Suicide Attempt: Immediate management 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

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

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 Gastric lavage 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

Physical restraint or sedation 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

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