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 36-year-old man is brought to the emergency department 20 minutes after being knocked unconscious while swimming in the ocean. He received basic life support with rescue breaths and regained consciousness after he was pulled from the ocean. On arrival, he is alert and in moderate respiratory distress.

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

A. Abdominal thrusts.

B. Continuous positive airway pressure.

C. Prophylactic antibiotics.

D. Steroid administration.

E. Tracheostomy.

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The correct answer is B.

When a patient experiences near-drowning, the first thing that needs to be done is removal from water, followed by securing the airway and other basic life support measures, including ABC (airway, breathing, circulation), stabilizing the spine, intubation, supplemental oxygen, and positive pressure mechanical ventilation, if needed.

The patients who gain consciousness but are still having difficulty breathing may develop hypoxia and acidosis. Continuous positive airway pressure (CPAP) is the most effective treatment and gives the best correction of hypoxia and acidosis in such cases. Even a stable patient needs to be observed for at least 24 hours, as adult respiratory distress syndrome (ARDS) may develop as a late complication.

Choice A: Abdominal thrusting is considered an ineffective treatment and may actually harm the patient, as it may lead to aspiration of gastric contents.

Choices C and D: Administration of prophylactic antibiotics or steroids are not the appropriate interventions at this time. Antibiotics may be needed if the patient develops pneumonia. Steroids may be used as a part of management if ARDS develops.

Choice E: If the patient is not breathing despite basic life support measures, it may be because of laryngospasm, a response to being immersed in fluid that may cause "dry drowning." Tracheostomy in apneic patients who do not respond to BLS would be necessary. This patient on the other hand is only having difficulty breathing, and CPAP would be the most appropriate management.

CPAP is the most effective treatment in near-drowning episodes to improve both hypoxia and acidosis.

For more prep questions on USMLE Steps 1, 2 and 3, view other posts in this series.

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