Anesthesiology APPLIED Exam › Exam skills and answer structure

Handling the mid-case complication

Exam skills and answer structure·~5 min read· Physician-reviewed✓ Sourced · 2

Stem

A 55-year-old woman, 68 kg, is having a posterior fossa craniotomy in the sitting position under general anesthesia. You have just finished explaining your maintenance plan when the examiner says, "Ninety minutes in, the end-tidal CO2 suddenly falls from 34 to 18 mmHg and the blood pressure drops to 75/40." She looks at you and waits.

Question

What is happening, and what do you do?

Ideal answer

HeadlineSudden end-tidal CO2 fall with hypotension in a sitting craniotomy: venous air embolism until proven otherwise. My loop: recognize, communicate, treat, reassess.

Recognize: the dangerous cause first, with the simple ones in the same breath: disconnection, measurement error.
Communicate: one sentence to the surgeon, "I think this is air; flood the field now": the surgeon stops entrainment faster than any drug. Help with a purpose: a second pair of hands, the pressors.
Treat one step at a time: 100% oxygen, nitrous off if running (it expands air); aspirate any right atrial catheter; head lowered if the surgeon can, raising venous pressure at the wound; phenylephrine 100 mcg.
Reassess: "If the pressure is not recovering within two minutes, I escalate." Surgery pauses until she is stable; I say so.
Then I stop: the loop showed all four attributes; the next inject is coming.

Breaking down the answer

Why the inject exists — adaptability to unexpected clinical changes is an attribute the ABA names for the SOE,¹ gradable only by changing something: recognizing a problem from raw data, communicating, treating the most dangerous cause first, reassessing while the original plan runs.
Where injects land — the ABA sample writes them into every block, usually once the candidate has settled: saturation 90% after 20 minutes of one-lung ventilation, a torn pulmonary vein, 50/35 in a sitting craniotomy, new ST elevation 8 hours after surgery.²
Dangerous before likely — the examiner is testing whether I would miss what kills. Naming hypovolemia first when the stem supports tension pneumothorax reads as a judgment failure, even if hypovolemia is more common.
The simple list — disconnection, light anesthesia, measurement error, the surgeon's hand on the vena cava. "While I confirm the monitor is real" shows organization without delaying treatment.
Why the surgeon — in most injects the surgeon can stop the cause: flood the field, release the retractor, deflate the abdomen. Treating silently leaves out the most effective intervention.
A reassessment point after each move — "I give 100 mcg phenylephrine and look at the pressure in 60 seconds" is a plan the examiner can follow. Five simultaneous interventions read as panic.
Keep the original case running — I state whether surgery continues, pauses or aborts. Help without a purpose (a second pair of hands, a specific drug, the airway cart) is noise.

Follow-up question

You treat, and the examiner says, "The pressure is still 60 systolic." A moment later you realize you do not recognize the pattern she is describing. What now?

Follow-up answer

HeadlineThe scored attribute is now adaptability, and repeating the same intervention louder loses it; I say so and escalate along a stated path.

A second cause, a stronger drug, a different route: "Phenylephrine did not work, so this is not pure vasodilation; I move to epinephrine, I ask the surgeon to stop, and I look at the right heart with echo if available." If I still cannot name the diagnosis, I treat the physiology I can see: oxygen, pressure, rhythm, ventilation, in that order, while I say what I am looking for, and reassess after each step. If the examiner moves on before it resolves, I let it go; returning to an unfinished inject reads as disorganized.

Pitfalls that cost points

Asking for a laboratory result or a chest film before doing anything; the examiner gives the data after I act, not instead.
Running through a memorized differential of twelve causes without saying which one I treat first.
Treating the number: 70 in a chronically hypertensive patient with an open skull is not 70 in a young trauma patient, and I say which.
Reporting the resolution before the examiner gives it; I do not get to decide that the patient got better.

Rapid-fire

Q: Why state the dangerous cause first even when I doubt it? A: The examiner scores whether I would miss a lethal diagnosis; saying it and excluding it costs five seconds and shows judgment.

Q: What if the inject is outside my practice, such as a pediatric arrest? A: The loop is the same; I run it on the physiology, state the weight-based drugs I know, and name the help I call.

Q: When do I abort the case? A: When the patient's safety requires an intervention the surgery prevents, or when the cause cannot be controlled with the surgery ongoing; I say this and let the surgeon argue.

Q: Can I ask the examiner for data? A: Yes, once I have acted on what I have; "after the first dose, what is the pressure?" is a reassessment and is scored well.

Numbers to know

Item	Value
Loop	Recognize, communicate, treat, reassess
Time to say the loop	~30 s
Reassessment window	1–2 min per intervention
Injects, ABA sample	Several per session, in every block²
Intra-op block, session 1 (sample)	10 min²
Intra-op block, session 2 (sample)	15 min²

Sources

1.APPLIED Exam · ABA · theaba.org
2.Sample Standardized Oral Exam Questions · ABA · theaba.orgPublic sample; block names and minutes are taken from the sample sessions.

Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.