These six questions come from the trauma section of the ACEMCQ fellowship bank, in the form the bank presents them: a clinical stem, four options of the same shape, one best answer. Each was rewritten in September 2026 so that the key cannot be found by picking the longest option or by a give-away in the stem; the distractors are all things a registrar might reasonably choose. Answer before you reveal, and read the explanation even when you were right, because the explanation is where the marks in the SAQ paper live.
Trauma is the largest single category in the SAQ paper, at about 10% of marks across the last eleven sittings, and the SCQ paper draws on the same material. Our topic analysis has the detail; our trauma revision guide covers the ground these questions test.
The questions
Click an option to answer; the explanation opens straight away. Options are in a fixed order on this page; in the bank they shuffle.
A 4-month-old girl is brought to the emergency department by her mother, who noticed a bruise while dressing her and thinks she may have rolled against the cot rail. The infant is well, feeding normally and alert, with a 2 cm bruise over the left flank and no other findings on a full examination including fundoscopy.
Which is the MOST appropriate management?
Why the correct answer is best. A 4-month-old cannot yet roll reliably or move herself against a cot rail, and any bruise in an infant who is not independently mobile is a red flag for inflicted injury whatever the offered mechanism. The response has three parts that run together: the infant is admitted so that she is not returned to an unassessed environment; a full skeletal survey is performed within 24 hours because she is under two years of age; and the notification to child protection is made now, on reasonable suspicion, because mandatory reporting is triggered by the suspicion and not by the result of an investigation. A limited repeat skeletal survey at 14 days is part of the standard protocol whether or not the first survey is normal, because metaphyseal and rib fractures may only become visible once periosteal reaction develops. Head CT is added if there is external evidence of head trauma or any neurological abnormality; here there is neither.
Why the distractors are wrong. Waiting for the survey result before notifying reverses the legal duty and delays the multidisciplinary assessment, and dropping the repeat survey when the first is normal misses the fractures that are occult in the first fortnight. Discharge to the carer before the assessment is complete returns the infant to the setting in which the injury occurred. Deferring the initial survey to 14 days abandons the information it gives now and leaves the infant unprotected in the interval.
References: RCH Melbourne Clinical Practice Guideline, Child abuse (any bruise or soft-tissue injury in an infant aged 0–5 months is a red-flag finding; fundoscopy in all) https://www.rch.org.au/clinicalguide/guideline_index/Child_abuse/; RANZCR Guideline for Imaging of Suspected Non-Accidental Injury, v1.0, October 2022 (skeletal survey in all suspected abuse under two years; limited repeat survey at 14 days and no later than 28; head CT for abnormal neurology or external evidence of head trauma); Cameron, paediatric trauma and non-accidental injury.
A 24-year-old man presents 40 minutes after a single stab wound to the left chest in the anterior axillary line at the level of the sixth rib. He is alert, BP 124/78 mmHg, HR 88/min, SpO2 98% on air. Breath sounds are equal, the abdomen is soft and non-tender, chest X-ray is normal and the FAST is negative.
Which is the MOST appropriate next step?
Why the correct answer is best. A wound between the nipple line and the costal margin is thoracoabdominal, and a left-sided one can lacerate the diaphragm without producing any sign on examination, chest X-ray or FAST. A diaphragmatic laceration does not heal, and the pressure gradient between the abdomen and the chest draws bowel through it months or years later, when it presents as obstruction or strangulation with a high mortality. In a haemodynamically stable patient without peritonitis the injury is excluded by looking at the diaphragm directly, and the Eastern Association for the Surgery of Trauma guideline conditionally recommends laparoscopy over CT for this purpose in left thoracoabdominal stab wounds; the same procedure allows repair.
Why the distractors are wrong. CT is the right test for solid-organ and vascular injury but is insensitive for a small diaphragmatic laceration, so a normal scan does not exclude the injury and discharge on that basis is the mechanism of the delayed presentations. Serial examination detects hollow-viscus and solid-organ injury but not an isolated diaphragmatic laceration, which is asymptomatic until herniation. Local wound exploration is used for anterior abdominal stab wounds to establish fascial penetration; it cannot assess the diaphragm and risks converting a sealed pleural breach into a pneumothorax.
References: McDonald AA et al. Evaluation and management of traumatic diaphragmatic injuries: a Practice Management Guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2018;85:198–207; Cameron, thoracic injuries (diaphragmatic injury) and abdominal trauma (penetrating).
A 52-year-old man admitted 36 hours ago after a high-speed motor-vehicle collision had a damage-control laparotomy and external fixation of an open femoral fracture on the day of arrival. He was extubated this morning and is now alert on the ward. During routine care he reports pain in the left wrist on passive movement; the wrist was not examined or imaged on arrival.
Which is the MOST appropriate action?
Why the correct answer is best. The tertiary survey is a repeat head-to-toe examination with a re-review of every image and blood result, performed within 24 hours of admission and repeated once the patient is awake and able to localise pain. Its purpose is to find the injuries hidden on arrival by intubation, sedation, shock and the competing major injuries, and about one major-trauma patient in ten has a missed injury found this way, most often a limb fracture. This patient has just become able to cooperate and has already declared one missed injury; a wrist that was never examined is a signal that other regions were not either, so the whole survey is done now rather than the one joint that happens to hurt.
Why the distractors are wrong. Treating the wrist alone and postponing the survey to discharge planning leaves the other missed injuries undetected for the length of the admission. The secondary survey on arrival is not a substitute: it was performed on a shocked patient who was intubated soon after, which is precisely the situation the tertiary survey exists to correct. Waiting for the fixator to come off delays the survey by weeks; the examination is adapted around the device, not deferred for it.
References: Cameron, initial management of the trauma patient (tertiary survey); Royal Australasian College of Surgeons, Australian Trauma Quality Improvement Program guidance on the tertiary survey.
A 44-year-old man is brought to the resuscitation bay after a high-speed motor vehicle collision. BP is 64/40 mmHg, HR 138/min despite 4 units of red cells and 4 units of plasma. FAST is positive in Morrison's pouch and the pelvis, and there is gross pelvic instability. He has no penetrating chest injury and is in extremis without cardiac arrest. The team has experience and equipment for both REBOA and emergency thoracotomy.
Which is the MOST appropriate next intervention?
Why the correct answer is best. In exsanguinating sub-diaphragmatic haemorrhage from blunt trauma without cardiac arrest, REBOA in zone 1 (descending thoracic aorta) provides temporary haemorrhage control and increases proximal perfusion as a bridge to definitive operative or interventional control. Cameron describes REBOA as a developing technique for traumatic abdominal and pelvic exsanguination.
Why the distractors are wrong. Resuscitative thoracotomy with aortic cross-clamping carries higher morbidity than REBOA and is preferred for penetrating chest trauma with cardiac arrest or imminent arrest. Transfer to CT and angioembolisation is the pathway for the haemodynamically stable patient or the responder: the WSES 2017 guideline reserves CT for patients who are stable or have stabilised, and a non-responder with a systolic pressure of 64 mmHg spends the time in the scanner and the angiography suite bleeding. It also does nothing for the intra-abdominal source shown by the FAST, which needs laparotomy; angioembolisation is complementary to packing and surgery, not a substitute for them. Continued transfusion alone — without haemorrhage control — does not address the source of bleeding and accepts ongoing blood-product consumption.
Discussion. REBOA is the answer this stem is built to test, but the evidence for it is thin and the only randomised trial points the other way. UK-REBOA (Jansen et al, JAMA 2023) randomised 90 trauma patients with exsanguinating haemorrhage in 16 UK major trauma centres to REBOA plus standard care or standard care alone and was stopped early at a pre-specified harm boundary: 90-day mortality was 54% with REBOA against 42% without (odds ratio 1.58, 95% credible interval 0.72 to 3.52, posterior probability of harm 87%). The large propensity-matched registry analysis before it (Joseph et al, JAMA Surgery 2019, ACS TQIP 2015 to 2016) found REBOA associated with higher mortality, more acute kidney injury and more lower-limb amputation than matched controls. Defenders argue that the trial's patients were too sick, that balloon times were long and that the technique is operator-dependent; critics reply that this is the population the device is meant for. In Australasia REBOA remains confined to a few centres under protocol and is not standard care, and a candidate who wrote that the patient should go straight to theatre with a binder on would not be marked down in an SAQ. For this MCQ the question is which of the four options is best in a centre that has chosen to use the device; in the exam, the safer general statement is that REBOA is an unproven bridge, not an established treatment.
References: Cameron 6e Section 3.5 — Abdominal trauma, future directions, REBOA; Cameron 6e Section 3.12 — Major haemorrhage, damage-control; Jansen JO et al. Emergency department resuscitative endovascular balloon occlusion of the aorta in trauma patients with exsanguinating hemorrhage: the UK-REBOA randomized clinical trial. JAMA 2023;330:1862–1871; Joseph B et al. Nationwide analysis of resuscitative endovascular balloon occlusion of the aorta in civilian trauma. JAMA Surg 2019;154:500–508; Brenner M et al. Joint statement from the ACS COT and ACEP regarding the clinical use of REBOA. Trauma Surg Acute Care Open 2018;3:e000154; Coccolini F et al. Pelvic trauma: WSES classification and guidelines. World J Emerg Surg 2017;12:5 https://pmc.ncbi.nlm.nih.gov/articles/PMC5241998/.
A 70-year-old woman on apixaban for atrial fibrillation falls and is brought to the emergency department with reduced GCS. CT brain shows an acute subdural haematoma with mass effect. Her last apixaban dose was approximately 6 hours ago.
Which is the most appropriate reversal strategy?
Why the correct answer is best. Apixaban is a direct factor Xa inhibitor, and a subdural haematoma with mass effect six hours after a dose is life-threatening bleeding that is reversed immediately. Since the Australian registration of andexanet alfa lapsed in May 2026 there is no specific antidote, and the Australian and New Zealand guidance endorsed by THANZ (2025) gives four-factor prothrombin complex concentrate 25 to 50 U/kg, or a fixed 2,000 IU, for major bleeding on a factor Xa inhibitor; 50 IU/kg is the dose most protocols use for intracranial bleeding. It is given at once, with tranexamic acid where local protocol includes it, blood pressure control and urgent neurosurgical referral, without waiting for an anti-Xa level.
Why the distractors are wrong. Andexanet alfa is the specific factor Xa inhibitor reversal agent and the regimen given is the correct low-dose one for apixaban, but it cannot be chosen in Australia: the TGA’s provisional registration lapsed on 21 May 2026 and the product is no longer supplied. Its evidence was also equivocal. In ANNEXA-I, the only randomised trial, andexanet controlled haematoma expansion better than usual care in factor Xa inhibitor-associated intracerebral haemorrhage (haemostatic efficacy 67% against 53%) but caused more thrombotic events (10.3% against 5.6%, including ischaemic stroke in 6.5% against 1.5%) with no difference in 30-day mortality or functional outcome, and usual care in that trial was mostly prothrombin complex concentrate. Fresh frozen plasma contains too little factor X to overcome the drug and adds volume and delay. Idarucizumab is the antibody fragment for dabigatran, a direct thrombin inhibitor, and does nothing for apixaban.
References: Tran H et al. Anticoagulant reversal and management of bleeding on direct oral anticoagulants: Australian and New Zealand guidance endorsed by THANZ. Intern Med J 2025;55:1174 (https://onlinelibrary.wiley.com/doi/10.1111/imj.70103); Therapeutic Goods Administration, Lapse of provisional registration for Andexxa, 21 May 2026 (https://www.tga.gov.au/news/news-articles/lapse-provisional-registration-andexxa-andexanet-alfa-used-factor-xa-inhibitor-apixabanrivaroxaban-reversal); Connolly SJ et al. Andexanet for factor Xa inhibitor-associated acute intracerebral hemorrhage (ANNEXA-I). N Engl J Med 2024;390:1745–1755; Cameron's Textbook of Adult Emergency Medicine, anticoagulant reversal and head injury.
A 25-year-old woman is brought to the emergency department after a low-speed motor-vehicle collision. She is intoxicated with alcohol, GCS 14 with confusion, and has no focal neurological deficit and no injury other than a forehead abrasion. She was moved off the extrication board on arrival and remains in a cervical collar. A CT of the cervical spine with multiplanar reconstruction is reported as normal.
Which is the MOST appropriate management of the collar?
Why the correct answer is best. Intoxication and an altered conscious state mean she cannot be cleared clinically, so the decision rests on the imaging. A normal high-quality multiplanar CT is enough. In the Western Trauma Association prospective multicentre study of 10,191 blunt trauma patients, CT in the intoxicated subgroup had a negative predictive value of 99.5% for any cervical spine injury, 99.9% for clinically significant injury and 100% for unstable injury, and the authors concluded that intoxication should not delay collar removal after a normal scan. The Eastern Association for the Surgery of Trauma reached the same position for the obtunded patient in 2015 with a conditional recommendation to remove the collar after a negative high-quality CT. The collar comes off now; she is nursed with routine care and re-examined when sober, and any new neck pain or neurological symptom then is investigated on its merits.
Why the distractors are wrong. Keeping the collar until she is sober adds hours of an uncomfortable device that causes pressure injury, raises intracranial pressure and provokes agitation in an intoxicated patient, for a clinical examination that adds nothing after a normal CT in this population. MRI detects ligamentous and soft-tissue signal that is common after blunt trauma and almost never changes management when the CT is normal; it delays clearance, requires a cooperative or sedated patient, and is reserved for persisting neurological signs or symptoms. Flexion–extension radiographs have no place in acute clearance: they are inadequate in a large proportion of patients, painful, and do not add to a normal CT.
Discussion. Many Australian departments still hold the collar until a reliable examination is possible, on the grounds that a purely ligamentous injury can be present with a normal CT. That injury exists but is rare, is almost always accompanied by CT findings when unstable, and was not missed in the prospective data above. Where a local protocol mandates re-examination when sober, following it is reasonable; the evidence does not require it.
References: Martin MJ et al. Cervical spine evaluation and clearance in the intoxicated patient: a prospective Western Trauma Association multi-institutional trial and survey. J Trauma Acute Care Surg 2017;83:1032–1040; Patel MB et al. Cervical spine collar clearance in the obtunded adult blunt trauma patient: a systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2015;78:430–441; Cameron, spinal trauma (clearing the spine).
Frequently asked questions
Are these real ACEMCQ bank questions?
Yes. They are six questions from the trauma category of the ACEMCQ fellowship bank, shown exactly as subscribers see them, with the same referenced explanations. They remain in the bank.
Who writes the ACEMCQ questions?
Emergency clinicians, led by Dr Liam Stephens FACEM. Every topic is reviewed on a rolling annual cycle against current Australasian sources, and these six were rewritten in September 2026 as part of that review.
How many trauma questions are in the full bank?
154 at the time of writing, within a bank of more than 2,000 fellowship MCQs and 700 SAQs across 24 topic categories. The free trial gives access without a card.