Trauma is the second-most tested domain in the ACEM fellowship written exam. Questions test your ability to make rapid management decisions, interpret imaging, prioritise interventions, and recognise patterns of injury. This guide covers the high-yield topics and decision points that appear most frequently.
Primary survey and resuscitation priorities
Fellowship-level trauma questions go beyond listing the ABCDE approach. They test whether you can identify the immediately life-threatening problem in a complex multi-system scenario and select the correct priority intervention. Common exam scenarios present competing priorities — for example, a patient with both airway compromise and haemodynamic instability — and expect you to sequence your interventions correctly.
Haemorrhage control and massive transfusion
Massive transfusion protocols, damage control resuscitation, and the permissive hypotension approach are consistently tested. Key areas include indications for massive transfusion activation, component ratios (packed red cells, FFP, platelets), the role of tranexamic acid (including the time window for benefit), and when to consider REBOA or resuscitative thoracotomy.
High-yield injury patterns
Head injury
CT decision rules (Canadian CT Head Rule), management of raised intracranial pressure, indications for intubation, and the approach to anticoagulated patients with head injuries. Mild TBI management and return-to-activity guidance are also tested.
Cervical spine
Canadian C-spine Rule and NEXUS criteria, clearance in the obtunded patient, and management of specific injury patterns including hangman’s fracture, odontoid fractures, and bilateral facet dislocations.
Thoracic trauma
Tension pneumothorax management, massive haemothorax (indications for thoracotomy), cardiac tamponade recognition, and traumatic aortic injury. Understand the imaging findings for each and the management priorities.
Abdominal and pelvic trauma
FAST examination interpretation and limitations, the role of CT vs operative management, pelvic binder application, and the approach to solid organ injury (conservative vs operative management including the grading systems).
Orthopaedic emergencies
Open fracture classification and management, vascular injuries associated with specific fractures (e.g., popliteal artery with knee dislocation, axillary artery with proximal humerus fracture), and compartment syndrome recognition and management.
Special populations
Trauma in pregnancy, paediatric trauma (including non-accidental injury patterns), and elderly trauma (increased bleeding risk, atypical presentations, lower thresholds for investigation) are all tested regularly and present unique management challenges.
Imaging decisions
The exam frequently tests appropriate imaging selection: when to CT vs when clinical assessment is sufficient, the role of whole-body CT in major trauma, and interpretation of key findings on trauma CT. You should be comfortable identifying pneumothorax, haemoperitoneum, solid organ injury, and vascular injury on CT.
Practice tip: ACEMCQ has over 130 fellowship-standard trauma MCQs with image-based questions and referenced explanations. Start a free trial to test your trauma decision-making.