, making it unsuitable for patients with potential intracranial pathology. Question 11. In the “difficult airway” algorithm, after failed direct laryngoscopy and inability to mask ventilate, the next step is: A) Perform cricothyrotomy B) Insert a supraglottic airway (LMA) C) Attempt video-laryngoscopy D) Administer a paralytic agent Answer: B Explanation: When both intubation and mask ventilation fail, the algorithm recommends immediate placement of a supraglottic airway to restore oxygenation before surgical airway. Question 12. Which drug is most commonly used for rapid sequence induction (RSI) to provide analgesia and amnesia? A) Etomidate B) Ketamine C) Propofol D) Midazolam Answer: C
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Explanation: Propofol provides rapid onset hypnosis and amnesia, making it a frequent choice for RSI; analgesia is supplied by a separate opioid (e.g., fentanyl). Question 13. During RSI, which neuromuscular blocker is preferred for its rapid onset and short duration? A) Succinylcholine B) Rocuronium C) Vecuronium D) Pancuronium Answer: A Explanation: Succinylcholine depolarizes the neuromuscular junction within 30 - 60 seconds and wears off in 5- 10 minutes, ideal for emergency intubation. Question 14. A mechanically ventilated patient develops a sudden rise in peak inspiratory pressure (PIP) with unchanged tidal volume. The most likely cause is: A) Decreased airway resistance B) Disconnected circuit C) Endotracheal tube obstruction (e.g., mucus plug) D) Increased respiratory rate Answer: C Explanation: An abrupt increase in PIP suggests a blockage in the airway, such as a mucus plug or kinked tube, hindering flow while the ventilator attempts to deliver the set volume. Question 15. In an acute severe asthma exacerbation, the first-line inhaled medication is: A) Ipratropium bromide B) Short-acting β 2 - agonist (albuterol) C) Inhaled corticosteroid (fluticasone) D) Magnesium sulfate nebulization Answer: B
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Explanation: Point-of-care ultrasound can rapidly identify absent lung sliding and a “lung point,” confirming tension pneumothorax faster than radiography. Question 19. The classic triad of cardiac tamponade includes all of the following EXCEPT: A) Hypotension B) Jugular venous distension (JVD) C) Muffled heart sounds D) Pulsus paradoxus >10 mm Hg Answer: D Explanation: While pulsus paradoxus is often present, it is not part of Beck’s classic triad; the triad consists of hypotension, JVD, and muffled heart sounds. Question 20. In the FAST exam, which view is used to assess for intra-abdominal free fluid around the spleen? A) Subxiphoid (cardiac) view B) Right upper quadrant (RUQ) view C) Left upper quadrant (LUQ) view D) Pelvic (sagittal) view Answer: C Explanation: The LUQ view visualizes the splenorenal recess, allowing detection of fluid accumulation near the spleen. Question 21. A patient with a mid-shaft femur fracture develops increasing pain, tense swelling, and paresthesia in the lower leg. The most likely diagnosis is: A) Deep-vein thrombosis B) Compartment syndrome C) Cellulitis D) Acute osteomyelitis Answer: B
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Explanation: The “5 P’s” (pain, pallor, paresthesia, pulselessness, paralysis) describe compartment syndrome, a surgical emergency requiring fasciotomy. Question 22. According to the Parkland formula, the total fluid requirement for a 70 - kg adult with 30 % TBSA burns over the first 24 hours is: A) 2 L B) 4 L C) 5 L D) 7 L Answer: D Explanation: Parkland = 4 mL × body weight (kg) × %TBSA = 4 × 70 × 30 = 8 400 mL. Half (4 200 mL) is given in the first 8 hours, the remainder over the next 16 hours, totaling ~8 L; rounding to the nearest answer gives 7 L as the closest option. Question 23. Which of the following is the most appropriate initial management for a patient with suspected inhalation injury after a house fire? A) Immediate bronchoscopy in the ED B) High-flow humidified oxygen and airway assessment for edema C) Intravenous steroids to reduce airway swelling D) Nebulized albuterol only Answer: B Explanation: High-flow oxygen mitigates carbon monoxide poisoning and supports airway patency; early airway evaluation is critical as edema can progress rapidly. Question 24. The “time is brain” concept in ischemic stroke emphasizes: A) Initiating thrombolysis within 12 hours of symptom onset B) Obtaining a CT scan within 30 minutes of arrival C) Beginning antiplatelet therapy within 24 hours D) Performing mechanical thrombectomy within 6 hours for large-vessel occlusion
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Answer: C Explanation: Insulin drives potassium into cells within minutes; glucose prevents hypoglycemia. Calcium stabilizes the membrane but does not lower serum potassium. Question 28. Which opioid overdose reversal agent is administered intravenously at a dose of 0.4 mg for an adult? A) Naloxone B) Flumazenil C) N-acetylcysteine D) Atropine Answer: A Explanation: Naloxone is the opioid antagonist; 0.4 mg IV is a typical initial dose for reversal in adults. Question 29. A patient with suspected anaphylaxis receives intramuscular epinephrine. The recommended anatomical site for injection is: A) Deltoid muscle B) Vastus lateralis (anterolateral thigh) C) Gluteus maximus D) Rectus femoris Answer: B Explanation: The anterolateral thigh provides rapid absorption due to its rich vascular supply, making it the preferred site for IM epinephrine. Question 30. Which of the following best describes the physiological response to severe hypothermia (core temperature <28 °C)? A) Hyperventilation leading to respiratory alkalosis B) Increased metabolic rate and shivering C) Decreased myocardial contractility and bradyarrhythmias D) Vasodilation of peripheral vessels
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Answer: C Explanation: Severe hypothermia depresses the myocardium, leading to bradycardia, arrhythmias, and reduced contractility; shivering ceases at low temperatures. Question 31. The most appropriate initial management for a pregnant woman at 34 weeks gestation presenting with severe hypertension (BP > 160/110 mm Hg) and proteinuria is: A) Immediate cesarean delivery B) Intravenous labetalol infusion C) Oral nifedipine 10 mg PO D) Magnesium sulfate loading dose only Answer: B Explanation: Labetalol is safe in pregnancy and rapidly lowers severe hypertension; delivery is reserved for refractory cases or fetal compromise. Question 32. During neonatal resuscitation, after drying and stimulating the newborn, the next step if the infant remains apneic is: A) Administer 0.5 mg epinephrine IV push B) Provide positive-pressure ventilation (PPV) with a bag-valve-mask C) Immediate endotracheal intubation D) Chest compressions Answer: B Explanation: The NRP algorithm calls for PPV within the first 30 seconds of life if the newborn does not breathe spontaneously. Question 33. In the START triage system for mass casualty incidents, a patient who can walk but has a complaint of severe bleeding is categorized as: Answer: Yellow (Delayed) Explanation: START classifies ambulatory patients as “Walking wounded” (Green). However, severe hemorrhage requiring immediate intervention upgrades the patient to Yellow (delayed) because resources are needed to control bleeding.
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Question 37. Which of the following is a contraindication to the use of succinylcholine in RSI? A) Severe asthma B) Known or suspected hyperkalemia C) Acute coronary syndrome D) Pregnancy Answer: B Explanation: Succinylcholine can cause a rapid rise in serum potassium; it is contraindicated in patients with hyperkalemia or conditions predisposing to it (e.g., burns, neuromuscular disease). Question 38. The most reliable bedside method to confirm endotracheal tube placement in an adult is: A) Auscultation of bilateral breath sounds only B) Observation of chest rise C) Capnography showing a consistent waveform (ETCO₂) D) Pulse oximetry increase to >95 % Answer: C Explanation: Continuous waveform capnography is the gold standard for confirming tracheal intubation, detecting exhaled CO₂ in real time. Question 39. In a patient with a suspected aortic dissection, which imaging study provides the fastest definitive diagnosis in the ED? A) Transesophageal echocardiography (TEE) bedside B) Chest CT angiography with contrast C) MRI of the thoracic aorta D) Conventional aortography Answer: B Explanation: CT angiography is rapid, widely available, and highly sensitive for detecting aortic dissections, making it the preferred first-line imaging.
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Question 40. Which of the following is the most appropriate initial fluid for resuscitation of a patient in septic shock? A) 0.45 % saline B) Lactated Ringer’s solution C) 5 % albumin D) Hypertonic saline (3 %) Answer: B Explanation: Balanced crystalloids like Lactated Ringer’s are first-line for septic shock due to their physiologic electrolyte composition and lower risk of hyperchloremic acidosis. Question 41. During the management of status epilepticus, after benzodiazepine failure, the next recommended medication is: A) Phenobarbital B) Phenytoin or fosphenytoin C) Valproic acid D) Levetiracetam Answer: B Explanation: IV fosphenytoin (or phenytoin) is the standard second-line agent after benzodiazepines for refractory status epilepticus. Question 42. A patient with severe hypernatremia (serum Na⁺ > 160 mmol/L) presents with seizures. The safest rate of serum sodium correction is: A) Decrease by 1–2 mmol/L per hour B) Decrease by 5–10 mmol/L per hour C) Decrease by 0.5 mmol/L per hour D) No correction is needed acutely Answer: A Explanation: Rapid over-correction can cause cerebral edema; the recommended limit is 1– 2 mmol/L per hour (no more than 10– 12 mmol/L per day).
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Explanation: BiPAP provides both inspiratory support (reducing work of breathing) and expiratory pressure (improving alveolar recruitment) beneficial in cardiogenic pulmonary edema. Question 46. Which of the following laboratory values is most specific for diagnosing hyperthyroid storm? A) Serum TSH <0.1 μIU/mL B) Free T4 >5 ng/dL C) Serum cortisol >30 μg/dL D) Serum calcium >11 mg/dL Answer: B Explanation: Extremely elevated free T4 levels correlate with thyroid storm; suppressed TSH is less specific as it can be low in many hyperthyroid states. Question 47. A patient with a suspected spinal cord injury at the C5 level is most likely to present with which of the following? A) Loss of lower-extremity motor function with preserved diaphragmatic breathing B) Complete quadriplegia with loss of diaphragmatic function C) Isolated loss of hand function only D) Normal motor function but loss of sensation below the umbilicus Answer: A Explanation: A C5 injury spares the diaphragm (phrenic nerve C3-C5) but results in quadriplegia below the level, preserving respiratory drive. Question 48. In the context of a mass casualty incident, the JumpSTART triage system is specifically designed for: A) Adult patients only B) Pediatric patients C) Both adult and pediatric patients D) Only patients with traumatic injuries Answer: B
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Explanation: JumpSTART modifies START criteria to accommodate pediatric physiologic differences, such as higher normal respiratory rates. Question 49. Which of the following is the most appropriate initial step in the management of a patient with suspected acute aortic dissection who is hemodynamically unstable? A) Immediate surgical repair without imaging B) IV labetalol to target heart rate <60 bpm and SBP <120 mm Hg C) High-dose nitroglycerin infusion D) Administration of thrombolytic therapy Answer: B Explanation: Beta-blockade (e.g., labetalol) reduces shear stress by lowering heart rate and blood pressure, stabilizing the dissection before definitive repair. Question 50. Which of the following is the most sensitive bedside test for detecting early hypovolemic shock? A) Blood pressure measurement B) Capillary refill time >2 seconds C) Serum lactate level D) Urine output <0.5 mL/kg/h Answer: C Explanation: Elevated serum lactate reflects tissue hypoperfusion and rises earlier than overt hypotension or oliguria. Question 51. A 30-year-old male presents with sudden onset of severe chest pain radiating to the back, and a blood pressure difference of 30 mm Hg between arms. The most appropriate diagnostic test is: A) Chest X-ray B) Bedside transthoracic echocardiogram (TTE) C) CT angiography of the chest D) D-dimer assay
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Answer: B Explanation: In COPD exacerbations, low tidal volumes reduce auto-PEEP; permissive hypercapnia is tolerated to avoid barotrauma. Question 55. The most common cause of a sudden drop in end-tidal CO₂ (ETCO₂) during CPR is: A) Hyperventilation B) Endotracheal tube dislodgement C) Return of spontaneous circulation (ROSC) D) Airway obstruction Answer: B Explanation: A sudden loss of ETCO₂ often indicates loss of airway continuity, such as tube displacement, requiring immediate reassessment. Question 56. In a patient with a suspected intracranial hemorrhage, which medication should be avoided because it may exacerbate bleeding? A) Mannitol B) Furosemide C) Desmopressin D) Prothrombin complex concentrate (PCC) Answer: B Explanation: Loop diuretics like furosemide can increase bleeding risk by causing platelet dysfunction; they are not indicated in acute ICH. Question 57. Which of the following statements regarding the use of magnesium sulfate in severe asthma is true? A) It is given as a continuous infusion only. B) It acts as a bronchodilator by inhibiting calcium influx in smooth muscle. C) It should be administered only after intubation. D) It is contraindicated in patients with renal failure.
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Answer: B Explanation: Magnesium sulfate relaxes bronchial smooth muscle by antagonizing calcium channels, providing bronchodilation in severe asthma. Question 58. A child presents with a penetrating abdominal injury. The initial bedside assessment to evaluate for intra-abdominal bleeding is: A) Plain abdominal radiograph B) Diagnostic peritoneal lavage (DPL) C) Focused Assessment with Sonography for Trauma (FAST) D) CT scan with contrast Answer: C Explanation: FAST is rapid, non-invasive, and can be performed at the bedside to detect free fluid in the abdomen. Question 59. In the management of a patient with severe hyponatremia (serum Na⁺ < 120 mmol/L) who is symptomatic, the recommended initial therapy is: A) Free water restriction only B) Hypertonic saline 3 % infusion at 100 mL bolus C) Isotonic saline 0.9 % infusion at 1 L/h D) Oral sodium tablets Answer: B Explanation: Hypertonic saline rapidly raises serum sodium, reversing neurological symptoms while minimizing the risk of osmotic demyelination. Question 60. Which of the following is the most appropriate next step after confirming a diagnosis of tension pneumothorax in the ED? A) Insert a chest tube (tube thoracostomy) B) Perform needle decompression followed by chest tube placement C) Administer high-flow oxygen only D) Observe the patient for spontaneous resolution
