Case: De-escalate before you sedate

Candidate brief (2 minutes reading)

You are the paediatric consultant on. A 15-year-old is brought to the emergency department by ambulance after an unknown ingestion at a party. He is severely agitated, has struck a paramedic, and is screaming that he is being chased. Observations: temperature 39.0 degrees Celsius, heart rate 155, blood pressure 175 over 105, respiratory rate 28, SpO2 96 percent in room air. He has mydriasis, diaphoresis, inducible clonus and hyperreflexia. Behavioural Activity Rating Scale 7. Bedside glucose 5.8 millimoles per litre. The cubicle is crowded with ambulance crew, security and onlookers. His parents have not yet arrived.

You have a registrar, a senior nurse, a junior doctor, an enrolled nurse, and a security officer available.

Encounter

The examiner plays the role of the registrar and the senior nurse, and feeds information as the candidate proceeds.

Phase 1: Safety, team and primary survey (5 minutes)

The candidate is expected to:

• Ensure safety first. Clear the cubicle of onlookers and of hazards, move other patients, ensure the exit is clear, and ask the security officer to wait outside the cubicle (visible but not confrontational). [1]
• Name the leader and assign roles. Self as team leader; registrar to lead the de-escalation and airway assessment; senior nurse to prepare monitoring, draw up medications, and act as airway observer; junior doctor to obtain collateral from the ambulance crew; enrolled nurse to clear the environment and prepare a low-stimulation space. [1]
• Run a primary survey adapted for agitation. Airway patent; breathing at 28 per minute with SpO2 96 percent; circulation with heart rate 155 and blood pressure 175 over 105, capillary refill 2 seconds; disability with GCS approximately 13 (agitated, opens eyes, vague verbal, localising), pupils 6 mm reactive, mydriasis, inducible clonus and hyperreflexia; exposure with diaphoresis and a core temperature of 39.0 degrees Celsius. [1] [7]
• Recognise the toxidrome. The combination of severe agitation, autonomic surge, mydriasis, diaphoresis, hyperreflexia, inducible clonus and hyperthermia is most consistent with severe sympathomimetic intoxication (methamphetamine, MDMA, cocaine) with possible serotonin syndrome. The candidate names this and calls for early toxicology and senior psychiatric input. [7]

Phase 2: Investigation and resuscitation (5 minutes)

• Send a focused set of investigations. Venous blood gas, electrolytes including magnesium and calcium, creatine kinase (given the severe agitation and hyperthermia, with rhabdomyolysis risk), renal function, blood glucose (already 5.8), paracetamol and salicylate levels (co-ingestion always considered), a blood ethanol, a 12-lead ECG (methamphetamine and likely antipsychotic use both prolong the QT interval), and a urine drug screen as a clinical tool with known limitations. [7] [9]
• Begin physiological resuscitation. Active cooling for the hyperthermia (exposure, fan, cool intravenous fluids, ice packs to groins and axillae); intravenous fluids for the tachycardia and likely dehydration; benzodiazepine as first-line pharmacological therapy (titrated intravenously to effect) to reduce the sympathetic surge, settle the agitation, lower the temperature and reduce muscle activity; continuous pulse oximetry, ECG, respiratory rate, sedation score and blood pressure. [7]

Phase 3: Pharmacological approach (5 minutes)

• Defend the benzodiazepine-first choice. Benzodiazepines are first-line in sympathomimetic intoxication because they treat the sympathetic surge, the muscle activity and the temperature; they are reversible with flumazenil (with caution about seizure threshold); and they avoid the additive QT prolongation of an antipsychotic in a methamphetamine-intoxicated patient. [7]
• Reserve the antipsychotic for refractory agitation, with ECG monitoring. Droperidol or olanzapine as a second-line agent if agitation is refractory to benzodiazepine, with continuous ECG monitoring because both the methamphetamine and the antipsychotic prolong the QT interval; a QTc of greater than 460 to 480 ms in adolescents is concerning, and greater than 500 ms is high risk for torsades de pointes. [8] [9]
• Explicitly avoid the olanzapine-benzodiazepine combination without close monitoring. The candidate names the FDA warning on the combination of intramuscular olanzapine with a parenteral benzodiazepine, and explains that in this adolescent they would choose an agent from a different class if escalation is needed (for example droperidol), give it sequentially, and intensify airway and sedation monitoring with reversal agents immediately available. [1] [1]
• Note that oral is not appropriate here. The adolescent is too agitated to accept oral medication safely; the oral-first approach supported by the PEAChY-O trial applies where the child will accept oral, and this child will not. [4]

Phase 4: Restraint as a last resort (3 minutes)

• Brief physical restraint may be required initially. The candidate describes how restraint is conducted by a trained team with a named leader, in an upright or side position with the airway visible at all times, never face-down and never in a hobble, for the minimum duration, with continuous observation and reassessment at least every 15 minutes. Restraint is ended as soon as pharmacological control is achieved. [1] [7]
• Recognise the medical emergency. The candidate states that hyperactive delirium with severe agitation is a medical emergency with risk of cardiovascular collapse, rhabdomyolysis, hyperkalaemia and sudden death, and that the physiological derangement (temperature, heart rate, blood pressure, creatine kinase, electrolytes, acid-base) is monitored and treated as aggressively as the behaviour. [7]

Phase 5: Communication, capacity and the family (3 minutes)

• Involve the parents when they arrive. The candidate explains the situation clearly, the proposed treatment, the risks and benefits, and the legal framework. Capacity is assessed: an adolescent in severe sympathomimetic intoxication with delusional thinking does not have capacity, and treatment proceeds under the relevant guardianship or mental health legislation, with the statutory forms completed and the reasons documented. [1] [2]
• Communicate with the team. A clear team huddle at the start and a structured debrief at the end. The candidate names the risk of re-traumatisation for the team and the patient, and the value of a Plan-Do-Study-Act debrief. [11]

Phase 6: Disposition and post-event care (4 minutes)

• Disposition. Admission to a high-dependency or PICU-equivalent setting given the hyperthermia, autonomic instability, rhabdomyolysis risk and the cumulative sedation; ongoing toxicology, mental health and paediatric involvement; safeguarding and youth-justice liaison as indicated. [1] [7]
• Mandatory post-event care. Medical review for injury (self-harm, restraint-related, fall), aspiration and restraint-related injury; structured debrief with the patient when able, the family and the team; safeguarding review; notification under the local restraint reporting framework and the mental health legislation; update of any behavioural care plan; follow-up with drug and alcohol, mental health and paediatric services. The ETAPE study reminds the team to warn the family about adverse effects in antipsychotic-naive adolescents and to arrange follow-up. [11] [11] [7]

Examiner marking domains