Acute behavioural disturbance and agitation — formative SAQs

SAQ 1 — The least-restrictive ladder (10 marks)

A 13-year-old boy with autism is brought to the emergency department by his mother after he became distressed and aggressive at school. He is pacing, shouting and hitting the cubicle wall. His mother says he has not eaten today and the department is loud and crowded. [3] [1]

Questions

1. Outline the stepped least-restrictive ladder you would use to manage this episode, and justify why each rung comes in that order. (6 marks) [1]
2. Describe the verbal de-escalation skills you would apply first, and state what you would do in parallel to exclude an organic cause. (4 marks) [7]

Model answer

The ladder (6). The least-restrictive ladder runs from least to most restrictive: zero is safety and triage, with stimulus reduction, a single staff voice, removal of the audience, and an early call to a senior, security and the mental-health team. The first rung is verbal de-escalation, the first-line treatment of acute agitation. The second rung is offering oral medication if the child will engage — oral midazolam or oral olanzapine plus or minus diazepam, per the PEAChY-O trial. The third rung is parenteral medication if oral is refused and the danger remains uncontained. The fourth rung is physical restraint as a last resort only, team-trained, brief and continuously monitored. The order matters because each rung above de-escalation carries its own harms — over-sedation, respiratory depression, QTc prolongation, injury and retraumatisation — so you escalate one step at a time only when the step below has genuinely failed, and you justify, time-limit and document every step. [1] [5]

De-escalation and organic exclusion (4). I would respect personal space, keep a calm single voice, use short simple phrases, identify his wants and feelings, listen, set clear limits, offer realistic choices such as a quieter room, and remove the audience and reduce the noise — adapting to his autism by using his own communication aids and his mother as a familiar regulator. In parallel I would check a capillary glucose because he has not eaten, his temperature and his oxygen saturation, and take a rapid collateral history from his mother on his baseline, his triggers and whether this episode is typical or new, because a new episode in a settled child raises the possibility of an organic cause that sedation would mask. [7] [3]

SAQ 2 — Pharmacotherapy, restraint and recovery (10 marks)

The same boy remains agitated despite de-escalation and a reduced-stimulus environment. He refuses oral medication and lunges at a nurse. The team is considering parenteral medication and physical restraint. [2] [4]

Questions

1. Justify the pharmacological options now, citing the relevant trial evidence, and outline the monitoring required afterwards. (6 marks) [5]
2. Describe how you would minimise the harms of physical restraint if it becomes unavoidable, and what you would do in the recovery and debrief phase. (4 marks) [8]

Model answer

Pharmacotherapy and monitoring (6). Because he is refusing oral medication and the danger is uncontained, parenteral medication is the appropriate rung. Reviews of paediatric pharmacological management support intramuscular olanzapine or droperidol, with or without midazolam, selected against his history, the suspected cause and local protocol; the PEAChY-M trial is formally testing intramuscular options, so I would cite it as ongoing rather than read it as a finished result. I would avoid medication he is known to tolerate poorly and I would choose the agent per local protocol. After any parenteral dose, the mandatory monitoring is the airway and breathing, a sedation score, the respiratory rate and oxygen saturation, the blood pressure and heart rate, and an ECG if an antipsychotic has been given or a prolonged QTc is suspected, with reversal and resuscitation immediately available because over-sedation and respiratory depression are reversible if caught and fatal if missed. [4] [2] [6]

Restraint minimisation and recovery (4). Restraint is a last resort and never a routine. If it is unavoidable I would ensure it is applied by a trained team, held for the briefest possible time, continuously monitored, never used as solitary confinement, and never with a prone hold or pressure on the neck because positional asphyxia is a real risk; I would document the justification, the duration and the monitoring. In the recovery phase I would monitor his sedation and airway until he returns to baseline, re-assess for organic causes now that arousal has settled — including the glucose I flagged earlier — and then debrief with the boy, his mother and the team: what triggered the episode, what calmed it, and what will reduce the chance of a repeat, including sensory and communication supports for his autism. [8] [7]