SAEM Emergency Medicine Actual Practice
Exam & Board Preparation Complete
Questions with Verified Answers
DOMAIN 1: RESUSCITATION & CRITICAL CARE (Q1-15)
1. A 65-year-old female is brought in after collapsing at home. Paramedics found her in
V-fib, performed 2 minutes of CPR, and delivered one 200J shock with ROSC. On arrival,
she is intubated, BP 70/40 on norepinephrine drip, HR 110, SpO2 94% on ventilator. ECG
shows anterolateral ST depressions. Temperature is 35.8°C. The MOST critical next
intervention to improve neurologic outcome is:
A. Immediate coronary angiography for suspected STEMI
B. Initiation of targeted temperature management (therapeutic hypothermia)
C. Head CT to rule out intracranial hemorrhage
D. Loading dose of amiodarone for recurrent V-fib prophylaxis
Correct Answer: C
Rationale: C is correct. Following ROSC after cardiac arrest, targeted temperature
management (TTM) at 32-36°C for at least 24 hours is a Class I recommendation per
AHA guidelines to improve neurologic recovery. This takes priority over cardiac
catheterization (A), which may be indicated later but not before TTM initiation. Head CT
(C) is not immediately indicated without focal neurologic signs. Prophylactic
antiarrhythmics (D) are not recommended post-ROSC unless recurrent arrhythmias
occur.
2. A 42-year-old male presents in severe respiratory distress 48 hours post-op from
laparoscopic appendectomy. BP 88/52, HR 128, RR 38, SpO2 84% on NRB. He is
,diaphoretic with diminished breath sounds bilaterally and JVD. Bedside echo shows RV
dilation and paradoxical septal motion. The MOST likely diagnosis and immediate
treatment is:
A. Acute COPD exacerbation with bronchodilator therapy
B. Tension pneumothorax requiring immediate needle decompression
C. Massive pulmonary embolism requiring systemic thrombolysis or embolectomy
D. Acute MI requiring immediate PCI
Correct Answer: C
Rationale: C is correct. The presentation of acute hypotension, hypoxia, JVD, and echo
findings of RV strain (McConnell's sign) in a post-surgical patient is classic for massive
PE. Systemic thrombolysis or surgical embolectomy is indicated for massive PE with
hemodynamic compromise. COPD (A) would not cause acute cardiovascular collapse
or echo findings. Tension pneumothorax (B) typically shows unilateral findings and
tracheal deviation. MI (D) would show LV dysfunction, not isolated RV dilation.
3. An 8-year-old child is brought in by EMS after drowning in a backyard pool. The child
was submerged for approximately 3 minutes, received bystander CPR, and has
spontaneous circulation but is apneic. Core temperature is 30°C. The MOST appropriate
next step is:
A. Immediate endotracheal intubation with rapid sequence intubation
B. Warm the patient to 37°C before any invasive procedures
C. Intubation with care to avoid cardiovascular collapse, followed by active rewarming at
1-2°C per hour
D. Administration of prophylactic antibiotics for aspiration pneumonia
Correct Answer: C
Rationale: C is correct. In hypothermic drowning victims, intubation is necessary but
must be performed carefully as cold myocardium is irritable and prone to arrhythmias.
Active rewarming at controlled rates prevents complications like rewarming shock.
Intubation (A) is indicated but the approach must account for hypothermia. Delaying
procedures until normothermic (B) is dangerous as the patient needs airway protection.
,Prophylactic antibiotics (D) are not recommended for drowning; treat infection if it
develops.
4. A 38-year-old female with severe asthma presents with altered mental status, silent
chest, and bradycardia at 45 bpm. She is cyanotic with minimal air movement. After 3
rounds of nebulized albuterol and ipratropium, there is no improvement. The NEXT most
appropriate intervention is:
A. Continue aggressive beta-agonist therapy with continuous nebulization
B. Administer magnesium sulfate 2g IV over 10 minutes
C. Proceed to immediate endotracheal intubation with ketamine induction
D. Initiate non-invasive positive pressure ventilation (BiPAP)
Correct Answer: C
Rationale: C is correct. This patient has life-threatening asthma with impending
respiratory arrest (altered mental status, silent chest, bradycardia). Immediate airway
control with intubation is indicated; ketamine is the preferred induction agent as it
provides bronchodilation. Continuing nebulizers (A) is futile at this stage. Magnesium
(B) is appropriate for severe asthma but not when arrest is imminent. NIV (D) is
contraindicated with altered mental status and impending arrest.
5. A 55-year-old male with ESRD on hemodysis presents with K+ of 8.2 mEq/L, wide QRS
complexes, and sine wave pattern on ECG. He is alert with BP 90/60. The FIRST priority
intervention is:
A. Administration of sodium bicarbonate 50 mEq IV
B. Emergent hemodialysis
C. Calcium gluconate 1g IV to stabilize cardiac membranes
D. Insulin and glucose to shift potassium intracellularly
Correct Answer: C
Rationale: C is correct. In severe hyperkalemia with ECG changes, calcium gluconate is
the immediate antidote to prevent fatal arrhythmias by antagonizing potassium's
cardiotoxic effects. This takes precedence over all other interventions. Bicarbonate (A)
, and insulin/glucose (D) shift potassium but do not protect the heart immediately.
Hemodialysis (B) is definitive but takes time to arrange; cardiac protection cannot wait.
6. A 28-year-old male is brought in after high-speed MVC with ejection. He is
unresponsive with BP 60/40, HR 140, and distended abdomen. FAST exam is positive
for free fluid. The trauma team has established two large-bore IVs. The MOST
appropriate next step is:
A. Immediate CT scan of abdomen/pelvis to identify specific injuries
B. Administration of 2L crystalloid bolus before any other intervention
C. Activation of massive transfusion protocol and emergent laparotomy
D. Placement of bilateral chest tubes for potential hemothoraces
Correct Answer: C
Rationale: C is correct. This patient has hemorrhagic shock from intra-abdominal
bleeding (positive FAST, unstable vital signs). The standard of care is immediate
operative intervention with massive transfusion protocol. CT imaging (A) is
contraindicated in unstable trauma patients. Aggressive crystalloid (B) exacerbates
coagulopathy and dilutional anemia. Chest tubes (D) are not indicated without thoracic
findings.
7. A 72-year-old nursing home resident presents with urosepsis and septic shock. After
2L crystalloid, BP remains 68/42, lactate 6.2. Central line is placed showing CVP 2,
ScvO2 58%. The NEXT most appropriate intervention is:
A. Additional 2L crystalloid bolus
B. Initiation of norepinephrine at 0.1 mcg/kg/min
C. Administration of hydrocortisone 50mg IV q6h for septic shock
D. Transfusion of PRBCs to Hgb >10 for optimal oxygen delivery
Correct Answer: C
Rationale: C is correct. This patient has refractory septic shock despite adequate fluid
resuscitation (CVP 2 suggests still preload responsive, but persistent hypotension
requires vasopressors). Vasopressors should be started if MAP <65 after fluids.
Norepinephrine (B) is appropriate but the dosing should start lower (0.01-0.1
Exam & Board Preparation Complete
Questions with Verified Answers
DOMAIN 1: RESUSCITATION & CRITICAL CARE (Q1-15)
1. A 65-year-old female is brought in after collapsing at home. Paramedics found her in
V-fib, performed 2 minutes of CPR, and delivered one 200J shock with ROSC. On arrival,
she is intubated, BP 70/40 on norepinephrine drip, HR 110, SpO2 94% on ventilator. ECG
shows anterolateral ST depressions. Temperature is 35.8°C. The MOST critical next
intervention to improve neurologic outcome is:
A. Immediate coronary angiography for suspected STEMI
B. Initiation of targeted temperature management (therapeutic hypothermia)
C. Head CT to rule out intracranial hemorrhage
D. Loading dose of amiodarone for recurrent V-fib prophylaxis
Correct Answer: C
Rationale: C is correct. Following ROSC after cardiac arrest, targeted temperature
management (TTM) at 32-36°C for at least 24 hours is a Class I recommendation per
AHA guidelines to improve neurologic recovery. This takes priority over cardiac
catheterization (A), which may be indicated later but not before TTM initiation. Head CT
(C) is not immediately indicated without focal neurologic signs. Prophylactic
antiarrhythmics (D) are not recommended post-ROSC unless recurrent arrhythmias
occur.
2. A 42-year-old male presents in severe respiratory distress 48 hours post-op from
laparoscopic appendectomy. BP 88/52, HR 128, RR 38, SpO2 84% on NRB. He is
,diaphoretic with diminished breath sounds bilaterally and JVD. Bedside echo shows RV
dilation and paradoxical septal motion. The MOST likely diagnosis and immediate
treatment is:
A. Acute COPD exacerbation with bronchodilator therapy
B. Tension pneumothorax requiring immediate needle decompression
C. Massive pulmonary embolism requiring systemic thrombolysis or embolectomy
D. Acute MI requiring immediate PCI
Correct Answer: C
Rationale: C is correct. The presentation of acute hypotension, hypoxia, JVD, and echo
findings of RV strain (McConnell's sign) in a post-surgical patient is classic for massive
PE. Systemic thrombolysis or surgical embolectomy is indicated for massive PE with
hemodynamic compromise. COPD (A) would not cause acute cardiovascular collapse
or echo findings. Tension pneumothorax (B) typically shows unilateral findings and
tracheal deviation. MI (D) would show LV dysfunction, not isolated RV dilation.
3. An 8-year-old child is brought in by EMS after drowning in a backyard pool. The child
was submerged for approximately 3 minutes, received bystander CPR, and has
spontaneous circulation but is apneic. Core temperature is 30°C. The MOST appropriate
next step is:
A. Immediate endotracheal intubation with rapid sequence intubation
B. Warm the patient to 37°C before any invasive procedures
C. Intubation with care to avoid cardiovascular collapse, followed by active rewarming at
1-2°C per hour
D. Administration of prophylactic antibiotics for aspiration pneumonia
Correct Answer: C
Rationale: C is correct. In hypothermic drowning victims, intubation is necessary but
must be performed carefully as cold myocardium is irritable and prone to arrhythmias.
Active rewarming at controlled rates prevents complications like rewarming shock.
Intubation (A) is indicated but the approach must account for hypothermia. Delaying
procedures until normothermic (B) is dangerous as the patient needs airway protection.
,Prophylactic antibiotics (D) are not recommended for drowning; treat infection if it
develops.
4. A 38-year-old female with severe asthma presents with altered mental status, silent
chest, and bradycardia at 45 bpm. She is cyanotic with minimal air movement. After 3
rounds of nebulized albuterol and ipratropium, there is no improvement. The NEXT most
appropriate intervention is:
A. Continue aggressive beta-agonist therapy with continuous nebulization
B. Administer magnesium sulfate 2g IV over 10 minutes
C. Proceed to immediate endotracheal intubation with ketamine induction
D. Initiate non-invasive positive pressure ventilation (BiPAP)
Correct Answer: C
Rationale: C is correct. This patient has life-threatening asthma with impending
respiratory arrest (altered mental status, silent chest, bradycardia). Immediate airway
control with intubation is indicated; ketamine is the preferred induction agent as it
provides bronchodilation. Continuing nebulizers (A) is futile at this stage. Magnesium
(B) is appropriate for severe asthma but not when arrest is imminent. NIV (D) is
contraindicated with altered mental status and impending arrest.
5. A 55-year-old male with ESRD on hemodysis presents with K+ of 8.2 mEq/L, wide QRS
complexes, and sine wave pattern on ECG. He is alert with BP 90/60. The FIRST priority
intervention is:
A. Administration of sodium bicarbonate 50 mEq IV
B. Emergent hemodialysis
C. Calcium gluconate 1g IV to stabilize cardiac membranes
D. Insulin and glucose to shift potassium intracellularly
Correct Answer: C
Rationale: C is correct. In severe hyperkalemia with ECG changes, calcium gluconate is
the immediate antidote to prevent fatal arrhythmias by antagonizing potassium's
cardiotoxic effects. This takes precedence over all other interventions. Bicarbonate (A)
, and insulin/glucose (D) shift potassium but do not protect the heart immediately.
Hemodialysis (B) is definitive but takes time to arrange; cardiac protection cannot wait.
6. A 28-year-old male is brought in after high-speed MVC with ejection. He is
unresponsive with BP 60/40, HR 140, and distended abdomen. FAST exam is positive
for free fluid. The trauma team has established two large-bore IVs. The MOST
appropriate next step is:
A. Immediate CT scan of abdomen/pelvis to identify specific injuries
B. Administration of 2L crystalloid bolus before any other intervention
C. Activation of massive transfusion protocol and emergent laparotomy
D. Placement of bilateral chest tubes for potential hemothoraces
Correct Answer: C
Rationale: C is correct. This patient has hemorrhagic shock from intra-abdominal
bleeding (positive FAST, unstable vital signs). The standard of care is immediate
operative intervention with massive transfusion protocol. CT imaging (A) is
contraindicated in unstable trauma patients. Aggressive crystalloid (B) exacerbates
coagulopathy and dilutional anemia. Chest tubes (D) are not indicated without thoracic
findings.
7. A 72-year-old nursing home resident presents with urosepsis and septic shock. After
2L crystalloid, BP remains 68/42, lactate 6.2. Central line is placed showing CVP 2,
ScvO2 58%. The NEXT most appropriate intervention is:
A. Additional 2L crystalloid bolus
B. Initiation of norepinephrine at 0.1 mcg/kg/min
C. Administration of hydrocortisone 50mg IV q6h for septic shock
D. Transfusion of PRBCs to Hgb >10 for optimal oxygen delivery
Correct Answer: C
Rationale: C is correct. This patient has refractory septic shock despite adequate fluid
resuscitation (CVP 2 suggests still preload responsive, but persistent hypotension
requires vasopressors). Vasopressors should be started if MAP <65 after fluids.
Norepinephrine (B) is appropriate but the dosing should start lower (0.01-0.1
