Page 1 of 235
SAEM PRACTICE EXAM STUDY GUIDE LATEST
VERSION WITH COMPLETE 500 QUESTIONS AND
CORRECT ANSWERS JUST RELEASED THIS YEAR
Question: The most sensitive bedside test for nerve injury in a finger after trauma is:
A. light touch
B. O'Riain wrinkle test
C. pain
D. temperature sensation
E. two-point discrimination - CORRECT ANSWER✔✔E. two-point discrimination
Light touch is a good screening test, but two-point discrimination is more sensitive and should
be used routinely in evaluating injuries to digits. The O'Riain wrinkle test involves placing the
digit in warm water and looking for wrinkling of the digital pulps. Presence of wrinkling indicates
the nerve is intact.
Question: Which is *not* part of the Ottawa ankle rules?
A. inability to walk 4 steps at the time of the injury
B. inability to walk 4 steps in the emergency department
C. tenderness over the lateral malleolus
D. tenderness over the medial malleolus
E. tenderness over the talus - CORRECT ANSWER✔✔E. tenderness over the talus
The Ottawa ankle rules are a validated (for adults) set of physical exam findings to determine if
an ankle X-ray is needed after an injury. If any of the first 4 answers is present or if there is
*tenderness over the navicular or base of the 5th metatarsal*, an X-ray should be obtained. If
the correct answer to all questions is no, then an X-ray is not needed.
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Question: Choose the INCORRECT statement regarding thoracentesis from the anterior
approach (needle decompression):
A. An upright chest X-ray should always be performed following a thoracentesis to confirm the
successful relief of a tension pneumothorax and the absence of hemothorax or other
complications.
B. A 14- to 20-gauge needle is inserted perpendicularly over the superior edge of the rib.
C. The recommended insertion site is the second intercostal space, midaxillary line.
D. After the needle is inserted into the pleural space, a rush of air confirms the presence of a
tension pneumothorax.
E. If a tension pneumothorax is confirmed via needle decompression, then a thoracostomy tube
should be placed as soon as possible. - CORRECT ANSWER✔✔C. The recommended insertion
site is the second intercostal space, midaxillary line.
The recommended insertion site for needle decompression of tension pneumothoraces is the
second intercostal space along the midclavicular line. If a lateral approach is needed, the
recommended insertion site is the fourth or fifth intercostal space in the midaxillary line. The
lateral approach poses a greater risk of parenchymal injury. The needle should always be
inserted over the superior edge of the rib as the neurovascular bundle runs along the inferior
margin. The remaining answers are all correct statements regarding thoracentesis.
Question: In a patient with a suspected ruptured globe from penetrating trauma to the eye, all
of the following should be performed EXCEPT:
A. ascertainment of intraocular pressure via tonometry
B. administration of broad spectrum antibiotic therapy
C. visual acuity assessment
D. ascertainment of tetanus status
E. ophthalmology consultation - CORRECT ANSWER✔✔A. ascertainment of intraocular pressure
via tonometry
The answer is A. Tonometry should not be performed in patients with suspected ruptured
globe, as application of the Tono-Pen pressure to the eye may cause the vitreous humor to
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exude from the eye, thereby complicating the injury. Tetanus status is important to check, as
ocular injuries, like skin injuries, may be a portal for tetanus exposure. Broad-spectrum
antibiotic therapy is indicated. Anti-emetic therapy may be helpful in preventing the elevations
in intraocular pressure associated with vomiting. Visual acuity assessment is important and
ophthalmology consultation is critical.
Question: Following a motor vehicle crash, a 25 year old man presents complaining of a painful
right eye. Visual acuity is 20/200 in the right eye and 20/25 in the left eye. The right eye
protrudes from the orbit and the patient has right eye pain with extraocular movement. What is
the most likely cause of his symptoms?
A. retrobulbar hematoma
B. chemosis
C. hyphema
D. orbital blow-out fracture
E. ruptured globe - CORRECT ANSWER✔✔A. retrobulbar hematoma
The answer is A. Traumatic proptosis with impaired extraocular movements is classic for
retrobulbar hematoma. Sequelae include optic nerve ischemia and secondary visual
impairment. A ruptured globe presents with enophthalmos, not proptosis, as vitreous humor
leaks out of the eye. Neither hyphema nor chemosis causes proptosis. Orbital blowout fractures
can cause inferior rectus muscle entrapment and secondary pain with impairment of
extraocular movement. Yet, they do not present with proptosis - unless complicated by
retrobulbar pathology.
Question: Following a brawl at a local bar, a gentleman presents with an impressive right-sided
periorbital ecchymosis. All of the following physical examination findings would suggest an
orbital blowout fracture EXCEPT:
A. diplopia with upward gaze
B. right-sided infraorbital subcutaneous emphysema
C. right-sided epistaxis
D. proptosis
E. anesthesia of the right infraorbital region - CORRECT ANSWER✔✔D. proptosis
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D. Orbital blowout fractures classically involve the *maxillary or ethmoid sinus* and
consequently often cause either epistaxis (through the connection of the maxillary sinus with
the nose) or subcutaneous emphysema (through the entry of air from the sinuses into the
subcutaneous tissue). A fracture through the maxillary sinus may extend through the portal by
which the second branch of the trigeminal nerve exits, thus causing anesthesia of the ipsilateral
infraorbital region. *If the inferior rectus muscle gets trapped within the fracture of the inferior
orbital wall, patients will be unable to look upward causing diplopia with upward gaze*. Orbital
blowout fractures are not typified by proptosis. In fact, proptosis in the setting of trauma should
prompt physicians to suspect the possibility of a retrobulbar hematoma.
Question: The patient depicted in the figure presents to the ED just after sustaining a pellet-
gun wound to the right eye. What do the arrows most likely indicate?
[image]
A. hyphema
B. iritis
C. keratitis
D. pterygium
E. hypopion - CORRECT ANSWER✔✔A. hyphema
The answer is A. The patient has a *fluid level/meniscus in the anterior chamber*, that is most
likely indicative of hyphema (collection of blood). Hypopion (collection of purulent material) is
less likely in this setting, and keratitis (corneal inflammation) and iritis (inflammation of the iris)
are not indicated by the arrows. A pterygium is a growth which is visible on the sclera, and
which crosses the limbus onto the cornea.
Question: The patient in the figure sustained minor blunt trauma to the eye, and has a normal
head/orbital computed tomography (CT) scan. Ophthalmological examination is normal, other
than the blood as shown in the figure (the blood does not cross the limbus). Of the choices
below, which diagnosis is the most likely based upon the figure?
[image]
A. foreign body
4
SUCCESS!
SAEM PRACTICE EXAM STUDY GUIDE LATEST
VERSION WITH COMPLETE 500 QUESTIONS AND
CORRECT ANSWERS JUST RELEASED THIS YEAR
Question: The most sensitive bedside test for nerve injury in a finger after trauma is:
A. light touch
B. O'Riain wrinkle test
C. pain
D. temperature sensation
E. two-point discrimination - CORRECT ANSWER✔✔E. two-point discrimination
Light touch is a good screening test, but two-point discrimination is more sensitive and should
be used routinely in evaluating injuries to digits. The O'Riain wrinkle test involves placing the
digit in warm water and looking for wrinkling of the digital pulps. Presence of wrinkling indicates
the nerve is intact.
Question: Which is *not* part of the Ottawa ankle rules?
A. inability to walk 4 steps at the time of the injury
B. inability to walk 4 steps in the emergency department
C. tenderness over the lateral malleolus
D. tenderness over the medial malleolus
E. tenderness over the talus - CORRECT ANSWER✔✔E. tenderness over the talus
The Ottawa ankle rules are a validated (for adults) set of physical exam findings to determine if
an ankle X-ray is needed after an injury. If any of the first 4 answers is present or if there is
*tenderness over the navicular or base of the 5th metatarsal*, an X-ray should be obtained. If
the correct answer to all questions is no, then an X-ray is not needed.
1
SUCCESS!
,Page 2 of 235
Question: Choose the INCORRECT statement regarding thoracentesis from the anterior
approach (needle decompression):
A. An upright chest X-ray should always be performed following a thoracentesis to confirm the
successful relief of a tension pneumothorax and the absence of hemothorax or other
complications.
B. A 14- to 20-gauge needle is inserted perpendicularly over the superior edge of the rib.
C. The recommended insertion site is the second intercostal space, midaxillary line.
D. After the needle is inserted into the pleural space, a rush of air confirms the presence of a
tension pneumothorax.
E. If a tension pneumothorax is confirmed via needle decompression, then a thoracostomy tube
should be placed as soon as possible. - CORRECT ANSWER✔✔C. The recommended insertion
site is the second intercostal space, midaxillary line.
The recommended insertion site for needle decompression of tension pneumothoraces is the
second intercostal space along the midclavicular line. If a lateral approach is needed, the
recommended insertion site is the fourth or fifth intercostal space in the midaxillary line. The
lateral approach poses a greater risk of parenchymal injury. The needle should always be
inserted over the superior edge of the rib as the neurovascular bundle runs along the inferior
margin. The remaining answers are all correct statements regarding thoracentesis.
Question: In a patient with a suspected ruptured globe from penetrating trauma to the eye, all
of the following should be performed EXCEPT:
A. ascertainment of intraocular pressure via tonometry
B. administration of broad spectrum antibiotic therapy
C. visual acuity assessment
D. ascertainment of tetanus status
E. ophthalmology consultation - CORRECT ANSWER✔✔A. ascertainment of intraocular pressure
via tonometry
The answer is A. Tonometry should not be performed in patients with suspected ruptured
globe, as application of the Tono-Pen pressure to the eye may cause the vitreous humor to
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exude from the eye, thereby complicating the injury. Tetanus status is important to check, as
ocular injuries, like skin injuries, may be a portal for tetanus exposure. Broad-spectrum
antibiotic therapy is indicated. Anti-emetic therapy may be helpful in preventing the elevations
in intraocular pressure associated with vomiting. Visual acuity assessment is important and
ophthalmology consultation is critical.
Question: Following a motor vehicle crash, a 25 year old man presents complaining of a painful
right eye. Visual acuity is 20/200 in the right eye and 20/25 in the left eye. The right eye
protrudes from the orbit and the patient has right eye pain with extraocular movement. What is
the most likely cause of his symptoms?
A. retrobulbar hematoma
B. chemosis
C. hyphema
D. orbital blow-out fracture
E. ruptured globe - CORRECT ANSWER✔✔A. retrobulbar hematoma
The answer is A. Traumatic proptosis with impaired extraocular movements is classic for
retrobulbar hematoma. Sequelae include optic nerve ischemia and secondary visual
impairment. A ruptured globe presents with enophthalmos, not proptosis, as vitreous humor
leaks out of the eye. Neither hyphema nor chemosis causes proptosis. Orbital blowout fractures
can cause inferior rectus muscle entrapment and secondary pain with impairment of
extraocular movement. Yet, they do not present with proptosis - unless complicated by
retrobulbar pathology.
Question: Following a brawl at a local bar, a gentleman presents with an impressive right-sided
periorbital ecchymosis. All of the following physical examination findings would suggest an
orbital blowout fracture EXCEPT:
A. diplopia with upward gaze
B. right-sided infraorbital subcutaneous emphysema
C. right-sided epistaxis
D. proptosis
E. anesthesia of the right infraorbital region - CORRECT ANSWER✔✔D. proptosis
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, Page 4 of 235
D. Orbital blowout fractures classically involve the *maxillary or ethmoid sinus* and
consequently often cause either epistaxis (through the connection of the maxillary sinus with
the nose) or subcutaneous emphysema (through the entry of air from the sinuses into the
subcutaneous tissue). A fracture through the maxillary sinus may extend through the portal by
which the second branch of the trigeminal nerve exits, thus causing anesthesia of the ipsilateral
infraorbital region. *If the inferior rectus muscle gets trapped within the fracture of the inferior
orbital wall, patients will be unable to look upward causing diplopia with upward gaze*. Orbital
blowout fractures are not typified by proptosis. In fact, proptosis in the setting of trauma should
prompt physicians to suspect the possibility of a retrobulbar hematoma.
Question: The patient depicted in the figure presents to the ED just after sustaining a pellet-
gun wound to the right eye. What do the arrows most likely indicate?
[image]
A. hyphema
B. iritis
C. keratitis
D. pterygium
E. hypopion - CORRECT ANSWER✔✔A. hyphema
The answer is A. The patient has a *fluid level/meniscus in the anterior chamber*, that is most
likely indicative of hyphema (collection of blood). Hypopion (collection of purulent material) is
less likely in this setting, and keratitis (corneal inflammation) and iritis (inflammation of the iris)
are not indicated by the arrows. A pterygium is a growth which is visible on the sclera, and
which crosses the limbus onto the cornea.
Question: The patient in the figure sustained minor blunt trauma to the eye, and has a normal
head/orbital computed tomography (CT) scan. Ophthalmological examination is normal, other
than the blood as shown in the figure (the blood does not cross the limbus). Of the choices
below, which diagnosis is the most likely based upon the figure?
[image]
A. foreign body
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