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]}