Treatment Algorithms on Anesthesiology Board Exams

For the most part, clinical knowledge is tested by the medical board exams. Assessment of knowledge about treatment interventions are common questions on the anesthesiology board exams. Primarily, three different treatment aspects can be tested:

• Details about specific treatment interventions
• Treatments of disease variants and in particular populations
• Treatment algorithms

This post focuses on treatment algorithms. Treatment algorithms are the ordering of treatment interventions, ranking them from the first-line treatments followed by second-, third-, and fourth-line treatments, eventually ending at the last-line treatments at a certain level.

On the exam, questions sometimes present a case vignette in which the patient should be prescribed a first-line treatment intervention, AND a first-line treatment is an option available in the response options.

Such a question is considerably easier, as it only tests knowledge about first-line treatments. Two scenarios exist for which such questions are appropriate for the board exam: One, for rare disorders because you are not expected to have more than basic knowledge regarding clinical management. And two, for common disorders which are usually treated by a physician from a different specialty; the expectation is that in your specialty you should know only the basics of the disorder’s presentation, diagnostic tools, and management. For example: an anesthesia-related condition being tested on the internal or family medicine boards, or an emergency medicine disorder being tested on anesthesia boards.

Another type of question on the board exams can present a clinical case vignette that tests knowledge regarding treatment interventions at lower levels of the algorithm like second, third, fourth, or further down the stages. There are two ways to structure such types of questions:

The first way is to clearly describe in the vignette that the patient is NOT suitable for first-line treatment. For example, the case vignette may state that the patient is allergic to a specific first-line treatment drug, has a history of poorly responding to first-line treatment, or had a severe adverse reaction to a prior trial of a first-line treatment. Hence, you have been given a reason in the vignette to look for treatment interventions other than the first line treatments from the options available.

The second approach is to force you to choose an option with a second-line or lower treatment intervention by not providing a first-line treatment intervention in the response options. The question vignette presents a straightforward case in which the patient should be prescribed first-line treatment, but since the response options do not include a first-line treatment intervention, you are forced to choose the most appropriate option from the available ones.

Example Exam Question from Anesthesia

Question: A 25-year-old woman is admitted for an elective cesarean section. After the perioperative assessment, she is taken into the operative room for the induction of anesthesia. The anesthetist is unable to intubate the patient for ventilation. Which of the following is the next appropriate step in the management of this patient?

1. Bag and Mask Ventilation
2. Laryngeal Mask Ventilation
3. Cricothyrotomy
4. Proceed with regional anesthesia
5. Fiber-optic intubation

Question Explanation

In the case of unanticipated failed intubation, the first-line intervention is to use the bag and mask ventilation (BMV) with cricoid pressure if needed. If BMV is not adequate, then laryngeal mask ventilation (LMV) can be used. Further, if LMV is unable to ventilate the patient adequately, a cricothyrotomy can be performed for ventilation before proceeding for cesarean section. When the anesthetist fails to intubate the patient on the first attempt, and first-line intervention with BMV is adequate, the anesthetist should scan monitors for SpO2, heart rate, and blood pressure, call for a skilled person to help, call for a difficult airway cart, and should inform the obstetrician before attempting to intubate the patient again. If the second attempt also fails, BMV along with cricoid pressure should be used. If BMV is adequately ventilating the patient, the anesthetist should then proceed with regional anesthesia in case of an elective cesarean section or use fiberoptic intubation in case of a cesarean section due to a maternal emergency.

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