10 OCSE EXAMPLES

DISCLAIMER:  These examples have been obtained with A.I., therefore treat them as suggestions with possible errors to be checked.

10 OSCE Scenarios in a Forensic Psychiatric Hospital
Each scenario follows a standard structure: clinical presentation, A‑E assessment findings with embedded NEW(S)2 parameters and risk evaluation, interventions performed during assessment, overall risk grading, escalation and management plan, and SBARD handover. Equipment use and specific techniques for engagement and bedside manner are highlighted.

Scenario 1: Suspected Myocardial Infarction
Setting: Medium-secure male ward. A 54‑year‑old man with paranoid schizophrenia, obese, smoker, on clozapine, suddenly complains of crushing central chest pain radiating to the left arm, sweating, and nausea.
A‑E Assessment & Interventions

• Airway: Patent, speaking in short sentences. Intervention: Reassure and encourage slow breaths; maintain sitting upright.
• Breathing: RR 24/min, SpO₂ 93% on air. Intervention: Apply high-flow oxygen via non-rebreather mask at 15 L/min. Auscultate chest – clear.
• Circulation: BP 150/95 mmHg, HR 112 bpm regular, CRT 3 s, cool peripheries. Intervention: Attach cardiac monitor, obtain 12-lead ECG (shows ST elevation in leads II, III, aVF). Gain IV access, give aspirin 300 mg chewed, GTN spray 400 µg sublingual (after checking no recent sildenafil use). Call 999.
• Disability: Alert (A on AVPU), BGL 6.2 mmol/L, anxious but orientated. Intervention: Keep calm, explain every step.
• Exposure: No rashes, no leg swelling, abdomen soft. Intervention: Cover with blanket after examination.

NEWS2 Calculation:
RR 24 = 2, SpO₂ 93% (on O₂) = 2 (weighted if on O₂, use Scale 2 score 2 for 93%), SBP 150 = 0, HR 112 = 2, Consciousness Alert = 0, Temp 36.9°C = 0. Total NEWS2 = 6 (high risk, urgent response).
Overall Risk: NEWS2 6 (≥7 is high, 5‑6 medium but clinical picture of STEMI makes it high‑risk emergency). Clinical presentation consistent with acute coronary syndrome requiring immediate transfer to emergency department.
Escalation: Inform nurse in charge, request 999 ambulance, medical registrar on-call, and secure escort team (minimum 2 staff due to forensic risk).
Management Plan

• Continue oxygen, monitor vitals every 5 minutes.
• Second GTN after 5 minutes if pain persists and SBP >100 mmHg.
• Prepare patient for transfer: take full drug chart, clozapine monitoring record, legal documents (Section papers).
• Maintain calm, therapeutic presence.

SBARD Handover (to paramedic/ED)

• Situation: 54‑year‑old man, detained under Section 37/41, acute chest pain with ECG changes.
• Background: Paranoid schizophrenia, stable on clozapine 400 mg/day. Smoker, BMI 32. No known cardiac history.
• Assessment: Crushing chest pain, ST‑elevation inferior leads, NEWS2 6, given aspirin, GTN, oxygen.
• Recommendation: Urgent transfer to PCI‑capable centre. Continue dual antiplatelet on route.
• Decision: 999 called, escort ready, family not contactable – advance decision documented by Responsible Clinician.

Equipment Used: Oxygen cylinder & mask, sphygmomanometer, pulse oximeter, 12‑lead ECG machine, IV cannula, GTN spray, aspirin, defibrillator on standby, NEWS2 chart.
Engagement/Bedside Manner: Sit at eye level, validate the patient’s pain, use simple language, explain the sensation of GTN spray, maintain eye contact while respecting paranoia cues. Maintain safe distance and ensure exit is accessible; use a calm, low tone.

Scenario 2: Severe Hypoglycaemia
Setting: Low-secure rehabilitation ward. A 29‑year‑old woman with schizoaffective disorder and type 1 diabetes found slumped in chair, confused, diaphoretic.
A‑E Assessment & Interventions

• Airway: Maintained, able to speak but incoherent.
• Breathing: RR 16, SpO₂ 98% air, breath sounds equal.
• Circulation: BP 105/68, HR 108 sinus, skin clammy. CRT 2 s.
• Disability: Responds to Voice (V on AVPU), BGL 2.1 mmol/L (capillary). Intervention: Immediately give 30 g fast‑acting carbohydrate – 200 mL orange juice orally (patient can swallow). Recheck BGL after 15 min. If unsafe swallow or unresponsive, would have administered IM glucagon 1 mg. Check ketones (0.3 mmol/L – not DKA).
• Exposure: No other injury; insulin pump disconnected? Pump site checked, correctly attached.

NEWS2 Calculation:
RR 16=0, SpO₂ 98%=0, SBP 105=1, HR 108=1, Conscious V=3, Temp 36.5°C=0. Total = 5 (medium risk).
Overall Risk: Medium-high. Although NEWS2 5, the dangerously low BGL makes this a clinical high risk; risk of neuroglycopenic injury.
Escalation: Inform medical team, repeat BGL, consider referral to diabetes specialist nurse. If no improvement or GCS drops, call ambulance.
Management Plan

• Re‑check BGL 15 mins: now 3.9 mmol/L. Provide long‑acting carbohydrate snack (sandwich, milk).
• Monitor vitals every 30 mins for 2 hours.
• Review insulin regime with pharmacist; temporary dose reduction discussed due to recent missed meals (psychotic episode).
• Increase observations to level 2 (every 15 mins) for 4 hours.

SBARD Handover (to on‑call physician)

• Situation: 29‑year‑old female, Type 1 DM, hypoglycaemic episode with altered consciousness.
• Background: Schizoaffective disorder, insulin pump, poor oral intake for 2 days due to persecutory delusions about food.
• Assessment: BGL 2.1 mmol/L, initially responsive to voice, improved with oral glucose to 3.9. NEWS2 5.
• Recommendation: Review insulin pump settings, consider basal reduction, ensure dietary support and 1:1 observation during meals.
• Decision: Plan agreed, diabetes team to review tomorrow, continue enhanced monitoring.

Equipment Used: Glucometer, ketone meter, BP cuff, pulse oximeter, emergency glucagon kit (available), NEWS2 chart.
Engagement: Approach calmly from the front, validate the confusion (“I can see you’re not feeling right”), avoid physically restraining, involve the patient in the choice of oral sugar if possible. Reassure that she is safe.

Scenario 3: Opioid Overdose (Suspected Illicit Use)
Setting: High-secure ward. A 41‑year‑old male with antisocial personality disorder and substance misuse history is found unresponsive in his room, pinpoint pupils, shallow breathing. Needle found in bin.
A‑E Assessment & Interventions

• Airway: Snoring, partly obstructed. Intervention: Head‑tilt chin‑lift, oropharyngeal airway inserted (size 4). Suction available.
• Breathing: RR 5/min, shallow, SpO₂ 82% on air. Intervention: Bag‑valve‑mask ventilation with 15 L/min O₂ at 10‑12 breaths/min. Call cardiac arrest team (as per policy for respiratory arrest risk).
• Circulation: Weak radial pulse, HR 50 bpm, BP 80/50. Intervention: Apply defibrillator pads, monitor rhythm (sinus bradycardia). Prepare naloxone: 400 µg IV (or IM if no IV). Cannulate.
• Disability: Unresponsive to Pain (P on AVPU), GCS 6. Intervention: Administer naloxone 0.4 mg IV stat. Observe for response; respiratory rate should increase within minutes. Second dose after 2‑3 min if RR remains <10.
• Exposure: Check for other injection sites, track marks; no head injury signs. Intervention: Once stabilised, maintain dignity, cover patient.

NEWS2 Calculation:
RR 5=3, SpO₂ 82% on O₂ (Scale 2: SpO₂ 82% = 3, on O₂ add 2? NEWS2 uses Scale 2 for SpO₂ if target 88‑92% but here assume standard scale; using standard, 82% = 3, on O₂ yes, add 2 = 5), SBP 80=3, HR 50=1, Conscious P=3. Total=3+5+3+1+3 = 15 (extreme high). Score triggers immediate emergency.
Overall Risk: Critical. Coma, respiratory depression, high NEWS2 (>7). Risk of cardiorespiratory arrest.
Escalation: Emergency buzzer, medical emergency team, 999, secure removal of illicit substance evidence per policy, inform security.
Management Plan

• Continue BVM until naloxone restores spontaneous ventilation.
• Repeat naloxone every 2‑3 min up to 2 mg if needed; start naloxone infusion if repeated doses (400 µg in 100 mL over 10 min).
• Once RR >10 and SpO₂ >92% on air, place in recovery position, high-flow O₂ via mask, monitor.
• Transfer to acute hospital for observation (risk of re‑sedation).
• Mental Health Act assessment for capacity to refuse: treat under common law (emergency).

SBARD Handover (to paramedics/ED)

• Situation: 41‑year‑old male, unresponsive, pinpoint pupils, ? opioid overdose.
• Background: Forensic patient, history of intravenous heroin use, on methadone maintenance (60 mg). Detained under Section 37.
• Assessment: GCS 6, RR 5, SpO₂ 82%, responded partially to 0.4 mg IV naloxone – now RR 10, SpO₂ 90% on O₂. NEWS2 15.
• Recommendation: Immediate transfer for ongoing naloxone, monitored bed.
• Decision: Escort with 3 staff, Section papers, drug chart, handover to toxicology.

Equipment Used: BVM, O₂, OP airway, suction, defibrillator, IV start kit, naloxone ampoules, syringe driver for infusion, pulse oximeter, NEWS2 chart.
Engagement: Despite unconsciousness, speak to patient during procedures (“We are helping you breathe”). Post‑naloxone, when awake, patient may be agitated and combative due to acute withdrawal and antagonism of opioid effect. Use non‑threatening posture, soft voice, explain why naloxone was necessary. Ensure sufficient staff for safety.

Scenario 4: Generalised Tonic‑Clonic Seizure
Setting: Medium-secure female ward. A 35‑year‑old woman with emotionally unstable personality disorder and epilepsy (non‑adherent to lamotrigine) is witnessed having a seizure lasting 3 minutes.
A‑E Assessment & Interventions during seizure

• Airway: Do not insert anything; protect head, clear dangerous objects. Note time. After convulsions cease, place in recovery position, open airway with jaw thrust.
• Breathing: During post‑ictal, RR irregular 18, SpO₂ 94% on air. Intervention: Administer O₂ via mask at 10 L/min if SpO₂ <94%.
• Circulation: HR 115, BP 140/90. Intervention: Check BGL (4.8 mmol/L). Insert cannula.
• Disability: Post‑ictal confusion, responds to pain, GCS 10. Pupils equal and reactive. Intervention: Check for injuries; if seizure continues >5 min or repeats, give buccal midazolam 10 mg or IV lorazepam 4 mg as per protocol.
• Exposure: Check for incontinence, injury; cover to maintain dignity.

NEWS2 Calculation (post‑ictal):
RR 18=0, SpO₂ 94% (Scale 2 if target 88‑92%? Usually not, so 94% = 1), SBP 140=1, HR 115=2, Conscious V=3, Temp 36.8°C=0. Total = 0+1+1+2+3+0=7 (high risk). Use of Scale 2 for hypercapnic risk: not applicable; assume normal.
Overall Risk: High NEWS2, prolonged post‑ictal state, risk of recurrence or status epilepticus.
Escalation: Medical registrar, 999 if seizure >5 min or new onset, inform nursing shift leader, document in seizure chart.
Management Plan

• Maintain recovery position, O₂, suction available.
• Monitor vitals every 10 min until fully conscious.
• If seizure recurs within 1 hour, treat as status – give lorazepam and call ambulance.
• Review lamotrigine levels and adherence; consider IM depot anticonvulsant?
• Increase observations to level 1 (constant) for 24 h.

SBARD Handover (to on‑call doctor/neurology)

• Situation: 35‑year‑old witnessed tonic‑clonic seizure, post‑ictal, NEWS2 7.
• Background: Epilepsy, poorly compliant with lamotrigine 200 mg BD. EUPD. No recent alcohol or drug use.
• Assessment: Seizure lasted 3 min, post‑ictal GCS 10, no injuries, BGL normal. Buccal midazolam not required.
• Recommendation: Urgent neurology review, check lamotrigine serum level, consider medication change or depot.
• Decision: Medical team to review within 1 hour, keep as inpatient for monitoring.

Equipment Used: Suction catheter, O₂, bag‑valve‑mask, pulse oximeter, glucometer, buccal midazolam/IV lorazepam, padded side rails removed, seizure observation chart.
Engagement: Protect the patient’s head without restraint; reassure calmly during the seizure; speak gently during post‑ictal confusion. Orientate the patient frequently (“You’re in hospital, you’ve had a seizure, you are safe”).

Scenario 5: Ligature Self‑Harm with Airway Threat
Setting: High-secure ward. A 27‑year‑old man with depression and PTSD found in his room with a ligature around his neck, conscious but stridulous breathing, petechiae on face.
A‑E Assessment & Interventions

• Airway: Partial obstruction, stridor, ligature still in place but loosened. Intervention: Immediately cut/remove ligature using safety shears. Stabilise cervical spine manually (consider drop, no C‑spine immobilisation unless fall). Inspect neck for swelling, crepitus. High‑flow O₂.
• Breathing: RR 30, laboured, SpO₂ 89% air, improves to 94% with 15 L O₂. Equal air entry. Intervention: Continuous O₂, prepare for difficult airway – call anaesthetist if available, otherwise 999 and paramedic.
• Circulation: HR 130, BP 150/100, CRT 2 s. Intervention: IV access, monitor.
• Disability: Alert but anxious, GCS 15. Intervention: Constant verbal reassurance, do not leave alone.
• Exposure: Neck ligature mark, facial petechiae, no other injuries. Intervention: Cover with gown after assessment.

NEWS2 Calculation:
RR 30=3, SpO₂ 89% (on O₂ now, but initially; we score initial SpO₂ before O₂? NEWS2 uses SpO₂ reading at assessment, if on O₂, use Scale 2. Initially 89% on air, after O₂ 94%. Score based on 89% on air = 2, but if now on O₂, the score for SpO₂ is 2 for 89%, and add 2 for O₂ = 4. Assume we record the worst. RR 30=3, SBP 150=0, HR 130=2, Alert=0. Total=3+4+0+2+0=9, high risk.)
Overall Risk: Extreme – airway compromise, high NEWS2, self‑inflicted injury. Risk of re‑attempt high.
Escalation: Emergency buzzer, security code, 999 ambulance, mental health crisis team, senior clinician, safeguarding incident.
Management Plan

• Manage airway as priority; if stridor worsens, consider emergency cricothyroidotomy kit (equipment check).
• Constant 1:1 observation; remove all potential ligature points.
• Transfer to acute hospital for ENT and psychiatric evaluation.
• Inform police? (ligature attempt in custody, follows local protocol). Document as serious untoward incident.

SBARD Handover (to paramedics/ED)

• Situation: 27‑year‑old male post‑ligature, partial airway obstruction, stridor.
• Background: Depression and PTSD, detained under Section 3. Previous self‑harm history. Ligature made from sheet.
• Assessment: Ligature removed, stridor present, SpO₂ improved on O₂, petechiae, no loss of consciousness. NEWS2 9.
• Recommendation: Urgent transfer for airway management and psychiatric assessment.
• Decision: 999 en route, 3 escorts, legal documents.

Equipment Used: Safety shears (ligature cutters), O₂, suction, airway adjuncts, cricothyroidotomy kit (check availability), pulse oximeter, gloves (forensic evidence preservation), sphygmomanometer.
Engagement: Use a compassionate, non‑judgmental tone; validate distress without reinforcing the act (“I can see you’ve been feeling overwhelmed, we are here to keep you safe”). Ensure safe environment for staff; do not enter room alone. Remove other patients from area.

Scenario 6: Acute Dystonic Reaction (Laryngeal Dystonia)
Setting: Acute admission ward. A 22‑year‑old male with first episode psychosis, started on haloperidol 10 mg yesterday, presents with neck twisted to right (torticollis), jaw clenched, stridor, difficulty speaking.
A‑E Assessment & Interventions

• Airway: Stridor, partial obstruction from laryngeal spasm. Intervention: Call emergency. Administer high‑flow O₂. Prepare procyclidine 5 mg IV/IM stat (or benztropine 2 mg). Reassure.
• Breathing: RR 26, laboured, SpO₂ 93% on air. Intervention: O₂ via mask. Monitor closely.
• Circulation: HR 120, BP 140/85. Intervention: IV access, administer procyclidine IV slowly (or IM if no IV). Observe for rapid relief.
• Disability: Alert, extremely anxious, unable to speak clearly. Intervention: Use pen and paper to communicate; show the medication and explain it will relax the muscles.
• Exposure: Observe for other dystonic postures, oculogyric crisis (eyes rolled up). Pupils normal.

After procyclidine 5 mg IV: Within minutes, stridor resolves, neck relaxes. SpO₂ rises to 98%, RR 18.
NEWS2 Calculation (at presentation):
RR 26=2, SpO₂ 93% (Scale 1? normal scale 93% = 2, not on O₂ initially), SBP 140=1, HR 120=2, Alert=0, Temp 37.0°C=0. Total = 2+2+1+2=7 (high risk).
Overall Risk: High due to airway compromise; rapid treatment crucial. Once resolved, risk falls.
Escalation: Medical registrar, document as adverse drug reaction, inform pharmacy, review antipsychotic.
Management Plan

• Discontinue haloperidol; document allergy/intolerance.
• Prescribe procyclidine 5 mg PRN for 48 h.
• Switch antipsychotic to an atypical with lower EPS risk (e.g., olanzapine 5 mg).
• 1:1 observation for 4 hours; reassurance.
• Report under MHRA Yellow Card.

SBARD Handover (to ward doctor/on‑call)

• Situation: 22‑year‑old, acute dystonic reaction with laryngeal involvement post haloperidol.
• Background: First episode psychosis, haloperidol 10 mg started yesterday, no other meds.
• Assessment: Stridor, torticollis, trismus, responded immediately to IV procyclidine. NEWS2 improved from 7 to 2.
• Recommendation: Stop haloperidol, change to alternative antipsychotic, add PRN anticholinergic.
• Decision: Plan agreed, monitor for re‑emergence.

Equipment Used: Procyclidine ampoule, syringes, IV start, pulse oximeter, oxygen, AVPU scale, NEWS2 chart.
Engagement: Recognize the frightening nature of dystonia. Stay calm, explain the reaction is treatable, use simple gestures. After resolution, thank the patient for cooperating, debrief the experience.

Scenario 7: Neuroleptic Malignant Syndrome (NMS)
Setting: Long‑stay forensic ward. A 48‑year‑old male with treatment‑resistant schizophrenia on fluphenazine decanoate and lithium presents with lead‑pipe rigidity, confusion, fever 39.8°C, tachycardia, labile blood pressure, and diaphoresis over 24 h.
A‑E Assessment & Interventions

• Airway: Patent.
• Breathing: RR 32, deep, SpO₂ 96% air, clear breath sounds.
• Circulation: HR 135, BP 170/100, CRT 3 s. Intervention: IV access, fluid bolus 500 mL 0.9% saline, monitor. ECG shows sinus tachycardia.
• Disability: Confused (new confusion, C on AVPU), GCS 14, rigid limbs, hyperreflexia? BGL 5.9. Intervention: Take temperature (tympanic). Stop all antipsychotics immediately. Initiate cooling measures (remove blankets, fan, tepid sponging). Check CK (send stat bloods).
• Exposure: Diaphoresis, warm extremities, no rash (meningococcal screen later). Intervention: Cover lightly, regular temp monitoring.

NEWS2 Calculation:
RR 32=3, SpO₂ 96%=0, SBP 170=2, HR 135=3, Conscious C=3 (new confusion), Temp 39.8°C=3. Total = 3+0+2+3+3+3 = 14 (critical). NMS is a medical emergency.
Overall Risk: Extreme – hyperthermia, autonomic instability, rigidity, risk of rhabdomyolysis, renal failure, mortality.
Escalation: 999 ambulance, medical emergency team, inform consultant psychiatrist, document as serious adverse event.
Management Plan

• Stop all dopamine antagonists (antipsychotics, metoclopramide).
• Active cooling: ice packs to groin/axillae, cooled IV fluids if available.
• If severe, dantrolene or bromocriptine may be started in hospital.
• Transfer to acute medical unit/HDU.
• Send bloods: CK, renal function, LFTs, FBC, CRP, blood cultures (sepsis screen).
• Catheterise and monitor urine output (risk of myoglobinuria).

SBARD Handover (to ambulance/ED)

• Situation: 48‑year‑old, suspected NMS, hyperthermia, rigidity, confusion.
• Background: Schizophrenia, on fluphenazine decanoate and lithium for years. Recent dose increase. No other medications.
• Assessment: Temp 39.8°C, RR 32, HR 135, BP labile, lead‑pipe rigidity, confusion. NEWS2 14.
• Recommendation: Urgent transfer to medical HDU for supportive care, dantrolene consideration, and psychiatric review.
• Decision: 999 requested, escort team, legal documents, medication chart, advance decision to stop neuroleptics.

Equipment Used: Thermometer (tympanic), sphygmomanometer, pulse oximeter, ECG machine, IV access, cooling packs, fan, NEWS2 chart.
Engagement: The patient may be frightened and combative due to confusion. Speak softly, explain that you are helping to bring down the temperature and that the medication has caused a reaction. Use de‑escalation techniques; maintain safe distance.

Scenario 8: Acute Pulmonary Embolism (PE)
Setting: Medium‑secure female ward. A 47‑year‑old obese woman with bipolar disorder and physical health comorbidity (recent DVT, non‑compliance with anticoagulation) suddenly complains of sharp right‑sided chest pain, breathlessness, and coughs up a small amount of blood‑tinged sputum. She is visibly distressed.
A‑E Assessment & Interventions

• Airway: Patent, speaking.
• Breathing: RR 36, SpO₂ 88% on air, auscultation clear, some wheeze? Intervention: High‑flow O₂ 15 L/min via reservoir mask, sit upright. Assess for signs of tension pneumothorax (none).
• Circulation: HR 140, BP 90/60, JVP raised? peripheral cool. Intervention: IV access, cautious fluid bolus 250 mL if hypotensive. ECG: sinus tachycardia, S1Q3T3 pattern. Immediate medical help.
• Disability: Alert, extremely anxious, GCS 15, BGL 7.1. Intervention: Reassure, stay with patient.
• Exposure: Check legs – left calf swollen, tender, red. Previous DVT site. Intervention: Elevate limb, document.

NEWS2 Calculation:
RR 36=3, SpO₂ 88% (on air) = 2 (if on O₂, score becomes weighted; initial air 88% = 2, then on O₂ add 2 = 4), SBP 90=3, HR 140=3, Alert=0, Temp 37.1=0. Total = 3+4+3+3 = 13 (critical). High risk of massive PE.
Overall Risk: Critical. Hypoxia, hypotension, tachycardia – massive PE.
Escalation: Call 999 immediately. Medical emergency team. Inform Responsible Clinician. Prepare for thrombolysis discussion in ED.
Management Plan

• Continue O₂, maintain supine position? Semi‑Fowler’s.
• Obtain IV access, do not give aspirin (could be massive PE, thrombolysis may be required).
• Monitor vitals every 5 min.
• Prepare patient for transfer; bring all current drug charts (especially if on warfarin/DOAC).
• Do not administer any anticoagulant without advice (patient may already have subtherapeutic INR).

SBARD Handover (to paramedics/ED)

• Situation: 47‑year‑old female, sudden pleuritic chest pain, breathlessness, haemoptysis, hypoxia.
• Background: Bipolar disorder, obese, known DVT, non‑compliant with rivaroxaban. Previous PE 2 years ago.
• Assessment: RR 36, SpO₂ 88% on air, HR 140, BP 90/60, ECG S1Q3T3, left calf DVT signs. NEWS2 13.
• Recommendation: Immediate transfer for CTPA, probable thrombolysis or anticoagulation.
• Decision: 999 transport, 3 escorts, legal paper, advance decision.

Equipment Used: O₂, pulse oximeter, sphygmomanometer, ECG, IV cannula, fluids, thermometer, NEWS2 chart.
Engagement: During panic, maintain a calm, steady voice. Coach breathing (“try to breathe with me, slow and deep”). Hold her hand if culturally acceptable, but respect boundaries. Explain each action.

Scenario 9: Severe Alcohol Withdrawal with Delirium Tremens
Setting: Admission ward. A 44‑year‑old man with severe alcohol dependence, detained under Section 2, admitted 36 hours ago. Now agitated, disoriented, seeing insects on walls, diaphoretic, severe tremor.
A‑E Assessment & Interventions

• Airway: Patent, but risk of vomiting; place in semi‑prone if drowsy.
• Breathing: RR 28, SpO₂ 95% air, clear.
• Circulation: HR 125, BP 160/100, CRT 3 s, warm. Intervention: IV access, bloods for FBC, U&E, LFT, clotting, glucose. Start IV Pabrinex (thiamine) – high‑potency B vitamins, 2 pairs three times daily.
• Disability: New confusion (C), agitated, hallucinating, GCS 14 fluctuating, BGL 5.2, tremor, hyperreflexia. Intervention: Administer oral lorazepam 2 mg (or IM if refuses) according to CIWA‑Ar protocol. Encourage fluids. Reduce stimuli.
• Exposure: Sweaty, no signs of injury, but check for head trauma (history of falls?). Intervention: Cover lightly, monitor temperature (37.6°C).

NEWS2 Calculation:
RR 28=3, SpO₂ 95%=0, SBP 160=2, HR 125=2, Conscious C=3, Temp 37.6°C=0. Total = 3+0+2+2+3 = 10 (high risk).
Overall Risk: High – risk of progression to seizures, Wernicke’s encephalopathy, cardiac arrhythmia, severe agitation.
Escalation: Medical registrar, critical care outreach if CIWA‑Ar score very high. Possibly 999 if uncontrolled.
Management Plan

• Start symptom‑triggered benzodiazepine regime: lorazepam 2‑4 mg PO/IM every 1‑2 hours as needed for CIWA‑Ar >10.
• Thiamine IV then oral.
• Fluid and electrolyte replacement.
• Regular observations: hourly NEWS2, CIWA‑Ar every hour initially.
• 1:1 nursing, low‑stimulus environment, seizure precautions.
• If hallucination and agitation severe, consider haloperidol 2‑5 mg IM (cautious, seizure threshold).

SBARD Handover (to medical team/psychiatrist on call)

• Situation: 44‑year‑old male, severe alcohol withdrawal, delirium tremens, NEWS2 10.
• Background: Alcohol dependence, admitted under Section 2, last drink 2 days ago. No known liver disease.
• Assessment: Disoriented, visual hallucinations, tremor, HR 125, BP 160/100. CIWA‑Ar score 24.
• Recommendation: Admit to medical ward for detoxification under constant observation; start CIWA‑Ar protocol.
• Decision: Patient transferred to general hospital medical ward with RMN escort due to mental health act status; handover completed.

Equipment Used: CIWA‑Ar chart, NEWS2, sphygmomanometer, pulse oximeter, thermometer, IV thiamine (Pabrinex), lorazepam, glucometer.
Engagement: Approach calmly, don’t argue with hallucinations (“I don’t see insects, but I believe that you do; you are safe here”). Orientate frequently. Avoid confrontation, use verbal de‑escalation, provide reassurance. Use minimal restraint; offer medication as “something to help you feel calmer.”

Scenario 10: Choking During Meal (Cafeteria Incident)
Setting: Medium‑secure unit, communal dining. A 62‑year‑old man with chronic schizophrenia, on clozapine (hypersalivation, dysphagia), suddenly stops speaking, clutches his throat, becomes cyanotic.
A‑E Assessment & Interventions

• Airway: Complete obstruction – cannot cough, speak, or breathe. Intervention: Call for help. Stand behind, perform abdominal thrusts (Heimlich manoeuvre) up to 5 times. If unsuccessful, alternate with 5 back blows. Continue cycles until obstruction relieved or unconscious.
• Breathing: If patient becomes unconscious, lower to floor, start CPR (begin with chest compressions, 30:2, check mouth for object before breaths). Attempt to visualise and remove visible object with Magill forceps if trained.
• Circulation: Check pulse during unconsciousness; if no pulse, full CPR with defibrillator when available.
• Disability: AVPU – if conscious during partial obstruction, encourage cough; if unconscious, GCS 3, manage as cardiac arrest.
• Exposure: Once airway cleared, assess for injury from thrusts.

*Obstruction clears after 3 cycles of back blows/abdominal thrusts – patient coughs out a piece of meat.* Now breathing, SpO₂ 90% on air → apply O₂ mask.
NEWS2 Calculation post‑choking:
RR 24, SpO₂ 90% on O₂ (Score: SpO₂ 90% = 2, on O₂ add 2 = 4), HR 110, BP 150/95, Alert, Temp 36.8°C. RR 24=2, SpO₂ total=4, HR 110=2, others 0. Total=8 (high risk).
Overall Risk: High due to recent complete airway obstruction and hypoxia. Risk of recurrence, aspiration pneumonia.
Escalation: Incident report, medical review, speech and language therapist (SALT) referral, dietician, 999 if any signs of pulmonary aspiration.
Management Plan

• Monitor SpO₂ and RR continuously for 4 hours.
• Chest auscultation – check for crackles.
• Keep NBM until SALT review and swallowing assessment.
• Review clozapine side effect management (hyoscine for hypersalivation).
• Provide modified diet (pureed/soft) if indicated.
• Incident debrief with patient and staff.

SBARD Handover (to medical team)

• Situation: 62‑year‑old male, choking incident resolved, NEWS2 8 post event.
• Background: Schizophrenia, on clozapine, known hypersalivation, possible dysphagia.
• Assessment: Complete obstruction relieved, now SpO₂ 90% on O₂, RR 24, coarse crackles left base. Alert.
• Recommendation: Urgent SALT assessment, chest X‑ray to rule out aspiration, hold clozapine dose? Discuss with psychiatrist.
• Decision: SALT and medical review within 1 hour, continue O₂, keep NBM, 1:1 supervision for meals.

Equipment Used: O₂ cylinder, pulse oximeter, suction, Magill forceps (if available), bag‑valve‑mask (standby), automatic defibrillator (if arrest), NEWS2 chart.
Engagement: Remain calm, reassure the patient throughout the episode (“I’m going to help you”). Afterward, explain what happened, avoid causing embarrassment. Ensure patient feels safe to eat again. Maintain dignity, clean up any mess discreetly.