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
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