Suicide Attempt: Immediate management

1. 20 June 2011 Suicide Attempt: Immediate management Dr Saman Yousuf Honorary Fellow - CSRP

2. Scenarios in which suicide attempters may be dealt with • Emergency Service (Hospital) • Outpatient clinic • Informal setting Different approach for each setting

3. 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

4. Self harm Patient in ED Protocols followed in hospital MINOR DRUG OVERDOSE OR INJURY DRUG OVERDOSE INJURIES Admit medical Admit ortho/ surgery Observe in ED Psychosocial assessment Follow up Discharge

5. 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

6. 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

7. 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)

8. 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)

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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)

16. 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

17. 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

18. 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

19. THANK YOU