100+ Free ABEM Medical Tox Practice Questions

Pass your ABEM Medical Toxicology Subspecialty Certification exam on the first try — instant access, no signup required.

✓ No registration✓ No credit card✓ No hidden fees✓ Start practicing immediately

~80-90% Pass Rate

100+ Questions

100% Free

1 / 10

Question 1

Score: 0/0

A 24-year-old is brought in altered, flushed, with dry mucous membranes, mydriasis, urinary retention, and a temperature of 39.2°C. Bowel sounds are diminished. Which toxidrome is most likely?

Anticholinergic

Cholinergic

Sympathomimetic

Opioid

to track

2026 Statistics

Key Facts: ABEM Medical Tox Exam

~200

Exam Questions

ABEM 2026

$2,215

Total Fees

ABEM 2026 ($470 + $1,745)

2 years

ACGME Fellowship

ABEM/ABPM/ABP Requirements

64+

Passing Score

ABEM MedTox

38%

Toxicants & Toxins Weight

2021 Core Content

3 boards

Co-Sponsors (ABEM/ABPM/ABP)

ABMS

The ABEM Medical Toxicology exam is a 200-question, computer-based subspecialty board examination co-sponsored by ABEM, ABPM, and ABP. It is administered annually (October 14, 2026) at Pearson VUE testing centers and tests knowledge across nine content domains — most heavily Toxicants and Toxins (38%), Principles of Toxicology (14%), Clinical Assessment (11%), and Therapeutics (11%). Candidates must hold primary board certification from ABEM, ABPM, or ABP and must have completed a 2-year ACGME-accredited Medical Toxicology fellowship. Fees total $2,215 ($470 application + $1,745 exam registration). The passing score is 64 or greater on a criterion-referenced scaled score. Content is based on the 2021 Core Content of Medical Toxicology, and certification is maintained through the MyToxCert continuous-certification program.

Sample ABEM Medical Tox Practice Questions

Try these sample questions to test your ABEM Medical Tox exam readiness. Each question includes a detailed explanation. Start the interactive quiz above for the full 100+ question experience with AI tutoring.

1A 24-year-old is brought in altered, flushed, with dry mucous membranes, mydriasis, urinary retention, and a temperature of 39.2°C. Bowel sounds are diminished. Which toxidrome is most likely?

A.Anticholinergic

B.Cholinergic

C.Sympathomimetic

D.Opioid

Explanation: The anticholinergic toxidrome — 'mad as a hatter, hot as a hare, red as a beet, dry as a bone, blind as a bat, full as a flask' — presents with delirium, hyperthermia, flushing, dry skin and mucosa, mydriasis, urinary retention, and decreased bowel sounds. Common culprits include diphenhydramine, TCAs, jimsonweed (Datura), and atropine. Physostigmine may reverse pure anticholinergic delirium but is contraindicated with TCA-type cardiotoxicity.

2A farmer is found confused and diaphoretic with pinpoint pupils, copious oral secretions, bronchospasm, urinary incontinence, and fasciculations. Which exposure best explains this presentation?

A.Organophosphate insecticide

B.Diphenhydramine

C.Heroin

D.Cocaine

Explanation: DUMBELS (defecation, urination, miosis, bronchorrhea/bronchospasm/bradycardia, emesis, lacrimation, salivation) plus fasciculations is the classic cholinergic crisis from organophosphate-induced acetylcholinesterase inhibition. Treatment is aggressive atropine doubling every 3-5 minutes until pulmonary secretions dry, plus pralidoxime (2-PAM) ideally within 24-48 hours before aging of the enzyme-phosphate bond.

3Which feature most reliably distinguishes serotonin syndrome from neuroleptic malignant syndrome (NMS)?

A.Inducible or spontaneous clonus, especially lower-extremity, with rapid onset (hours)

B.Fever above 40°C

C.Leukocytosis

D.Elevated creatine kinase

Explanation: The Hunter Serotonin Toxicity Criteria emphasize neuromuscular hyperactivity — inducible or spontaneous clonus (especially lower extremity) and hyperreflexia — with onset within hours of a serotonergic agent change. NMS evolves over days with lead-pipe rigidity, bradykinesia, and hyporeflexia after dopamine antagonist exposure. Fever, leukocytosis, and CK elevation occur in both and don't discriminate.

4A patient presents 6 hours after a single acute acetaminophen ingestion with a 4-hour-equivalent serum acetaminophen level of 160 mcg/mL. According to the Rumack-Matthew nomogram, which is correct?

A.The level is above the 150 mcg/mL treatment line at 4 hours — start N-acetylcysteine

B.The level is below the treatment line — observe without NAC

C.Nomogram is invalid; treat empirically only if LFTs elevated

D.Start hemodialysis immediately

Explanation: The Rumack-Matthew nomogram's US treatment line begins at 150 mcg/mL at 4 hours post-ingestion and declines with a half-life-based slope. A 4-hour level of 160 mcg/mL is above the line, mandating NAC. The nomogram applies only to single acute ingestions between 4 and 24 hours post-ingestion and does not apply to staggered or chronic exposures, where clinical/lab criteria drive treatment.

5Which IV N-acetylcysteine regimen corresponds to the standard 21-hour Prescott protocol?

A.150 mg/kg over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours

B.140 mg/kg loading, then 70 mg/kg every 4 hours for 17 doses

C.150 mg/kg bolus, then 150 mg/kg continuous over 24 hours

D.100 mg/kg over 2 hours, then 200 mg/kg over 10 hours

Explanation: The 21-hour IV Prescott regimen delivers 300 mg/kg total: 150 mg/kg over 1 hour, 50 mg/kg over 4 hours, and 100 mg/kg over 16 hours. Many centers extend the third bag if hepatotoxicity or persistent acetaminophen is present. The 140 mg/kg load + 70 mg/kg q4h × 17 doses describes the 72-hour oral protocol.

6Which metabolic derangement is the earliest hallmark of acute salicylate toxicity in adults?

A.Respiratory alkalosis from direct medullary stimulation

B.Respiratory acidosis from CNS depression

C.Metabolic alkalosis from vomiting

D.Hyperchloremic non-anion-gap acidosis

Explanation: Salicylates directly stimulate the medullary respiratory center producing tachypnea and primary respiratory alkalosis early. A coexisting or subsequent anion gap metabolic acidosis develops as salicylate uncouples oxidative phosphorylation. Adults classically show a mixed respiratory alkalosis + anion gap metabolic acidosis; infants and late-stage adults show predominant acidosis.

7A salicylate-poisoned patient has a level of 65 mg/dL and is alert. Urine pH is 5.5. What is the most appropriate intervention to enhance elimination?

A.IV sodium bicarbonate infusion targeting urine pH 7.5-8.0

B.IV acetazolamide

C.Ammonium chloride to acidify urine

D.IV furosemide

Explanation: Urine alkalinization with sodium bicarbonate (target urine pH 7.5-8.0) ion-traps salicylate as the ionized form, enhancing renal elimination 5- to 20-fold. Maintain serum K+ >4 mEq/L because hypokalemia prevents urine alkalinization (kidney reabsorbs K+ in exchange for H+). Acetazolamide causes metabolic acidosis worsening CNS salicylate penetration and is contraindicated.

8Which of the following is an EXTRIP-supported indication for hemodialysis in acute salicylate poisoning?

A.Serum salicylate >100 mg/dL in an acute overdose

B.Salicylate level >30 mg/dL with normal mental status

C.Any ingestion with tinnitus

D.Any hyperventilating patient

Explanation: EXTRIP consensus indications for hemodialysis in salicylate poisoning include serum level >100 mg/dL (acute) or >90 mg/dL with impaired renal function, altered mental status, acute lung injury/pulmonary edema, refractory acidosis (pH ≤7.20), or need for ventilatory support. HD corrects acidosis and rapidly removes salicylate. Tinnitus alone indicates therapeutic or mildly elevated levels.

9A 28-year-old with a TCA overdose shows QRS of 140 ms, hypotension, and altered mental status. What is the first-line pharmacologic intervention?

A.IV sodium bicarbonate 1-2 mEq/kg bolus

B.IV calcium gluconate 1 g

C.IV magnesium sulfate 2 g

D.IV lidocaine 1 mg/kg

Explanation: TCA-induced QRS widening (>100 ms predicts seizures; >160 ms predicts ventricular dysrhythmias) reflects sodium-channel blockade of the His-Purkinje system. Sodium bicarbonate 1-2 mEq/kg bolus provides a sodium load (overcomes channel blockade) and alkalinization (reduces drug binding). Repeat boluses and target serum pH 7.50-7.55. Class Ia, Ic, and III antiarrhythmics are contraindicated.

10A patient with known atrial fibrillation on digoxin presents with nausea, confusion, hyperkalemia (6.4 mEq/L), bradyarrhythmia, and a digoxin level of 6 ng/mL. What is the definitive therapy?

A.Digoxin-specific Fab antibody fragments (DigiFab)

B.IV calcium gluconate to stabilize myocardium

C.IV insulin and glucose only

D.Urgent hemodialysis

Explanation: Digoxin-specific Fab fragments rapidly bind free digoxin and are the definitive antidote for digoxin toxicity. Indications include life-threatening arrhythmia, hyperkalemia >5 mEq/L in acute toxicity, end-organ dysfunction, or large ingestions. Empiric dosing: 10-20 vials acute unknown, 3-6 vials chronic. Hemodialysis does not remove digoxin (large Vd) and calcium in digoxin toxicity is controversial due to theoretical 'stone heart' risk.

About the ABEM Medical Tox Exam

The Medical Toxicology subspecialty certification exam is jointly administered by ABEM, the American Board of Preventive Medicine (ABPM), and the American Board of Pediatrics (ABP). It certifies physicians in the evaluation and management of poisoned patients, envenomations, drug overdoses, occupational and environmental toxicology, and substance-use disorders. Candidates must complete a 2-year ACGME-accredited Medical Toxicology fellowship after primary board certification.

Questions

200 scored questions

Time Limit

Full-day computer-based examination (approximately 4-5 hours)

Passing Score

Final score of 64 or greater (criterion-referenced)

Exam Fee

$470 application + $1,745 exam registration (American Board of Emergency Medicine (with ABPM and ABP))

ABEM Medical Tox Exam Content Outline

38%

Toxicants and Toxins

Acetaminophen, salicylates, TCAs, digoxin, beta-blockers/CCBs, iron, lithium, heavy metals, toxic alcohols, CO, cyanide, organophosphates, anticoagulants, newer drugs of abuse

14%

Principles of Toxicology

Toxicokinetics, dose-response, mechanisms of cellular injury, CYP450 metabolism, biomonitoring fundamentals

11%

Clinical Assessment

Toxidrome recognition, poisoned-patient approach, airway/hemodynamic stabilization, GI decontamination, diagnostic adjuncts

11%

Therapeutics

Antidotes (NAC, DigiFab, glucagon, HIE, lipid emulsion, fomepizole, methylene blue, hydroxocobalamin, atropine/pralidoxime), chelation, hemodialysis indications

Addiction Toxicology and Substance Use

Fentanyl analogs, synthetic cannabinoids, cathinones, GHB/GBL, withdrawal syndromes, MAT (buprenorphine/methadone/naltrexone)

Analytical and Forensic Toxicology

Immunoassay vs GC-MS/LC-MS confirmation, SAMHSA cutoffs, chain of custody, workplace drug testing, postmortem redistribution

Environmental Toxicology

Pesticides/herbicides, hydrocarbons, radiation, plants and mushrooms (Amanita), envenomations (snakes, spiders, marine)

Occupational Toxicology

OSHA PELs, NIOSH RELs, biological monitoring, PPE, occupation-specific toxicants (lead, solvents, isocyanates, asbestos)

Assessment and Population Health

Poison center epidemiology, outbreak investigation, risk communication, regulatory frameworks

How to Pass the ABEM Medical Tox Exam

What You Need to Know

Passing score: Final score of 64 or greater (criterion-referenced)
Exam length: 200 questions
Time limit: Full-day computer-based examination (approximately 4-5 hours)
Exam fee: $470 application + $1,745 exam registration

Keys to Passing

Complete 500+ practice questions
Score 80%+ consistently before scheduling
Focus on highest-weighted sections
Use our AI tutor for tough concepts

ABEM Medical Tox Study Tips from Top Performers

1Memorize the six classic toxidromes cold — anticholinergic (hot/dry/red/blind/mad), cholinergic (DUMBELS/SLUDGE), sympathomimetic, opioid (miosis/apnea), sedative-hypnotic, and serotonin syndrome vs NMS

2Master acetaminophen management — Rumack-Matthew nomogram, 21-hour IV NAC protocol (150 mg/kg loading + 50 mg/kg over 4h + 100 mg/kg over 16h), and when to extend therapy for massive ingestions

3Know TCA toxicity management — QRS >100 ms triggers sodium bicarbonate 1-2 mEq/kg bolus; also useful for salicylate alkalinization (target urine pH 7.5-8.0)

4Drill the osmolar gap + anion gap algorithm for toxic alcohols — methanol and ethylene glycol both get fomepizole 15 mg/kg loading dose and hemodialysis for severe acidosis or end-organ injury

5Study EXTRIP workgroup recommendations for hemodialysis — key indications include lithium >4 mEq/L or severe symptoms, salicylate >100 mg/dL or altered mental status, methanol/EG, valproate, and metformin-associated lactic acidosis

6Practice envenomation management — CroFab 4-6 vials initial dose for Crotalid bites with progression; know coral snake antivenom is back on market; brown recluse is supportive care only

Frequently Asked Questions

Who is eligible for the ABEM Medical Toxicology exam?

Candidates must hold primary board certification (or active candidacy) from ABEM, ABPM, or ABP and must successfully complete a 2-year ACGME-accredited Medical Toxicology fellowship. All three boards co-sponsor the same examination under ABMS. Applicants must also hold an active unrestricted medical license and actively participate in continuing certification for their primary board.

Is the Medical Toxicology exam the same across ABEM, ABPM, and ABP?

Yes. The written certification examination is identical across all three co-sponsoring boards. Candidates apply through whichever of the three boards holds their primary certification (ABEM for emergency physicians, ABPM for preventive medicine physicians, ABP for pediatricians), but all sit for the same exam. The 2021 Core Content of Medical Toxicology drives the content blueprint.

What is the ABEM Medical Toxicology exam format?

The exam is a full-day computer-based examination administered at Pearson VUE testing centers. It contains approximately 200 single-best-answer multiple-choice questions. Content is weighted most heavily in Toxicants and Toxins (38%), with additional coverage of Principles of Toxicology (14%), Clinical Assessment (11%), Therapeutics (11%), Addiction (8%), Environmental (5%), Occupational (5%), Analytical (5%), and Assessment/Population Health (3%).

What score do I need to pass the ABEM Medical Toxicology exam?

All candidates achieving a final score of 64 or greater on the scaled score will pass the examination. The scale is criterion-referenced and set through standard-setting methodology — it is not a simple percentage correct. Historical first-time pass rates are approximately 80-90% across the three co-sponsoring boards.

How much does the ABEM Medical Toxicology exam cost?

The 2026 fee structure is $470 application fee (nonrefundable) plus $1,745 exam registration fee, for a total of $2,215. The application fee covers processing only. Candidates who do not pass must pay both fees again for a retake. ACMT membership is optional and costs an additional $0-$500 depending on career stage.

How long should I study for the ABEM Medical Toxicology exam?

Most candidates study 200-400 hours over 6-12 months during the final year of fellowship. Preparation typically combines Goldfrank's Toxicologic Emergencies (canonical reference), ACMT Total Tox Review or Tintinalli's tox section, EXTRIP hemodialysis guidelines, and daily case-based study through the poison control service. Clinical fellowship experience at a high-volume poison center is the single strongest predictor of success.

What happens if I fail the ABEM Medical Toxicology exam?

Candidates who do not pass may re-apply in the next annual administration cycle (held each October). Both the $470 application fee and the $1,745 exam registration fee must be paid again for each attempt. There is no limit on the number of attempts, but candidates must maintain primary board certification in good standing throughout the process.

How do I maintain ABEM Medical Toxicology certification?

Medical Toxicology diplomates maintain certification through ABEM's MyToxCert continuous-certification program, which follows a 10-year cycle with annual self-assessment activities and CME requirements. No decennial recertification exam is required as long as the annual requirements and primary-board MOC are met in parallel.