ABEM Emergency Medicine Qualifying Exam 2026: Comprehensive
Board Certification Practice Test — Trauma, Critical Care,
Cardiovascular Emergencies, Toxicology, Paediatric Emergencies &
Clinical Decision-Making — 190 Multiple-Choice Questions with
Answers & Detailed Rationales
SECTION 1: CARDIOVASCULAR DISORDERS
Question 1
A 58-year-old man presents with sudden-onset tearing chest pain radiating to the back.
Blood pressure is 180/95 mm Hg in the right arm and 145/80 mm Hg in the left arm. Chest
radiograph shows a widened mediastinum. Which of the following is the most appropriate
initial diagnostic study?
A. Transthoracic echocardiography
B. CT angiography of the chest
C. Coronary angiography
D. D-dimer assay
Correct Answer: B
Explanation: CT angiography is the gold standard for diagnosing aortic dissection, with
sensitivity and specificity approaching 100%. It rapidly visualizes the intimal flap, false
lumen, and extent of dissection. Transthoracic echocardiography has limited visualization of
the distal ascending aorta and arch. Coronary angiography is contraindicated as it may delay
definitive management and worsen outcomes. D-dimer has high negative predictive value
but low specificity.
,Clinical Pearl: The finding of a pulse deficit or interarm blood pressure differential >20 mm
Hg should immediately raise suspicion for aortic dissection.
Question 2
A 72-year-old woman with a history of hypertension and diabetes presents with 3 hours of
substernal chest pressure. ECG shows ST-segment elevation in leads II, III, and aVF. Which
coronary artery is most likely occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Left main coronary artery
Correct Answer: C
Explanation: ST elevations in leads II, III, and aVF indicate an inferior wall myocardial
infarction, which is most commonly caused by occlusion of the right coronary artery (80% of
cases). The left circumflex artery supplies the lateral wall and would show changes in leads I,
aVL, V5, and V6. The LAD supplies the anterior wall (V1-V4). Left main occlusion typically
presents with diffuse ST changes and hemodynamic instability.
Clinical Pearl: Inferior MI should prompt evaluation for right ventricular involvement; these
patients are preload-dependent and may become hypotensive with nitroglycerin
administration.
Question 3
A 45-year-old man presents with palpitations and lightheadedness. ECG shows a regular
narrow-complex tachycardia at 180 beats per minute. The patient is hemodynamically
stable. Which of the following is the most appropriate initial management?
,A. Synchronized cardioversion at 100 joules
B. Adenosine 6 mg rapid IV push
C. Amiodarone 150 mg IV over 10 minutes
D. Diltiazem 20 mg IV push
Correct Answer: B
Explanation: For stable narrow-complex tachycardia, adenosine is the first-line
pharmacologic agent for both diagnosis and treatment. It transiently blocks the AV node,
terminating AV nodal reentrant tachycardia and revealing underlying atrial activity.
Synchronized cardioversion is reserved for unstable patients. Amiodarone and diltiazem are
second-line agents or used for specific arrhythmias.
Clinical Pearl: Adenosine must be administered as a rapid bolus followed immediately by a
saline flush due to its very short half-life (<10 seconds).
Question 4
A 68-year-old man presents with progressive dyspnea, orthopnea, and bilateral lower
extremity edema. Examination reveals jugular venous distension, bibasilar crackles, and an
S3 gallop. Blood pressure is 160/90 mm Hg. Which of the following is the most appropriate
initial therapy?
A. Nitroglycerin infusion and furosemide
B. Dopamine infusion
C. Adenosine bolus
D. Atropine administration
Correct Answer: A
, Explanation: This presentation is consistent with acute decompensated heart failure with
volume overload and adequate perfusion pressure. Nitroglycerin reduces preload and
afterload, while furosemide provides diuresis. Dopamine is reserved for cardiogenic shock
with hypotension. Adenosine and atropine are inappropriate as they address arrhythmias,
not heart failure.
Clinical Pearl: Noninvasive positive pressure ventilation should be considered early in
patients with pulmonary edema and respiratory distress to improve oxygenation and reduce
intubation rates.
Question 5
A 24-year-old man sustains a stab wound to the left chest. He is hypotensive, tachycardic,
and has distended neck veins. Heart sounds are muffled. Which of the following is the most
appropriate immediate intervention?
A. Emergency department thoracotomy
B. Pericardiocentesis
C. Tube thoracostomy
D. Pericardial window in the operating room
Correct Answer: B
Explanation: Beck's triad (hypotension, distended neck veins, muffled heart sounds)
indicates cardiac tamponade. Pericardiocentesis is a temporizing measure to relieve
pericardial pressure and improve hemodynamics. Tube thoracostomy addresses hemothorax
or pneumothorax but not tamponade. Emergency thoracotomy is reserved for specific
penetrating trauma criteria. Pericardial window is diagnostic but performed in the OR.
Clinical Pearl: Pulsus paradoxus (systolic BP drop >10 mm Hg during inspiration) is a classic
finding in tamponade but may be absent in hypovolemic patients.
Board Certification Practice Test — Trauma, Critical Care,
Cardiovascular Emergencies, Toxicology, Paediatric Emergencies &
Clinical Decision-Making — 190 Multiple-Choice Questions with
Answers & Detailed Rationales
SECTION 1: CARDIOVASCULAR DISORDERS
Question 1
A 58-year-old man presents with sudden-onset tearing chest pain radiating to the back.
Blood pressure is 180/95 mm Hg in the right arm and 145/80 mm Hg in the left arm. Chest
radiograph shows a widened mediastinum. Which of the following is the most appropriate
initial diagnostic study?
A. Transthoracic echocardiography
B. CT angiography of the chest
C. Coronary angiography
D. D-dimer assay
Correct Answer: B
Explanation: CT angiography is the gold standard for diagnosing aortic dissection, with
sensitivity and specificity approaching 100%. It rapidly visualizes the intimal flap, false
lumen, and extent of dissection. Transthoracic echocardiography has limited visualization of
the distal ascending aorta and arch. Coronary angiography is contraindicated as it may delay
definitive management and worsen outcomes. D-dimer has high negative predictive value
but low specificity.
,Clinical Pearl: The finding of a pulse deficit or interarm blood pressure differential >20 mm
Hg should immediately raise suspicion for aortic dissection.
Question 2
A 72-year-old woman with a history of hypertension and diabetes presents with 3 hours of
substernal chest pressure. ECG shows ST-segment elevation in leads II, III, and aVF. Which
coronary artery is most likely occluded?
A. Left anterior descending artery
B. Left circumflex artery
C. Right coronary artery
D. Left main coronary artery
Correct Answer: C
Explanation: ST elevations in leads II, III, and aVF indicate an inferior wall myocardial
infarction, which is most commonly caused by occlusion of the right coronary artery (80% of
cases). The left circumflex artery supplies the lateral wall and would show changes in leads I,
aVL, V5, and V6. The LAD supplies the anterior wall (V1-V4). Left main occlusion typically
presents with diffuse ST changes and hemodynamic instability.
Clinical Pearl: Inferior MI should prompt evaluation for right ventricular involvement; these
patients are preload-dependent and may become hypotensive with nitroglycerin
administration.
Question 3
A 45-year-old man presents with palpitations and lightheadedness. ECG shows a regular
narrow-complex tachycardia at 180 beats per minute. The patient is hemodynamically
stable. Which of the following is the most appropriate initial management?
,A. Synchronized cardioversion at 100 joules
B. Adenosine 6 mg rapid IV push
C. Amiodarone 150 mg IV over 10 minutes
D. Diltiazem 20 mg IV push
Correct Answer: B
Explanation: For stable narrow-complex tachycardia, adenosine is the first-line
pharmacologic agent for both diagnosis and treatment. It transiently blocks the AV node,
terminating AV nodal reentrant tachycardia and revealing underlying atrial activity.
Synchronized cardioversion is reserved for unstable patients. Amiodarone and diltiazem are
second-line agents or used for specific arrhythmias.
Clinical Pearl: Adenosine must be administered as a rapid bolus followed immediately by a
saline flush due to its very short half-life (<10 seconds).
Question 4
A 68-year-old man presents with progressive dyspnea, orthopnea, and bilateral lower
extremity edema. Examination reveals jugular venous distension, bibasilar crackles, and an
S3 gallop. Blood pressure is 160/90 mm Hg. Which of the following is the most appropriate
initial therapy?
A. Nitroglycerin infusion and furosemide
B. Dopamine infusion
C. Adenosine bolus
D. Atropine administration
Correct Answer: A
, Explanation: This presentation is consistent with acute decompensated heart failure with
volume overload and adequate perfusion pressure. Nitroglycerin reduces preload and
afterload, while furosemide provides diuresis. Dopamine is reserved for cardiogenic shock
with hypotension. Adenosine and atropine are inappropriate as they address arrhythmias,
not heart failure.
Clinical Pearl: Noninvasive positive pressure ventilation should be considered early in
patients with pulmonary edema and respiratory distress to improve oxygenation and reduce
intubation rates.
Question 5
A 24-year-old man sustains a stab wound to the left chest. He is hypotensive, tachycardic,
and has distended neck veins. Heart sounds are muffled. Which of the following is the most
appropriate immediate intervention?
A. Emergency department thoracotomy
B. Pericardiocentesis
C. Tube thoracostomy
D. Pericardial window in the operating room
Correct Answer: B
Explanation: Beck's triad (hypotension, distended neck veins, muffled heart sounds)
indicates cardiac tamponade. Pericardiocentesis is a temporizing measure to relieve
pericardial pressure and improve hemodynamics. Tube thoracostomy addresses hemothorax
or pneumothorax but not tamponade. Emergency thoracotomy is reserved for specific
penetrating trauma criteria. Pericardial window is diagnostic but performed in the OR.
Clinical Pearl: Pulsus paradoxus (systolic BP drop >10 mm Hg during inspiration) is a classic
finding in tamponade but may be absent in hypovolemic patients.
