20 June 2011
Suicide Attempt:
Immediate management
Dr Saman Yousuf
Honorary Fellow - CSRP
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
Self harm
Patient in ED
DRUG
OVERDOSE
Admit
medical
MINOR DRUG
OVERDOSE OR
INJURY
INJURIES
Admit ortho/
surgery
Observe
in ED
Psychosocial
assessment
Protocols followed
in hospital
Discharge
Follow
up
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 highdose 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 19972003) 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