SAEM FINAL EXAM ACTUAL QUESTIONS AND ANSWERS
GRADED A+
✔✔A 24 year old woman is playing racquetball and sustains a direct blow from the ball
to the right eye. She presents to the emergency department complaining of eye pain
and double vision. On exam, her right eye does not track properly with upward gaze.
This finding suggests which of the following injuries?
A. Inferior orbital wall fracture
B. Superior orbital rim fracture
C. Ethmoid fracture
D. Zygomatic arch fracture
E. Inferior orbital rim fracture - ✔✔A. Inferior orbital wall fracture
The patient most likely has an orbital floor fracture with entrapment.
✔✔A 32 year old man is struck several times in the head with a baseball bat. Upon
emergency medical service arrival, he is mildly confused, vomits once, and complains of
a severe headache. The emergency medical technicians establish two large-bore IVs.
Prior to arrival at the emergency department, he loses consciousness and begins to
seize. He is actively seizing when he is brought into the trauma bay. What should be the
first step in the management of this patient?
A. Administration of phenytoin 1000mg IV
B. Administration of mannitol 50 g IV
C. Rapid sequence intubation using paralytic agent
D. Emergency craniotomy
E. Administration of 2 liters NS bolus - ✔✔C. Rapid sequence intubation using paralytic
agent
The airway should be managed as the first priority in this patient. The other maneuvers
may be helpful but are secondary to securing an airway and providing
oxygenation/ventilation. Airway comes first!
✔✔A 46 year old man is brought in by EMS after a motor vehicle collision in which he
was an unrestrained driver. Although he has no obvious injury to his head or neck, he
complains of chest pain and appears very short of breath. His vital signs are: T 99.2 F,
BP 85/57, HR 123, RR 36, SpO2 95% on non-rebreather. The CXR demonstrates a
tension pneumothorax. Of the following, which is the most appropriate next step in this
man's care?
A. Placement of a chest tube followed by a chest xray to determine proper placement
B. Transfusion of 2 units of O-negative packed red blood cells
C. Performance of a chest CT scan to further delineate the pathology
D. Placement of a needle decompression device, followed by repeat CXR - ✔✔D.
Placement of a needle decompression device, followed by repeat CXR
,This patient needs emergent chest decompression and this is rapidly done by needle
thoracostomy. A chest CT may be performed, but only once he is stabilized. A formal
chest tube will be placed, but placement may not be rapid enough and he may
decompensate in the meantime. Transfusion of blood does nothing to correct the
physiology of a tension pneumothorax
✔✔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 - ✔✔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.
✔✔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 - ✔✔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.
✔✔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. - ✔✔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.
✔✔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 - ✔✔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 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.
✔✔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 - ✔✔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.
✔✔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 - ✔✔D. proptosis
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.
✔✔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 - ✔✔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.
✔✔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
B. ruptured anterior chamber
C. subconjunctival hemorrhage
D. hyphema
E. globe rupture - ✔✔C. subconjunctival hemorrhage
The answer is C. The subconjunctival blood as depicted in this patient, can be expected
to resorb without intervention over days to weeks. The figure does not suggest rupture
GRADED A+
✔✔A 24 year old woman is playing racquetball and sustains a direct blow from the ball
to the right eye. She presents to the emergency department complaining of eye pain
and double vision. On exam, her right eye does not track properly with upward gaze.
This finding suggests which of the following injuries?
A. Inferior orbital wall fracture
B. Superior orbital rim fracture
C. Ethmoid fracture
D. Zygomatic arch fracture
E. Inferior orbital rim fracture - ✔✔A. Inferior orbital wall fracture
The patient most likely has an orbital floor fracture with entrapment.
✔✔A 32 year old man is struck several times in the head with a baseball bat. Upon
emergency medical service arrival, he is mildly confused, vomits once, and complains of
a severe headache. The emergency medical technicians establish two large-bore IVs.
Prior to arrival at the emergency department, he loses consciousness and begins to
seize. He is actively seizing when he is brought into the trauma bay. What should be the
first step in the management of this patient?
A. Administration of phenytoin 1000mg IV
B. Administration of mannitol 50 g IV
C. Rapid sequence intubation using paralytic agent
D. Emergency craniotomy
E. Administration of 2 liters NS bolus - ✔✔C. Rapid sequence intubation using paralytic
agent
The airway should be managed as the first priority in this patient. The other maneuvers
may be helpful but are secondary to securing an airway and providing
oxygenation/ventilation. Airway comes first!
✔✔A 46 year old man is brought in by EMS after a motor vehicle collision in which he
was an unrestrained driver. Although he has no obvious injury to his head or neck, he
complains of chest pain and appears very short of breath. His vital signs are: T 99.2 F,
BP 85/57, HR 123, RR 36, SpO2 95% on non-rebreather. The CXR demonstrates a
tension pneumothorax. Of the following, which is the most appropriate next step in this
man's care?
A. Placement of a chest tube followed by a chest xray to determine proper placement
B. Transfusion of 2 units of O-negative packed red blood cells
C. Performance of a chest CT scan to further delineate the pathology
D. Placement of a needle decompression device, followed by repeat CXR - ✔✔D.
Placement of a needle decompression device, followed by repeat CXR
,This patient needs emergent chest decompression and this is rapidly done by needle
thoracostomy. A chest CT may be performed, but only once he is stabilized. A formal
chest tube will be placed, but placement may not be rapid enough and he may
decompensate in the meantime. Transfusion of blood does nothing to correct the
physiology of a tension pneumothorax
✔✔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 - ✔✔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.
✔✔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 - ✔✔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.
✔✔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. - ✔✔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.
✔✔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 - ✔✔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 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.
✔✔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 - ✔✔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.
✔✔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 - ✔✔D. proptosis
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.
✔✔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 - ✔✔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.
✔✔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
B. ruptured anterior chamber
C. subconjunctival hemorrhage
D. hyphema
E. globe rupture - ✔✔C. subconjunctival hemorrhage
The answer is C. The subconjunctival blood as depicted in this patient, can be expected
to resorb without intervention over days to weeks. The figure does not suggest rupture
