Viva: branching structured oral

Stimulus. A nine-year-old boy with autism spectrum disorder and intellectual disability is brought to the emergency department in acute behavioural disturbance after a long wait in a noisy waiting room. He is throwing chairs.

Stage 1: The first 60 seconds

Examiner. You are the consultant on. The triage nurse calls you to the cubicle. Walk me through your first 60 seconds.

Model answer. I ensure the safety of the staff, the child and others first. I clear the cubicle of other patients and of hazards, I ask for the chairs to be moved out of reach, I confirm the exit is clear, and I call for senior nursing help and a second clinician. I name a team leader (me or a delegate), assign roles, and ask the parents to step back to a safe distance but to stay close because they will be central to the de-escalation. I do not approach the child yet. [1]

Examiner probe. Why not approach?

Model answer. Because approaching an autistic child in meltdown head-on, with multiple staff, in a noisy cubicle, reliably worsens the trajectory. The first intervention is environmental: reduce the noise, reduce the light, clear the space, and bring in people the child trusts. I am preparing the conditions for de-escalation, not confronting the behaviour. [6]

Stage 2: Recognising the driver

Examiner. The parents tell you he has autism and intellectual disability, that this started in the waiting room, and that he has not eaten or drunk for six hours. They have his positive behaviour support plan with them. What is your working formulation, and what reversible medical causes must you exclude?

Model answer. My working formulation is an autistic meltdown triggered by sensory overload and routine disruption in the waiting room, compounded by hunger and thirst, in a child with a known positive behaviour support plan. The medical causes I must exclude or treat alongside the de-escalation are: hypoglycaemia (he has not eaten for six hours), pain (could be dental, abdominal, from a constipation flare, from a recent fall), an intercurrent infection, a medication adverse effect or interaction, and (because he is non-verbal at baseline) any occult injury. I will check a bedside glucose as soon as I can approach him safely, his temperature, his other observations, and a focused history from the parents. [1] [6]

Examiner probe. A junior suggests intramuscular olanzapine now to settle him quickly. How do you respond?

Model answer. I decline. He is not in imminent danger to life; he is throwing chairs but not at people. The behavioural phenotype is autistic meltdown, in which sensory regulation, communication aids, a trusted adult and time are first-line, and escalation with a parenteral antipsychotic typically worsens the trajectory. The oral-first approach is supported by the PEAChY-O trial, and an orally disintegrating tablet can be offered once he is regulated enough to accept it. A benzodiazepine is also not first-line here because paradoxical disinhibition is more common in children with intellectual disability. The exception is if the agitation escalates to imminent danger to life; then a parenteral agent may be needed, but we are not there. [3] [4] [6]

Stage 3: De-escalation and the positive behaviour support plan

Examiner. Take me through your de-escalation plan in detail.

Model answer. First, the environment: move him to a low-stimulation room if it can be done safely, dim the lights, reduce the noise, remove unnecessary staff, offer his own sensory items from home (his parents can call someone to bring them). Second, the people: bring in his mother as the primary soother if it is safe, and have one calm clinician at eye level at a respectful distance, one voice, hands visible. Third, communication: use his communication aid, allow processing time, give one short instruction at a time, respect non-verbal signals. Fourth, the plan: his positive behaviour support plan from the developmental paediatrician identifies the early signs, the strategies that work, the medications and doses that have helped or caused adverse effects, the trusted adults and the escalation pathway. I read it and follow it. Fifth, offer food and drink if safe; he has not eaten or drunk for six hours and hunger may be contributing. [6] [1]

Examiner probe. He settles to the point where he can take an oral medication. What do you offer, at what dose, and how do you frame the consent?

Model answer. I offer an oral atypical antipsychotic, olanzapine as an orally disintegrating tablet at an age-appropriate dose, because it dissolves on the tongue without water and without swallowing. I explain to him and to his parents what the medication is, why I am offering it, what to expect, and the common adverse effects; for an antipsychotic-naive child I warn about sedation and extrapyramidal effects given the ETAPE data on adverse-event rates in this group. I obtain consent from the parents and, to the extent he is able to engage, his assent. If he prefers a benzodiazepine (diazepam) I would consider it, with caution about paradoxical disinhibition. Clonidine is an alternative in some plans. [3] [4] [11] [1]

Stage 4: Escalation

Examiner. The plan does not work. He becomes more agitated, climbs onto a windowsill, and threatens to jump. How does your response change?

Model answer. He is now in imminent danger to his own life, and the threshold for escalation has been crossed. I move up the stepped ladder. First, a clear verbal instruction and a safety positioning of the team. Second, if he will not come down safely, parenteral rapid tranquillisation: an intramuscular agent (midazolam or olanzapine, at the weight-based dose from our local guideline), drawn up in advance, given by a named clinician, with monitoring and emergency airway equipment immediately available. I explicitly avoid combining intramuscular olanzapine with a parenteral benzodiazepine in the same visit without close monitoring, given the FDA warning on respiratory depression. Third, brief physical restraint may be needed to enable the injection, 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. The restraint is ended as soon as pharmacological control is achieved. [1] [1] [7]

Examiner probe. He has now received intramuscular olanzapine. Twenty minutes later he is still agitated. The junior suggests adding intramuscular midazolam. What is your response?

Model answer. I consider the combination hazardous: olanzapine plus a parenteral benzodiazepine carries a substantial risk of respiratory depression, sedation, hypotension and airway loss, and the FDA has warned against it. Before adding a benzodiazepine, I would: re-assess the cause (is there a medical cause I am missing, is there an intoxication, is the dose adequate, is the formulation absorbed), involve senior help, and if a second agent is essential, choose an agent from a different class where possible (for example droperidol, with an ECG given the QT concern), give it sequentially rather than mixed, and intensify the airway and sedation monitoring with reversal agents immediately available. I would not reflexively add a benzodiazepine. [8] [1]

Stage 5: Monitoring and post-event care

Examiner. Take me through your monitoring over the next hour, and the post-event care that is mandatory regardless of the outcome.

Model answer. Monitoring: pulse oximetry, respiratory rate, sedation score, blood pressure and heart rate every 15 minutes for at least one hour after the parenteral dose, longer if he remains drowsy; ECG if a QT-prolonging agent has been used; serial BARS to document response; airway equipment and reversal agents immediately available. Post-event care: medical review for injury (self-harm, restraint-related), aspiration, restraint-related injury and physiological deterioration; structured debrief with the child when able, the family and the team (Plan-Do-Study-Act or equivalent); update of his positive behaviour support plan with what worked and what did not; notification under the local restraint reporting framework and under the mental health or guardianship legislation where it applies; and follow-up with his developmental paediatrician and his usual team. Because this is a child with autism who has had a restraint event, I also flag the case for a service-level review of what could have been different (the wait, the waiting room, the availability of a low-stimulation space, the early use of his plan), because restraint in this group is both a clinical and a human-rights event. [1] [11] [11] [7]

Closing probe

Examiner. One sentence to summarise your approach.

Model answer. Treat acute behavioural disturbance as a behaviour with medical, psychiatric, toxicological and developmental drivers, ensure safety first, treat the reversible medical causes, de-escalate verbally and environmentally, offer oral medication before any injection, escalate to parenteral only when oral fails or is unsafe, reserve physical restraint for grave and imminent danger, monitor every sedated child, and debrief every restrictive intervention with an automatic safeguarding lens. [1] [4]