USMLE® Step 1 & 2

Kaplan USMLE Step 2: Choking child comes to ED. What’s next?


If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 2 exam, you might want to know which questions are most often missed by test-prep takers. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series.

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A 5-year-old boy suddenly begins coughing while eating peanuts at home. When he is brought to the emergency department, his parents state that he has been choking and gagging for the past 15 minutes. He is awake and can give his name, but he continues to cough. On physical examination, he is afebrile, respirations are 30 per minute, pulse is 100 beats per minute, and blood pressure is 100/68 mm Hg in his right arm while seated. He is pink and well-perfused and has no stridor, wheezing, retractions or accessory muscle use.

Which of the following is the most appropriate initial step in management?

A. Allow the patient to clear the foreign object by spontaneous coughing.

B. Clear the oropharynx with multiple blind sweeps with a finger.

C. Intubate the patient.

D. Perform emergency tracheostomy and take the patient to surgery.

E. Position the patient and perform back blows.

F. Stand behind the patient and perform abdominal thrusts.













The correct answer is A.

In cases of foreign-object obstruction, if the patient can cough and breathe, it is best to initially observe and allow for spontaneous resolution. Forceful coughing can be more effective than other interventions in expelling a foreign object.

Parents can be taught this response during well-child care visits. Children who cannot produce a forceful cough should receive help, and back blows or abdominal thrusts are appropriate options for these patients. If unsuccessful, rigid bronchoscopy is the procedure of choice to identify and remove the foreign object.

Choice B: Blind finger sweeps should never be performed. The only time that finger-sweep clearance may be performed is in the initial evaluation of airway obstruction. The airway is first opened with a head-tilt/chin-lift maneuver and then inspected for a foreign body. Only if one is seen should an attempt be made to remove it with a visualized finger sweep.

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