6 - Self Harm and Suicide Flashcards
How do you do a risk assessment for suicide?
- When did you first want to harm yourself?
- Any final acts?
- What were the circumstances?
- How do you feel about it now?
- Who called for help?
- Risk factors?
- Protective factors?
- Psychiatric history?
- Full history?
- Collateral history?
How do you do a risk assessment in a MSE?
- Risk to self
- Risk to others
- Risk to children (even adult saying they were abused as child)
- Drug use/Alcohol use
- Forensic History
- Driving
What is deliberate self-harm?
Does asking someone if they are suicidal increase the risk of them actually doing it?
No - if anything it decreases the risk
When is the risk of suicide highest?
As an inpatient or up to 14 days post-discharge
Should you start treatment after a suicide attempt in ED?
NO!
Start in GP or Crisis team as they can monitor
What is the definition of suicide and what is the epidemiology of this?
Intentional self-inflicted death
3rd biggest cause of death in UK
Hanging was main way followed by poisoning
What are some factors that increase a person’s risk of suicide?
(image is important)
- Male
- Age
- PMHx: Bipolar, Depression, BPD, Anorexia
- Substance abuse
- No job
- Occupation: Vets, doctors, nurses, farmers
What are some protective factors that lower the risk of suicide?
- Marriage
- Children
- Religious belief
- Responsibility for others
- Supportive community
How may someone who is suicidal present?
- Preoccupations with death
- Emotional distance from others
- Focus on the past and anticipate no future
- Withdrawal from society
- Feelings of hopelessness
How can you determine the risk of suicide following an attempt?
Note: Planned Attempt Are Very Frightening
- Note left behind
- Planned attempt
- Attempt to avoid discovery
- Afterwards help was not sought
- Violent method
- Final Acts e.g sorting finances and writing will
What are some questionnaires you can use for suicide risk?
- Tool for Assessment of Suicide Risk (TASR)
- Beck Suicide Intent Scale
How do you do a suicide risk assessment in an OSCE?
(important)
- Explore ideation
- Explore intent
- Explore risk factors
- Explore protective factors
- MSE
- Explore risk to others e.g children
After doing a suicide risk assessment who should you refer to secondary care?
SUSPicious
- Suicidal ideation
- Underlying severe psychiatric illness
- Social support lack of
- Presentation change for someone who has repeatedly self-harmed
How is suicide risk managed?
- Ensure safety e.g remove means
- Admit to hospital and consider using MHA
- Crisis and Home treatment team
- Treat any depression and psychosis
What are some of the differences in epidemiology between suicide and deliberate self-harm?
What is the definition of deliberate self harm and some examples of this?
Intentional act of self-poisoning or self-injury irrespective of the motivation/purpose of the act
Often an expression of emotional distress. OD and cutting are most common
What is the prevalence/epidemiology of DSH?
0.2-0.4%
More common in females and adolescents
Increases risk of suicide
What are some risk factors for deliberate self-harm?
DSH Largely Comes Via Self Poisoning
What are the top 2 causes of DSH?
- Over dose (90%)
- Self-Injury (8-10%)
What are some complications of DSH?
- Permanent scarring of skin
- Damage to tendons and nerves
- Acute liver failure from OD
- Accidental death
How can you work out the motive behind self-harm?
DRIPS
- Death wish
- Relief
- Influencing Others
- Punishment
- Seeking attention
What bloods should you do for an overdose?
- Paracetamol levels t 4 hours
- Salicyclate levels
- U+Es
- LFTs
- Clotting profile
What is the management for self-harm?
Biological: Treat any overdose with antidote and suture any injuries
Psycho: Assess risk of suicide. Counselling and CBT if depressed. Psychodynamic therapy if personality disorder
Social: Voluntary organisations e.g Mind, explore life stressors
CONSIDER USING MHA IF REFUSING TREATMENT. FOLLOW UP IN 48 HOURS
What is the antidote for the following:
What are some of the clinical features of paracetamol overdose?
- No symptoms
- Nausea and vomiting
- Loin pain
- Haematuria and proteinuria
- Jaundice
- Abdominal pain
- Coma
- Severe metabolic acidosis
How does paracetamol overdose cause harm?
Metabolism of paracetamol results in a buildup of a toxic substance called NAPQI (N-acetyl-p-benzoquinone-imine).
NAPQI is inactivated by glutathione. In an overdose, glutathione stores are rapidly depleted, and NAPQI is left un-metabolised. It can cause liver and kidney damage.
What questions do you need to ask if a patient presents with paracetamol overdose?
- Timing of ingestion: single overdose or staggered
- Time since last ingestion (even staggered)
- Weight: if >110 kg, used 110 kg as the maximum weight for calculations.
- Total amount ingested (mg/kg)
- Current suicidal risk
How is paracetamol overdose medically managed?
- If ingestion less than 1 hour ago + dose >150mg/kg: Activated charcoal
- If staggered overdose or ingestion >15 hours ago: Start NAC now
- If ingestion <4 hours ago: Wait until 4 hours to take a level and treat then
- If ingestion 4-15 hours ago: Take immediate level and treat based on level
Use nomogram and start NAC once over treatment line
If a patient presents after 16 hours, there is uncertainty about timing or has a staggered overdose then NAC should be started regardless of the nomogram
What is an adverse effect of NAC?
Anaphylactoid reactions
Seen in up to 30% of patients treated with the 21-hour regimen
It usually occurs soon after the first infusion with features of nausea, vomiting, urticarial rash, angioedema, tachycardia, and bronchospasm.
Temporarily stop the infusion, consider chlorphenamine (anti-histamine) and nebulised salbutamol. Once the reaction has settled, restart the infusion
What patients would you start NAC immediately on?
