Suicide Attempt: Immediate management

Dr Saman YousufHonorary Fellow - CSRP

20 June 2011

Scenarios in which suicide attempters may be dealt with

• Emergency Service (Hospital)

• Outpatient clinic

• Informal setting

Different approach for each setting

Emergency presentations

• History of self harm or self injury reported by the relative

• Signs of self harm observed on examination

• Self-poisoning• Drug overdose• Toxic substance eg. charcoal

• Self-injury• Jumping from height• Hanging• Cutting

Protocols followed in hospital

Self harm Patient in ED

Admit medical

Admit ortho/surgery

Observein ED

Psychosocial assessment

DischargeFollow

up

DRUG OVERDOSE INJURIES

MINOR DRUG OVERDOSE OR INJURY

Presentation – Drug Overdose

• Problems with vital signs

• Sleepiness, confusion or coma

• Aspiration

• Skin changes

• Chest pain

• Breathing changes

• Abdominal pain, nausea, vomiting, diarrhea

• Drug-specific damages to internal organs

Treatment of overdose

• Resuscitation measures• Triage assessment • Airway – Breathing – Circulation• Stabilization of the body (for physical injuries)• Thorough examination

• Gastric lavage• Nasogastric intubation• Stomach wash to mechanically remove unabsorbed

drug• Usually done within

an hour

• Activated Charcoal• Binds drugs in the stomach and intestines

preventing them from further absorption• Expelled in stools• 50-100 mg for adults• Not for small molecules eg alcohol, metallic ions

• Physical restraint or sedation• For violent, agitated or confused patients only

• Antidote• Specific to the poison drug• Counter its effects on the body• Narcotics overdose = IV Naloxone (0.4-2 mg)• Hypnotics / Benzodiazepines overdose = IV Flumazenil (0.5 – 2

mg)

• Observation on the medical ward• Level of monitoring to be determined in ED• Suicidal precautions on the ward

• Psychosocial assessment• Psychiatric evaluation • Evaluation by the medical social workers

• Follow-up• Assessment of risk before discharge• Frequent follow-up (continuity of care)

Case of Charcoal Burning

• Burning of charcoal in closed spaces with the intention of suicide

• Carbon monoxide poisoning

• Carbon monoxide bind to hemoglobin and displace oxygen causing tissue hypoxia

Treatment

• The treatment for carbon monoxide poisoning is high-dose oxygen, usually using a facemask attached to an oxygen reserve bag

• Carbon monoxide levels in the blood may be periodically checked until low enough

• In severe poisoning, if available, a hyperbaric pressure chamber may be used to give even higher doses of oxygen

Presentation – Self injury

• Jumping – often fatal

• Hanging – often fatal

• Other self inflicted injuries• Stop bleeding for sites• Repair wound

• Psychosocial assessment

• Discharge and follow-up

Important aspects of emergency care

• People who have self-harmed should be treated with the same care, respect and privacy as any patient

• After the emergency management is over – while waiting for psychosocial assessment, they should be transferred to a safe environment and remain in observation

• All clinical and non-clinical staff should be trained to deal with patients who self-harm

• Availability of psychosocial services at the hospital

HK JC Centre for Suicide Research and Prevention formed a report of Deliberate Self-Harm cases (between 1997-2003) in 2004

They showed the peak time for admission of self harm patients into emergency departments was 22:00 – 02:00 hours but

2001 study

Outpatient presentations

• Doctor may find out about a recent suicide attempt by the patient through him/her, a family member or suspect it upon examination

• Risk assessment – Important!

• Overall physical condition will determine the need for emergency or medical services

• Psychosocial assessment as soon as possible

Informal presentation

• A friend• A colleague• A family member

• Involve a health care professional for independent assessment and management

• Possible role in de-stigmatizing treatments and mental health professionals

• Discuss your reactions and difficulties with a senior colleague or supervisor (while respecting confidentiality)

Psychosocial management of suicide attempters

• Assessment determines possible causes and modifiable risk factors

• Individual-specific treatment • Psychiatric illness• Social problems• Consider support groups of suicide attempt survivors• Other resources

• Dealing with stigma following suicide attempt• From family• From doctors• From colleagues

• Dealing with families affected by the suicide attempt

• Educate families about common reactions they should expect towards the attempter

– ANGER– GUILT– ANXIETY / JUMPINESS– SENSE OF INSECURITY– POWERLESSNESS OR HELPLESSNESS– BETRAYAL

• Counsel them about how to deal with attempt survivors

– DO(S) AND DON’T(S)– FOCUS ON TRIGGERS AND RISKS RATHER THAN

METHOD OF ATTEMPT– SUGGEST SUPPORT GROUPS

• Follow-up and re-assessment of risk as there is high risk of re-attempt

Involuntary detention of suicidal patients

• Mental Health Ordinance of Hong Kong• Based on the Mental Health Ordinance of UK (1983)

• Sections 31, 32, 35A and 36

• Application to be made to the district judge stating details of the decision and why hospital treatment is recommended

• Detention period for observation may extend to 7 days and extension of stay may be given for maximum of 21 days

THANK YOU