Humane restraint and behavioural support in emergency care — formative SAQs

SAQ 1 (10 marks, 15 minutes)

Stem. A seven-year-old boy with no prior psychiatric history is brought to the emergency department acutely agitated after a two-day febrile illness. He is pacing the cubicle, cannot engage in conversation, and has just thrown a cup at a nurse. Observations: temperature 38.9 degrees Celsius, heart rate 150, respiratory rate 32, SpO2 92 percent in room air, capillary refill 2 seconds. Bedside glucose 3.2 millimoles per litre. His mother is present and frightened.

Task. Outline your immediate, team-led response over the next 30 minutes, including how you would ensure safety, the order of your clinical priorities, the role of de-escalation, your pharmacological approach with rationale, and the circumstances under which you would escalate to physical restraint.

Model answer

Safety and team (1 mark). Ensure the safety of staff, the child and others first: clear the cubicle of hazards and other patients, ensure the exit is clear, call for senior paediatric and nursing help, name a team leader, assign roles, and prepare monitoring and emergency equipment. [1]

Treat medical causes first (3 marks). The abnormal observations (fever, tachycardia, tachypnoea, SpO2 92 percent) and the borderline-low glucose in a young child with no psychiatric history make a medical cause the most likely driver of the agitation. Apply high-flow oxygen immediately for the hypoxia. Treat the borderline-low glucose with oral glucose if the child can swallow safely, or 2 to 5 millilitres per kilogram of 10 percent glucose intravenously if not; recheck. Send a septic screen and give empiric antibiotics and aciclovir if meningitis or encephalitis is suspected. Treat pain. The agitation is highly likely to settle as the hypoxia and the underlying illness are treated; sedating through the deterioration would mask the medical child. [1]

De-escalation and environment (2 marks). In parallel, a calm lead clinician at eye level, one voice, low-stimulation room with reduced light and noise, mother present if safe, offer a drink, and remove clinical uniforms and equipment that signal threat. A genuine trial of de-escalation runs alongside the medical work-up, not after it. [1]

Pharmacological approach (3 marks). Oral medication offered with consent as the first pharmacological step; the PEAChY-O randomised controlled trial supports oral as effective first-line. Olanzapine orally disintegrating tablet at an age-appropriate dose, or diazepam, are reasonable choices once the airway and glucose are secure. Parenteral rapid tranquillisation is reserved for refusal, safety concern, or failure of oral, with close monitoring for respiratory depression and QT effects. Because he is febrile and hypoxic, the threshold for parenteral sedation is higher (respiratory risk) and the work-up for a medical cause is the priority. [3] [4] [1]

Escalation to physical restraint (1 mark). Physical restraint is reserved for grave and imminent danger that cannot be prevented any other way: minimum force, minimum duration, trained team with a named leader, airway visible at all times, never face-down or in a hobble, reassessed at least every 15 minutes, documented and debriefed. A safeguarding review is automatic for any unexplained or repeated restraint. [1] [7]

SAQ 2 (10 marks, 15 minutes)

Stem. A 16-year-old is brought to the emergency department by ambulance after an unknown ingestion at a party. He is severely agitated, violent, and has smashed a window. Observations: temperature 39.4 degrees Celsius, heart rate 160, blood pressure 190 over 110, respiratory rate 28, SpO2 95 percent in room air. He has mydriasis, diaphoresis, inducible clonus and hyperreflexia. Behavioural Activity Rating Scale (BARS) 7. Bedside glucose 6.1 millimoles per litre.

Task. Discuss your immediate and stepwise management, including the likely toxidrome, your pharmacological approach with specific cautions, your approach to monitoring, the place of physical restraint, and the post-event care that is mandatory.

Model answer

Likely toxidrome and immediate priorities (2 marks). The presentation (hyperthermia, autonomic surge, mydriasis, diaphoresis, clonus, hyperreflexia, severe agitation) is most consistent with severe sympathomimetic intoxication such as methamphetamine or MDMA, with possible serotonin syndrome. Treat as a medical emergency with airway, breathing and circulation priority, early senior and toxicology input, intravenous access, bloods (full blood count, electrolytes, creatine kinase, drug screen as indicated, blood gas), and a 12-lead ECG. [7]

Pharmacological approach with cautions (3 marks). Benzodiazepines are first-line: they reduce the sympathetic surge, settle the agitation, lower the temperature and reduce muscle activity. Titrate intravenously to effect with continuous monitoring. An antipsychotic (droperidol or olanzapine) is added second-line for refractory agitation, with ECG monitoring because both the methamphetamine and the antipsychotic prolong the QT interval. Explicitly avoid the combination of intramuscular olanzapine with a parenteral benzodiazepine in the same syringe or the same visit without close monitoring, given the FDA warning on respiratory depression and airway loss with this combination. Active cooling for the hyperthermia, intravenous fluids, and treatment of rhabdomyolysis if creatine kinase is markedly raised. [7] [9] [1]

Monitoring (2 marks). Continuous pulse oximetry, ECG, respiratory rate and sedation score; blood pressure and heart rate every 15 minutes during titration and for at least one hour after the last dose. Serial creatine kinase and renal function given the severe agitation and hyperthermia. Repeated BARS scoring to document response. Airway equipment and reversal agents (naloxone for any opioid component, flumazenil for any benzodiazepine) immediately available. [1] [8]

Physical restraint (1 mark). Brief physical restraint may be required initially to enable assessment and intravenous access, given the violence. It 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 or in a hobble, with continuous observation and reassessment at least every 15 minutes. Restraint is ended as soon as pharmacological control is achieved. [1] [7]

Post-event care (2 marks). Medical review for injury (self-harm, restraint-related), aspiration, restraint-related injury and physiological deterioration. Structured debrief with the patient when able, the family and the team (Plan-Do-Study-Act or equivalent). Safeguarding review and youth-justice liaison if applicable. Notification under the local restraint reporting framework and the mental health legislation where it applies. Update of any existing behavioural care plan. Follow-up with the relevant service (paediatric, mental health, toxicology, drug and alcohol). The ETAPE study reminds us that adverse effects in antipsychotic-naive adolescents are common, and the family should be warned and followed up. [11] [11] [7]