Acute behavioural disturbance

Any person, 10 to 15 years, whose behaviour places them or others at immediate risk of harm necessitating prompt intervention. This may include extreme distress, threatening or aggressive behaviour and serious self-harm.

This protocol is only to be used by nurses who have completed NSW Health Violence Prevention Management Personal Safety.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
Safety	Remove any potentially harmful items from the environment, such as IV poles, sharps, cords, cardiac leads, plastic bags and oxygen tubing, before the patient arrives Allocate patient into an appropriate environment that maximises their well-being, comfort and safety The patient should be within sight at all times Consider a low stimulus environment, particularly for patients with a neuro-developmental disorder such as autism spectrum disorder, attention deficit hyperactivity disorder or an intellectual disability
Behaviour and characteristics	For patients who have a management plan, use their personalised plan first Continue de-escalation techniques. See focused assessment section
General appearance/first impressions Patient descriptors	Position of comfort Document hair colour, eye colour, clothing and distinguishing features. This will assist police or people searching for the patient in the event of absconding

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and work of breathing Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93%

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm	Assess circulation Do not disturb the patient or escalate behaviour unnecessarily Use hands-off approach Assess heart rate and blood pressure, if clinically relevant, and the patient is cooperative Attach cardiac monitor if clinically relevant (post sedation, suspected drug ingestion) and safe to do so Consider 12 lead ECG if suspected drug ingestion or organic cause
IVC and/or pathology	IVC is often unsafe Insert IV cannula, if trained, only if required for urgent access (e.g. lifesaving medications) See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present, give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL

Disability

Assessment	Intervention
AVPU	If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature If suspected drug-induced hyperthermia, or rapidly escalating temperature, over 40oC, actively cool Consider causes for acute behavioural disturbance if febrile, e.g. sepsis, and switch to the appropriate protocol if required
Head-to-toe inspection, including posterior surfaces	Check and document any abnormalities Inspect for injuries and consider self-harm Ensure skin integrity is maintained and neurovascular observations are conducted if mechanical restraint is in situ

Fluids

Assessment	Intervention
Hydration status	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses Encourage oral hydration
Nausea and/or vomiting	If present, see nausea and/or vomiting section

Glucose

Assessment

Intervention

BGL

Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria): give quick-acting carbohydrate: sugary soft drink or fruit juice or 40% glucose gel buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone Criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access escalate as per local CERS protocol

Focused assessment

Complete a mental health focused assessment.

Precautions and notes

• People with a mental health condition may have a history of trauma.
• Minimise potential for distress through clear and respectful interactions.
• Restraint poses a risk of traumatising and injuring the patient and staff.
• Restraint removes patient autonomy and should only be used as a safety intervention when attempts to de-escalate have been exhausted.
• Restraint should only be carried out by trained staff using the safest techniques.
• Avoid restraining in the prone position.

Interventions and diagnostics

Specific treatment

Patient search

• A patient search (including their property) should be considered in high-risk patients, consistent with the provision of trauma-informed care and local guidelines.
• NSW Health staff can only search a patient or their property if they have received consent from the patient or carer or the patient is detained under the Mental Health Act.
• To avoid escalating behaviour, ensure the search is carried out by two staff members in a private and sensitive manner.
• Remove any patient belongings that may be used to harm themselves or others.
• Document patient items that have been removed and place them in a secure location.

Verbal de-escalation

• Attempts must be made to engage, reassure and establish rapport with the patient, providing an opportunity for the patient to de-escalate.
• See mental health focused assessment for verbal de-escalation techniques.
• Seek support from family or carer, as appropriate.

Medication management

• Emergency sedation aims to achieve an optimal reduction in agitation or behavioural disturbance, thereby allowing a thorough evaluation to take place.
• If verbal de-escalation is unsuccessful, give one of:
  • diazepam 0.2 mg/kg orally once only, maximum dose 10 mg
  • or olanzapine orally once only
    • Less than 40 kg: 2.5 mg
    • Over 40 kg: 5 mg
• If the patient is taking regular antipsychotics, olanzapine is the preferred medication rather than diazepam.

Post-sedation monitoring

• Patients should be visually monitored at all times.

Acute dystonia

• If dystonic reaction, give benzatropine mesilate 0.02 mg/kg IM/IV once only, maximum dose 2 mg.

Documentation

• Reasons for sedation
• Medications used: name, dose and route
• What worked and what was unsuccessful
• As applicable, additional documentation may be required to address the following:
  • code response
  • patient safety, using the local risk incident reporting system
  • staff safety and OHS
  • consent
  • Mental Health Act
  • Restraint Register (NSW)

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Analgesia

If pain score 1–6 (mild–moderate):

Give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg

and/or ibuprofen 10 mg/kg orally once only, maximum dose 400 mg

If severe pain present, give analgesia and escalate as per local CERS protocol.

Consider non-pharmacological pain relief (appendix).

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Nausea and/or vomiting

If nausea and/or vomiting is present, give:

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Radiology

Not usually indicated. If there is concern for urgent radiology, escalate care as per local CERS protocol.

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Pathology

Not usually indicated. If there is concern for urgent pathology, escalate as per local CERS protocol.

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au