OSCE — Psychiatric Emergencies & Acute Agitation

Brief (to candidate)

You will assess a patient with a presentation consistent with Psychiatric Emergencies & Acute Agitation.
You have 8 minutes to take a focused history, outline examination, investigations, and management including red flags.

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Clinical context

Psychiatric emergencies require immediate intervention to prevent harm. Core scenarios: acute agitation (de-escalation, then oral, then IM rapid tranquillisation — NICE NG10: IM lorazepam or IM haloperidol plus promethazine; BAP also IM olanzapine not concurrent with IM benzodiazepines, or IM aripiprazole; TREC: IM haloperidol 5–10 mg plus promethazine up to 50 mg superior to haloperidol alone), acute psychosis with risk, self-harm (NICE NG225: psychosocial assessment without delaying it for medical completion; no risk-tool prediction or discharge; aftercare within 48 hours if ongoing safety concerns), delirium, NMS (Gurrera: >38.0 °C on 2 occasions, CK ≥4× ULN; stop the antipsychotic; dantrolene best-evidenced drug; 2-week washout), serotonin toxicity (Hunter criteria; cyproheptadine 4–8 mg orally in the Graudins series), lithium poisoning (EXTRIP: ECTR if renal impairment with level >4.0 mEq/L, or decreased consciousness/seizures/life-threatening dysrhythmias at any level). ^{[28] [5] [18] [17] [4] [7] [10] [9] [16] [29] [11]}

Candidate tasks

1. Clarify onset, severity, associated features, and red-flag symptoms.
2. State focused examination priorities.
3. List first-line investigations and any named score/criteria.
4. Give immediate resuscitation steps.
5. Outline definitive management with doses/routes where the cited guideline or trial states them.
6. Name complications and disposition (ward / HDU / ICU / discharge safety-net).
7. Mention one special-population modifier (pregnancy, child, elderly, CKD).

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Examiner checklist

Model outline

Lead with working diagnosis and life threats. Resuscitate before non-urgent imaging. Use guideline-standard therapy with named agents and the doses that trials/guidelines actually state (TREC 5–10 mg + promethazine up to 50 mg; EXTRIP lithium thresholds; Gurrera 38.0 °C ×2). Document escalation criteria. ^{[18] [4] [11]}

References12ShowHide

1. [1]Battaglia J. Pharmacological management of acute agitation Drugs, 2005.PMID 15916448
2. [4]Gurrera RJ, Caroff SN, Cohen A, et al. An international consensus study of neuroleptic malignant syndrome diagnostic criteria using the Delphi method J Clin Psychiatry, 2011.PMID 21733489
3. [5]Patel MX, Sethi FN, Barnes TR, et al. Joint BAP NAPICU evidence-based consensus guidelines for the clinical management of acute disturbance: De-escalation and rapid tranquillisation J Psychopharmacol, 2018.PMID 29882463
4. [7]Perry PJ, Wilborn CA. Serotonin syndrome vs neuroleptic malignant syndrome: a contrast of causes, diagnoses, and management Ann Clin Psychiatry, 2012.PMID 22563571
5. [9]Graudins A, Stearman A, Chan B. Treatment of the serotonin syndrome with cyproheptadine J Emerg Med, 1998.PMID 9696181
6. [10]Dunkley EJ, Isbister GK, Sibbritt D, et al. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity QJM, 2003.PMID 12925718
7. [11]Decker BS, Goldfarb DS, Dargan PI, et al.; EXTRIP Workgroup. Extracorporeal Treatment for Lithium Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup Clin J Am Soc Nephrol, 2015.PMID 25583292
8. [16]Bush G, Fink M, Petrides G, et al. Catatonia. II. Treatment with lorazepam and electroconvulsive therapy Acta Psychiatr Scand, 1996.PMID 8686484
9. [17]Richmond JS, Berlin JS, Fishkind AB, et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup West J Emerg Med, 2012.PMID 22461917
10. [18]Huf G, Coutinho ES, Adams CE; TREC Collaborative Group. Rapid tranquillisation in psychiatric emergency settings in Brazil: pragmatic randomised controlled trial of intramuscular haloperidol versus intramuscular haloperidol plus promethazine BMJ, 2007.PMID 17954515
11. [28]National Institute for Health and Care Excellence Violence and aggression: short-term management in mental health, health and community settings NICE guideline NG10, 2015.Source
12. [29]National Institute for Health and Care Excellence Self-harm: assessment, management and preventing recurrence NICE guideline NG225, 2022.Source