Saudi Board Emergency Medicine Final Written Exam (SCFHS)

A 28-year-old male presents to the ED after a motor vehicle collision with a Glasgow Coma Scale (GCS) of 6. His blood pressure is 110/70 mmHg, heart rate is 98 bpm, and SpO2 is 98% on room air. An emergency airway is indicated. During rapid sequence intubation, which of the following is the most appropriate induction agent in the setting of suspected traumatic brain injury (TBI) to optimize cerebral perfusion pressure?

• APropofol (2.0 mg/kg IV)
• BEtomidate (0.3 mg/kg IV)
• CMidazolam (0.3 mg/kg IV)
• DThiopental (5.0 mg/kg IV)

A 34-year-old female is brought to the resuscitation bay in hemorrhagic shock after a pelvic crush injury. Her blood pressure is 74/40 mmHg and heart rate is 135 bpm. The massive transfusion protocol (MTP) is activated. After the administration of 6 units of packed red blood cells (PRBCs) and 6 units of fresh frozen plasma (FFP), the patient develops QTc prolongation and muscle tremors. Which of the following is the most likely cause of these symptoms?

• AHyperkalemia from rapid RBC lysis
• BHypocalcemia caused by citrate toxicity
• CHypomagnesemia from dilutional coagulopathy
• DMetabolic acidosis from tissue hypoperfusion

A 62-year-old male is in cardiac arrest with refractory ventricular fibrillation. He has received three shocks, CPR, 1 mg of epinephrine, and 300 mg of amiodarone. A fourth shock is delivered, and rhythm check shows persistent ventricular fibrillation. Which of the following is the most appropriate next intervention?

• AAdminister Lidocaine 1.5 mg/kg IV
• BPerform double sequential external defibrillation (DSED)
• CAdminister Vasopressin 40 units IV
• DInitiate an Esmolol infusion (500 mcg/kg bolus, then 50 mcg/kg/min)

A 45-year-old male with severe diabetic ketoacidosis (pH 6.85, bicarbonate 4 mEq/L, pCO2 12 mmHg) requires emergency intubation for airway protection due to obtundation. During rapid sequence intubation, which of the following is the most critical ventilator setting parameter to prevent immediate cardiac arrest post-intubation?

• ASet a low tidal volume (6 mL/kg) to prevent barotrauma
• BSet a high respiratory rate (30-35 breaths/minute) to match the pre-intubation minute ven…
• CSet a high positive end-expiratory pressure (PEEP > 15 cmH2O) to recruit alveoli
• DMaintain a prolonged expiratory time (I:E ratio of 1:4) to prevent auto-PEEP

According to the Advanced Trauma Life Support (ATLS) 10th edition guidelines, what is the preferred anatomical site for needle decompression of a tension pneumothorax in an adult patient?

• ASecond intercostal space in the midclavicular line
• BFourth intercostal space in the midclavicular line
• CFifth intercostal space, slightly anterior to the midaxillary line
• DThird intercostal space in the midaxillary line

A 22-year-old male is brought to the ED after falling from a height of 6 meters. He is hemodynamically unstable with a blood pressure of 80/40 mmHg and heart rate of 140 bpm. The pelvis is unstable to manual compression. What is the most appropriate anatomical landmark for the application of a pelvic binder?

• AAround the iliac crests
• BAround the femoral shafts
• CAround the greater trochanters
• DAround the anterior superior iliac spines (ASIS)

A 58-year-old female presents with cardiogenic shock due to an acute myocardial infarction. Her blood pressure is 78/42 mmHg, heart rate is 112 bpm, and index lactate is 4.2 mmol/L. What is the first-line vasopressor of choice to improve perfusion pressure while minimizing the risk of tachyarrhythmias?

• ADopamine
• BNorepinephrine
• CEpinephrine
• DPhenylephrine

A 64-year-old male is resuscitated from cardiac arrest (VF rhythm) and achieves return of spontaneous circulation (ROSC). He remains comatose. Targeted temperature management (TTM) is initiated. Which of the following is the most appropriate target temperature range and duration according to current guidelines?

• A32°C to 36°C for at least 24 hours
• B30°C to 32°C for 48 hours
• C36°C to 37.5°C for 12 hours
• D35°C to 36°C for 72 hours

A 25-year-old male presents with a stab wound to zone II of the left neck. On physical examination, he is alert and oriented. His blood pressure is 122/80 mmHg, heart rate is 88 bpm, and respiratory rate is 16/min. He has a small, non-expanding hematoma over the wound. There is no active bleeding, stridor, or subcutaneous emphysema. Which of the following is the most appropriate next step in management?

• AImmediate transfer to the operating room for surgical exploration
• BPerform a CT angiography of the neck
• CLocal wound exploration in the emergency department
• DDischarge home after a 6-hour observation period

A 19-year-old male is brought to the ED after a diving accident. He is awake but paralyzed from the nipple line down. His vital signs show a blood pressure of 82/40 mmHg, heart rate of 48 bpm, and respiratory rate of 20/min. His extremities are warm and dry. What is the pathophysiology of his hemodynamic state?

• AHemorrhagic shock from internal bleeding
• BCardiogenic shock from myocardial contusion
• CNeurogenic shock from loss of sympathetic vascular tone
• DSpinal shock from temporary loss of spinal cord reflexes

A 42-year-old male presents with abdominal pain and shock after a motor vehicle collision. A Focused Assessment with Sonography for Trauma (FAST) exam is performed. Which of the following statements is correct regarding the detection of free intraperitoneal fluid during a FAST exam?

• AA minimum of 50-100 mL of fluid can be reliably detected in the Morison's pouch
• BA minimum of 200-500 mL of fluid is required to yield a positive FAST exam
• CThe splenorenal view is the most sensitive view for detecting early intraperitoneal fluid
• DA negative FAST exam rules out the presence of intraperitoneal injury and retroperitoneal…

A 30-year-old female with severe status asthmaticus is intubated in the ED due to respiratory fatigue. Shortly after connection to the mechanical ventilator, her peak airway pressure rises to 60 cmH2O and her blood pressure drops to 70/40 mmHg. Which of the following is the most appropriate immediate intervention?

• AAdminister a 1 liter bolus of normal saline
• BDisconnect the patient from the ventilator and perform chest compression
• CDisconnect the patient from the ventilator and gently compress the chest wall
• DIncrease the respiratory rate to wash out carbon dioxide

A 35-year-old male presents in cardiac arrest due to severe pelvic hemorrhage after a blast injury. The emergency physician decides to perform Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). In which aortic zone should the balloon be inflated to manage pelvic hemorrhage?

• AZone I (descending thoracic aorta)
• BZone II (pararenal aorta)
• CZone III (infrarenal abdominal aorta)
• DZone IV (common iliac arteries)

A 40-year-old male weighing 80 kg presents with second- and third-degree burns covering 50% of his total body surface area (TBSA). Using the Parkland formula, what is the total fluid requirement in the first 8 hours from the time of the burn injury?

• A4,000 mL of Lactated Ringer's
• B8,000 mL of Lactated Ringer's
• C16,000 mL of Lactated Ringer's
• D6,000 mL of Normal Saline

A 48-year-old male with a history of hypertension on metoprolol presents to the ED in anaphylactic shock after a bee sting. He has received three doses of intramuscular epinephrine (0.3 mg IM), but his blood pressure remains 72/40 mmHg. Which of the following is the most appropriate next therapeutic option?

• AAdminister an intravenous epinephrine infusion at 20 mcg/min
• BAdminister Glucagon 1-5 mg IV slowly over 5 minutes
• CAdminister Terbutaline 0.25 mg SC
• DAdminister Hydrocortisone 100 mg IV

A 67-year-old male is brought to the ED after a fall, sustaining a flail chest. He is in moderate respiratory distress with a respiratory rate of 28/min and SpO2 of 89% on a non-rebreather mask. What is the primary pathophysiology of respiratory failure in patients with flail chest?

• AParadoxical chest wall movement causing alveolar hypoventilation
• BPulmonary contusion of the underlying lung parenchyma
• CRupture of the diaphragm leading to abdominal herniation
• DTracheobronchial injury causing anatomical dead space

A 24-year-old male is extricated from a cold lake after being submerged for 25 minutes. He is pulseless and apneic. His core body temperature is 27.8°C. What is the correct management strategy regarding resuscitation and pronouncement of death?

• ADeclare the patient dead immediately due to prolonged submersion time
• BResuscitate the patient and withhold defibrillation and epinephrine until the core temper…
• CPerform continuous CPR and rewarm the patient to a core temperature of 32°C to 35°C befor…
• DAdminister double doses of ACLS drugs due to hypothermia-induced metabolic suppression

A 38-year-old female develops sudden onset of chest pain, dyspnea, and hypotension immediately after the removal of a central venous catheter. An air embolism is suspected. What is the most appropriate initial positioning for this patient?

• ATrendelenburg and left lateral decubitus (Durant's maneuver)
• BReverse Trendelenburg and right lateral decubitus
• CProne position with head elevated
• DHigh Fowler's position

A 52-year-old male in cardiac arrest requires vascular access. The team attempts intraosseous (IO) access. Which of the following is an absolute contraindication to placing an IO needle in the proximal tibia?

• APresence of a proximal tibia fracture on the ipsilateral side
• BModerate overlying cellulitis at the insertion site
• CHistory of osteoarthritis in the ipsilateral knee
• DPatient is obese with thick subcutaneous tissue

A 61-year-old male presents with crushing chest pain and ST-elevation in leads II, III, aVF, and V4R. His blood pressure is 82/40 mmHg and heart rate is 60 bpm. Lungs are clear to auscultation. What is the most appropriate initial treatment for his hypotension?

• AAdminister a 250-500 mL bolus of normal saline
• BAdminister sublingual nitroglycerin 0.4 mg
• CStart a Dobutamine infusion at 5 mcg/kg/min
• DAdminister Morphine 2 mg IV for pain relief

A 54-year-old male presents with tearing chest pain radiating to his back. His blood pressure is 185/110 mmHg and heart rate is 108 bpm. A chest CT angiogram confirms an acute Stanford Type B aortic dissection. Which of the following represents the most appropriate initial pharmacological strategy?

• AStart Nitroprusside infusion, then add Esmolol infusion
• BStart Esmolol infusion first, then add Nitroprusside if needed to target SBP < 120 mmHg
• CAdminister Hydralazine 10 mg IV bolus
• DStart a Nicardipine infusion alone to target SBP < 100 mmHg

A 63-year-old female presents with acute right-sided hemiparesis and aphasia that started 2 hours ago. Her blood pressure is 195/115 mmHg. Her non-contrast head CT is negative for hemorrhage. She is otherwise a candidate for intravenous thrombolysis (tPA). Which of the following is the most appropriate management of her blood pressure?

• AWithhold thrombolysis because her blood pressure is greater than 185/110 mmHg
• BLower her blood pressure to < 185/110 mmHg using Labetalol before administering tPA
• CLower her blood pressure to < 140/90 mmHg immediately using a Nitroprusside infusion
• DAdminister tPA immediately and monitor blood pressure, treating only if SBP > 220 mmHg

A 28-year-old male is in status epilepticus. He has received two doses of Lorazepam (4 mg IV each) but continues to have generalized tonic-clonic activity. Which of the following is the most appropriate next-line antiepileptic drug choice?

• APropofol (2 mg/kg IV bolus followed by infusion)
• BLevetiracetam (60 mg/kg IV over 10 minutes)
• CPhenobarbital (20 mg/kg IV at 50 mg/min)
• DMidazolam (0.2 mg/kg IV bolus)

A 32-year-old female presents with severe tachycardia, hyperthermia (40.1°C), agitation, and mild jaundice. A diagnosis of thyroid storm is suspected. What is the correct sequence and timing of administration of Propylthiouracil (PTU) and potassium iodide?

• AAdminister potassium iodide first, followed by PTU 1 hour later
• BAdminister PTU first, followed by potassium iodide at least 1 hour later
• CAdminister PTU and potassium iodide simultaneously
• DAdminister PTU and withhold potassium iodide until thyroid levels are normal

A 65-year-old male with chronic kidney disease presents with generalized weakness. His ECG shows peaked T waves, prolonged PR interval, and loss of P waves. His serum potassium is 7.2 mEq/L. What is the primary mechanism of action of intravenous calcium gluconate in the management of this patient?

• APromotes intracellular shift of potassium
• BIncreases renal excretion of potassium
• CStabilizes the myocardial cell membrane
• DBinds potassium in the gastrointestinal tract

A 49-year-old female presents with dyspnea. Her CT angiogram shows a large saddle pulmonary embolism. Her blood pressure is 118/76 mmHg, but her echocardiogram reveals right ventricular strain and her troponin is elevated. Which of the following represents the most appropriate initial management?

• AImmediate systemic thrombolysis with Alteplase (100 mg IV over 2 hours)
• BAnticoagulation with unfractionated heparin and close monitoring
• CCatheter-directed embolectomy in the OR
• DPlacement of an inferior vena cava (IVC) filter

A 23-year-old male presents with diabetic ketoacidosis. His serum glucose is 450 mg/dL, pH is 7.15, and serum potassium is 2.9 mEq/L. Which of the following is the most appropriate initial step in potassium and insulin management?

• AStart an insulin infusion immediately, and add potassium to IV fluids once potassium is >…
• BAdminister potassium replacement and delay insulin infusion until potassium is > 3.3 mEq/L
• CAdminister a bolus of insulin (0.1 U/kg) and start an insulin infusion, ignoring potassiu…
• DGive oral potassium and start an insulin infusion simultaneously

A 36-year-old female with a history of Addison's disease presents with weakness, nausea, and hypotension (80/40 mmHg) refractory to fluid resuscitation. What is the medication and dose of choice for the treatment of suspected adrenal crisis?

• ADexamethasone 4 mg IV
• BHydrocortisone 100 mg IV
• CFludrocortisone 0.1 mg PO
• DMethylprednisolone 40 mg IV

A 72-year-old male presents with acute decompensated heart failure and severe respiratory distress. His blood pressure is 180/100 mmHg, heart rate is 115 bpm, and he has diffuse crackles bilaterally. What is the primary physiological benefit of starting non-invasive positive pressure ventilation (BiPAP) in this patient?

• ADecreases preload and afterload, reducing work of breathing
• BIncreases venous return to the right atrium
• CInduces bronchodilation of the terminal bronchioles
• DDecreases the alveolar-arterial oxygen gradient by increasing lung fluid clearance

According to the Surviving Sepsis Campaign guidelines, which of the following is the first-line vasopressor of choice for patients in septic shock refractory to fluid resuscitation?

• ADopamine
• BEpinephrine
• CNorepinephrine
• DVasopressin

A 42-year-old male presents with severe pain in his left leg. The skin is erythematous and warm, and there is visible ecchymosis and crepitus. Plain radiograph shows gas in the soft tissues. What is the most appropriate next step in management?

• AObtain an urgent MRI of the left lower extremity
• BStart broad-spectrum antibiotics and consult orthopedic surgery for emergent debridement
• CObtain a repeat radiograph in 6 hours to monitor gas progression
• DPerform a needle aspiration of the soft tissue gas in the ED

A 29-year-old female with a history of myasthenia gravis presents with respiratory distress and generalized weakness. She was recently prescribed an antibiotic for a urinary tract infection. Which of the following classes of antibiotics is most likely to precipitate a myasthenic crisis?

• ACephalosporins
• BPenicillins
• CFluoroquinolones
• DMacrolides

A 45-year-old female is brought to the ED after a generalized tonic-clonic seizure. Her serum sodium is 112 mEq/L. Which of the following is the most appropriate initial therapy to manage her hyponatremic seizure?

• AInfuse 3% hypertonic saline (100 mL IV bolus over 10 minutes)
• BAdminister a 1 liter bolus of normal saline (0.9% NaCl)
• CInitiate fluid restriction of < 500 mL/day
• DAdminister Conivaptan 20 mg IV

A 72-year-old male with type 2 diabetes presents with altered mental status and profound dehydration. His serum glucose is 950 mg/dL, serum osmolality is 345 mOsm/kg, and urine ketones are negative. What is the most critical initial therapeutic intervention for this patient?

• ARapid intravenous insulin bolus (0.15 U/kg)
• BAggressive fluid resuscitation with isotonic crystalloid (e.g., Normal Saline)
• CAdministration of sodium bicarbonate IV
• DIntravenous potassium replacement before fluid resuscitation

A 52-year-old male presents with headache, confusion, and visual disturbances. His blood pressure is 230/130 mmHg. Fundoscopic exam shows papilledema. Which of the following represents the most appropriate target for blood pressure reduction in the first hour?

• AReduce mean arterial pressure (MAP) by no more than 20-25%
• BLower blood pressure to < 140/90 mmHg immediately
• CLower systolic blood pressure to < 100 mmHg within 30 minutes
• DReduce mean arterial pressure by 50% to prevent hemorrhagic stroke

A 19-year-old university student is diagnosed with meningococcal meningitis. Which of the following is the most appropriate chemoprophylaxis regimen for his close contacts (e.g., roommates)?

• AAmoxicillin 500 mg PO three times daily for 5 days
• BRifampin 600 mg PO twice daily for 2 days
• CA single dose of Azithromycin 1 g PO
• DCeftriaxone 1 g IM daily for 3 days

A 34-year-old female presents with a painful, blistering rash involving 25% of her total body surface area, along with oral and conjunctival mucosal erosions. She recently started taking carbamazepine. Skin biopsy confirms toxic epidermal necrolysis (TEN). What is the pathognomonic physical exam sign associated with this condition?

• ANikolsky sign (detachment of epidermis with lateral pressure)
• BAuspitz sign (pinpoint bleeding after scaling removal)
• CDarier's sign (urtication after rubbing a lesion)
• DKoebner phenomenon (lesions appearing at sites of trauma)

A 45-year-old male with a history of cirrhosis presents with hematemesis. His blood pressure is 88/44 mmHg and heart rate is 120 bpm. In addition to fluid resuscitation and octreotide, which of the following interventions has been shown to reduce mortality in patients with acute variceal bleeding?

• AEarly administration of Ceftriaxone (1 g IV)
• BUrgent administration of Protonix (pantoprazole) infusion
• CEmpiric transfusion of platelets to a target of > 150,000/µL
• DInsertion of a Sengstaken-Blakemore tube immediately

A 31-year-old male with a history of intravenous drug use presents with fever and cough. Chest radiograph shows multiple nodular opacities with cavitation. Electrocardiogram is normal. What is the most likely cardiac valve involved in this patient's condition?

• AMitral valve
• BTricuspid valve
• CAortic valve
• DPulmonic valve

A 28-year-old male hiking at an altitude of 3,500 meters develops progressive dyspnea at rest, cough producing pink frothy sputum, and extreme fatigue. What is the most appropriate initial treatment of choice for high-altitude pulmonary edema (HAPE)?

• ADescent to lower altitude, supplemental oxygen, and Nifedipine
• BOral Acetazolamide 250 mg twice daily
• CIntravenous Dexamethasone 8 mg, followed by 4 mg every 6 hours
• DIntubate the patient and start mechanical ventilation in the field

A 4-year-old child weighing 16 kg is in cardiac arrest. The cardiac monitor shows ventricular fibrillation. According to the Pediatric Advanced Life Support (PALS) guidelines, what is the appropriate energy dose for the first defibrillation attempt?

• A32 Joules (2 J/kg)
• B64 Joules (4 J/kg)
• C16 Joules (1 J/kg)
• D160 Joules (10 J/kg)

A 2-year-old male is brought to the ED with a barking cough and stridor at rest. He has moderate chest wall retractions. Which of the following is the most appropriate initial therapy for this patient?

• AAlbuterol nebulizer and oral prednisone
• BNebulized racemic epinephrine and oral/IM dexamethasone
• CIntravenous Ceftriaxone and airway observation
• DCool mist therapy alone

A 5-year-old child presents with high fever, sore throat, drooling, and is sitting in a 'tripod' position. She is in moderate respiratory distress. Which of the following represents the most appropriate initial management step?

• APerform a thorough oral exam using a tongue depressor to visualize the epiglottis
• BKeep the patient calm, avoid agitation, and arrange for emergent intubation in the operat…
• CObtain a lateral neck radiograph in the radiology department
• DStart an intravenous line and administer Ceftriaxone immediately

A 9-month-old infant presents with episodes of inconsolable crying, during which he draws his knees to his chest. Between episodes, he is lethargic. On exam, a sausage-shaped mass is felt in the right upper quadrant. What is the diagnostic test of choice for this condition?

• AAbdominal CT scan with contrast
• BAbdominal ultrasound
• CPlain abdominal radiograph (KUB)
• DUpper GI series with barium contrast

A 6-year-old female presents with status asthmaticus refractory to continuous nebulized albuterol, ipratropium bromide, and systemic corticosteroids. What is the recommended dose and route of magnesium sulfate as an adjunctive therapy in this patient?

• A50-75 mg/kg IV infused over 20 minutes
• B25-50 mg/kg IV infused over 20 minutes
• C100 mg/kg IV bolus
• D2 g IV bolus

A 14-month-old male is brought to the ED after a 2-minute generalized tonic-clonic seizure. His temperature is 39.2°C. He has returned to his baseline mental status and is active and drinking fluids. What is the most appropriate management?

• APerform an urgent lumbar puncture to rule out meningitis
• BObtain a non-contrast head CT scan
• CReassure the parents, administer antipyretics, and discharge home with close follow-up
• DAdmit the patient for a 24-hour video EEG monitoring

A 14-day-old neonate presents with a rectal temperature of 38.4°C. The infant is feeding well and has a normal physical exam. What is the most appropriate management strategy?

• ADischarge home with oral amoxicillin and follow-up in 24 hours
• BObtain blood, urine, and cerebrospinal fluid (CSF) cultures, admit to the hospital, and s…
• CPerform a septic workup but withhold antibiotics until cultures are positive
• DCheck a rapid RSV test; if positive, discharge home with supportive care