Management of Suicide Attempts in the Emergency Department

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Author: Felix Matos Padilla, MSV
Medical Student
Universidad Iberoamericana (UNIBE) School of Medicine

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Suicide is by far the most common cause of premature death among patients with major mood and psychotic disorders.[1] Attempted suicide is defined as a nonfatal self-inflicted destructive act with the explicit or implicit intent to die.[2] In 2008, a total of 36,035 persons died as a result of suicide, and approximately 666,000 persons visited hospital emergency departments (EDs) for nonfatal self-inflicted injuries [3] With this in mind, it is fundamental for an emergency physician to know how to handle a suicide attempt.

During the initial encounter, the priority of the physician should be to stabilize the patient's medical condition, evaluating signs and symptoms without attributing them to a psychiatric origin. Intoxication and delirium should be ruled out, because the patient must be sober before the suicide evaluation can take place.[4] The greatest potential error in the ED is confusing a physical illness for a psychiatric illness.[1]

After the patient is medically stabilized, the next priority is to set up an appropriate environment for the interview. It is necessary to ask about the means by which the patient attempted suicide and to ask about past psychiatric history including prior suicide attempts. The use of basic interviewing techniques learned in medical school is a great way to gather information from the patient. This requires the physician to remain calm and non-judgmental while trying to identify the stressors that triggered the patient to attempt suicide.[4]

A patient should not be discharged from the ED prior to having a full evaluation. The physical examination is a critical step in the evaluation of patients who have attempted suicide. The patient should be changed into a hospital gown and the examination should be thorough and complete, paying close attention to physical findings associated with chronic disease, alcoholism, substance abuse, and trauma.[4] Special emphasis should be placed on the following parameters: appearance, level of attention, affect, dress and grooming, needle marks, unusual odors, or excoriations.[4]

Finally, to minimize the chances of repeat self- injury it is essential to maintain the patient in a safe area and keep him or her under observation at all times while in the ED. If there is an acute danger to the patient or others, physical (e.g., nylon or leather cuffs) or chemical (e.g., haloperidol) restraints might be necessary. A security guard should be present in the patient's room during the evaluation if the caregiver feels threatened or if the patient is placed on a temporary involuntary hold.[4] If a patient who attempted suicide leaves the ED, the police should be immediately contacted and provided with a description of the patient because he/she may be a threat to himself/herself and possibly to others.[5]

After the emergency physician’s medical evaluation, the physician should involve the hospital’s mental health services in the patient’s care. Each hospital has different resources for mental health care — whether a psychiatrist is available on site, a mental health professional screens the patient in the ED, or transfer to another facility is required — the physician should understand their hospital’s policy. Additionally, emergency physicians should be familiar with their state’s laws regarding involuntary psychiatric holds. After a full medical and mental health evaluation, if the physician decides to discharge the patient, he/she must ask about the availability of firearms, potentially lethal medications, and other means of suicide; establish a firm follow-up plan with visits during the days after the attempt, and involve the patient's family in the care of the patient.[4]


References:
1. Ramadan, M. Managing Psychiatric Emergencies. The Internet Journal of Emergency Medicine. 2006 Volume 4 Number 1. Retrieved from: http://ispub.com/IJEM/4/1/13551


2. Boyd, M. Psychiatric Nursing: Contemporary Practice (Internet). 4th Edition. China: Lippincott Williams & Wilkins; 2008.


3. Crosby, A., Han, B., Ortega, L., Parks, S., Gfroerer, J. Suicidal Thoughts and Behaviors Among Adults Aged ≥18 Years in the United States, 2008-2009. October 21, 2011 / 60(SS13);1-22. Retrieved from: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6013a1.htm?s_cid=ss6013a1_e


4. Carrigan, C., Lynch D. Managing Suicide Attempts: Guidelines for the Primary Care Physician. National Center for Biotechnology Information. 2003; 5(4): 169–174. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419387/.


5. NSW Department of Health. Suicide Risk Assessment and Management. Emergency Department. NSW Department of Health, 2004. Retrieved from: http://www0.health.nsw.gov.au/pubs/2004/pdf/emergency_dept.pdf