Acute behavioural disturbance and agitation — branching viva

Stem

The examiner will test whether you can classify acute agitation, run the least-restrictive ladder, choose pharmacotherapy with evidence, exclude organic causes, and manage restraint and recovery safely. [1] [3]

Branch 1 — Classification

Examiner: A 15-year-old is brought in highly agitated and aggressive. How do you classify this and where do you start? [2]

Strong answer: I classify along two axes. The severity axis — mild, moderate, severe — decides where on the ladder I start, and the cause axis — organic, toxicological, psychiatric, neurodevelopmental, environmental — decides the definitive treatment. This episode is severe because there is imminent danger, so I start with safety, help and de-escalation, while running the organic exclusions in parallel. [1] [2]

Examiner: Why two axes and not one? [3]

Strong answer: Because a severely agitated child can still be hypoglycaemic, and a mildly agitated child with hypoglycaemia still needs the glucose treated first. Severity drives the ladder; cause drives the treatment. If I only think severity, I sedate and forget the medical cause. [3]

Branch 2 — The least-restrictive ladder

Examiner: Talk me through the ladder. [1]

Strong answer: Zero is safety and triage — stimulus reduction, single staff voice, remove the audience, call senior and security early. Rung one is verbal de-escalation, the first-line treatment. Rung two is offering oral medication if the child engages. Rung three is parenteral medication if oral is refused and danger is uncontained. Rung four is physical restraint, a last resort. Then recovery and debrief. I escalate one rung at a time, only when the rung below has failed, and I justify, time-limit and document each step. [1] [7]

Examiner: Why is de-escalation first-line rather than a warm-up? [7]

Strong answer: Because arousal is state-dependent and short-lived, so changing the inputs — quieting the room, lowering the voice, giving a choice — buys time for the cortex to come back. Klein's trial analysis showed non-pharmacological de-escalation resolves many severe episodes without medication, so it is genuine treatment, not a preamble. [7] [1]

Branch 3 — Pharmacotherapy

Examiner: He is engaging a little. What do you offer, and what is the evidence? [5]

Strong answer: I offer oral medication first — oral midazolam or oral olanzapine plus or minus diazepam. The PEAChY-O randomised controlled trial compared those regimens in children and young people and found both effective, so oral is the preferred step whenever feasible because it respects autonomy and avoids injection and restraint. I choose the agent and dose per local protocol. [5] [4]

Examiner: He now refuses oral and lunges at a nurse. What changes? [2]

Strong answer: The danger is uncontained and oral is refused, so I move to parenteral medication — intramuscular olanzapine or droperidol, with or without midazolam, per local protocol. Reviews of paediatric pharmacological management support those agents, and the PEAChY-M trial is testing intramuscular options formally, so I cite it as ongoing. After the dose I monitor airway, breathing, sedation score, respiratory rate, oxygen saturation, blood pressure and heart rate, and an ECG if an antipsychotic was given, with reversal and resuscitation immediately available. [4] [6]

Branch 4 — Organic causes and restraint

Examiner: He settles after medication. What must you not forget? [3]

Strong answer: That a calm, sedated child is not an assessed child. I return to exclude organic causes now that the arousal has settled — capillary glucose, temperature, oxygen saturation, and a focused history and examination for intoxication, infection, head injury and pain. I do not let the calm seduce me into skipping the medical assessment the episode demanded. [3] [2]

Examiner: If restraint had been needed, how would you minimise its harms? [8]

Strong answer: Restraint is a last resort, team-trained, brief, continuously monitored, never solitary, and never with a prone hold or neck pressure because positional asphyxia is a real risk. I document the justification, duration and monitoring, and afterwards I debrief with the child, family and team, re-assess the cause, and make a plan to reduce the next episode — because repeat restraint predicts worse outcomes. [8] [7]

Examiner extras

• Severity drives the ladder; cause drives the treatment — two axes, never one. [1] [3]
• De-escalation is treatment, not a warm-up; it resolves most episodes without medication. [7] [1]
• Offer oral first whenever feasible — PEAChY-O supports an oral-first approach. [5] [4]
• After parenteral sedation, monitor airway, breathing, sedation score and QTc. [4] [2]
• Restraint is a last resort; minimise it, document it, debrief, and plan to reduce it. [8]