Self Harm Flashcards
What is parasuicide?
An act of non-fatal outcome, in which an individual has deliberately attempted to harm themselves
Both self harm and attempted suicide fall under this term
Definition of suicide…
The act of killing oneself deliberately, initiated and performed by the individual with full knowledge and expectation of the outcome
Assessment of self harm patient…
- Secure airway if reduced consciousness
- Recovery position - if patient vomits
- Gain IV access - take full bloods and toxicology screen
- Exposure of patient to look for: cuts, burns/scalds, ligature marks, scratching
- Focussed examination - looking for signs of drug misuse, alcoholism, psychiatric disorders
What are the five components of suicide risk assessment?
- Details about current attempt:
- Trigger/ precipitating event
- Impulsive/ planned?
- Have they put plans in place e.g. written a will
- Method used
- Effort to avoid being found
- Intention
- Did they seek help after the attempt - Assessment of risk factors:
- Previous suicide attempts/ DSA
- Past psych history: affective disorders, schizophrenia
- PMH- chronic pain, insomnia
- Substance misuse
- Bereavement
- Financial difficulty
- Relationship problems - Assessment of current mood
- Protective factors - what is stopping them?
- Current thoughts/ plans about suicide attempt
Further investigations for self harm…
- Toxicology tests
- Plasma paracetamol and salicylate levels
- FBC, U&Es, LFTs
- VBG
- Drug misuse urine screen
Management of self harm patient…
Drug overdose:
- Activated charcoal within 1 hr of ingestion
- TOXBASE guidelines for all overdoses - follow treatment protocol accordingly
Injury to self:
- Superficial wound closure
- Referral for wound assessment and exploration for: wounds >5cm, deep wounds, wounds affecting deep structures
Further psychological management dependent on risk:
- Admission to psychiatric services
- Home with home treatment team
- Home with referral to secondary mental health services
- Home with GP follow up - NOT recommended for attempted suicide
What are the different types of domestic abuse?
- Emotional abuse
- Sexual abuse
- Physical abuse
- Psychological abuse
- Financial abuse
HARKS questions to screen for domestic abuse…
Humiliation - do you feel embarrassed? made to feel like you have done something wrong?
Afraid - are you afraid of your partner?
Rape - have you had sex against your will?
Kicking: have you ever been physically harmed by your partner?
Safe: do you feel safe at home?
Signs of domestic abuse…
- Bruising or injury that is inconsistent with history
- Inappropriate delay to presenting to healthcare
- Contradicting histories from both partners
- Pathological relationship between partners
- Repeated visits to different EDs
- Unusual pattern of injury - bruises/ fractures of different ages
Management of domestic abuse victim…
- Need to ensure patient is aware they are safe and what they reveal is confidential!
- Identify if there are any children at home - if so, child safeguarding need to be informed ASAP
- Refer patient to police services - if refused, offer information about charitable agences that can offer support
- If there are no children involved and patient does not want police involvement, this decision must be respected
What 2 initial questions can be asked to screen for depression?
- ‘In the last month, have you been bothered by feeling down, depressed or hopeless?’
- ‘In the last month, have you been bothered by having little interest in doing things?’
If answer is yes to either question - further assessment should be carried out.
DSM IV criteria for grading depression…
Symptoms occurring nearly every day - lasting > 2weeks:
- Depressed mood most of the day
- Anhedonia
- Significant weight changes
- Insomnia/ hypersomnia
- Psychomotor agitation/ retardation
- Fatigue
- Feelings of worthlessness
- Difficulty concentrating
- Suicidal thoughts
Grading:
- Sub-threshold depression = <5 symptoms
- Mild depression = 5+ symptoms with minor functional impairment
- Moderate depression = more symptoms and greater functional impairment
- Severe = most symptoms, which significantly impair functioning
What tools are used to assess severity of depression ?
- Beck Depression Index
- Hospital Anxiety and Depression
- Patient Health Questionnaire
Management of depression…
Sub-threshold = low-intensity psychosocial interventions e.g. computerised CBT, physical activity programme
Mild = high intensity psychological tx e.g. CBT - 1st line
Moderate/severe = antidepressants: 1st line = SSRI - 4-6 week trial 2nd line = alternative SSRI 3rd line = venlafaxine/ mirtazapine *Can be augmented by combining mediations and adding antpsychotics
Resistant depression = ECT (6-12 sessions over 3-6wks),
psychosurgery e.g. cingulotomy
What are the main clinical features of borderline personality disorder?
- Erratic mood swings
- Emotionally unstable
- Multiple unstable relationships
- Impulsive behaviours - spending, sex, substance abuse
- Recurrent suicidal behaviour
- Difficulty controlling temper
Management of borderline personality disorder…
Psychotherapy:
- psychodynamic psychotherapy
- CBT
- interpersonal therapy - improving interpersonal relationships
- group psychotherapy
*Long term management for avoiding crises is important as they are likely to have recurrent admissions for DSA
What is psychotic depression?
Form of major depression that is associated with signs of psychosis.
This includes delusions (intense feelings of worthlessness and failure) and hallucinations (auditory hallucinations telling you that you are worthless)
Unlike schizophrenia - the thoughts are often in theme with feelings of depression i.e. tend to be more bizarre
Management of psychotic depression…
- Treat the depression with antidepressants
- Treat the psychosis with anti-psychotics
What is the definition of bipolar disorder?
Episodes of hypomania/mania along with alternating episodes of depression with complete recovery inbetween
What is the difference between hypomania and mania?
Hypomania = abnormally elevated mood lasting > 4days WITHOUT pscyhosis
Mania= abnormally elevated/ irritable mood with delusions and hallucinations - lasting > 7 days
Management of bipolar disorder…
- Mood stabiliser: Lithium = 1st line, valproate = 2nd line
- Acute mania: Olanzapine/ Haloperidol - stop antidepressant if taking one
- Bipolar depression: Fluoxetine = antidepressan tof choice
Procedure after remission of acute sx:
- Maintain therapeutic dose of mood stabiliser
- Slowly withdraw additional antipsychotic
- When euthymia is achieved , taper down antidepressant dose over 8 weeks
What is factitious disorder?
Condition where individual (without malingering motive) will deliberately feign or lie about symptoms to acquire the sick role.
It may involve the individual contaminating test results and injecting material into them which can lead to harm/ illness.
Signs of factitious disorder…
- Long elaborate histories that may be inconsistent
- Symptoms that are only present when the patient is alone
- Eagerness to take part in tests/ scans/ operations
- Medical textbook definitions of their illness
- Multiple visits to other hospitals/ EDs
- Sabotaging discharge plans/ becoming more ill as they are about to be discharged
First rank symptoms of schizophrenia…
- Thought disorder: insertion, withdrawal, broadcasting, echo
- Running commentary
- Passivity of thought (controlled by external force)
- Third person auditory hallucinations
- Delusions
Negative symptoms of schizophrenia…
- Catatonic behaviour
- Apathy/ blunting
- Decreased motivation
- Poverty of speech/ thought
Diagnosis of schizophrenia…
- At least 1 first rank sx OR 2 other sx
- Lasting longer than 1 month
Management of schizophrenia…
1st line = 2nd gen antipsychotic e.g. risperidone/ olanzapine
*Need adequate 6-week trial before retrialling a different antipsychotic
Clozapine = indicated after 2 failed 6 week trials - need to titrate very gradually
Admission under MHA indicated when: patient is non-compliant, treatment failure, risk of harm to self/others
Why must clozapine administration be carefully done?
Risk of AGRANULOCYTOSIS:
Need weekly FBC checks initially as patient is gradually tapered up.
Other S/Es = reduced seizure threshold, constipation, hypersalivation
Common side effects seen with antipsychotics…
Typical (1st gen) antipsychotics:
- Parkinsonism
- Acute dystonia (sustained muscle contractions)
- Akathisia (severe restlessness)
- Tardive dyskinesia (choreathetoid movements e.g. chewing and pouting of jaw)
Atypical (2nd gen) antipsychotics:
- Weight gain
- Hyperprolactinaemia
Timeline of features of alcohol withdrawal…
6-12 hours: anxiety, tremor, tachycardia, sweating
36hrs: withdrawal fits (tonic-clonic seizures - treat with diazepam 10mg IV)
48-72hrs: delirium tremens begins (lasting about 3-5 days)
Features of delirium tremens…
- Delirium - acute confusional state
- Tremor - severe
- Hallucinations - vivid, chaotic, bizarre
Management of alcohol withdrawal…
Diagnosis of DT:
- Chlordiazepoxide 50mg PO 2 hourly
- Pabrinex - IV 2 ampoule pairs (4 amps) - TDS
Moderate/ severe withdrawal:
- Oral chlordiazepoxide
- Pabrinex IV 1 amp pair (2amps)
Clinical features of Wernicke’s encephalopathy…
- Thiamine deficiency leads to mammillary body and third ventricle damage
- Nystagmus
- Ophthalmaplegia
- Ataxia
- Confusion
What is the relationship between Wernicke’s encephalopathy and Korsakoff’s syndrome?
Untreated Wernicke’s may develop into Wernicke’s-Korsakoff where the individual also develops:
- Antero and retrograde amnesia
- Confabulation
What is anorexia nervosa?
Disorder commonly seen in young women, where there is marked distortion of body image with pathological desire to lose weight
Diagnostic features of anorexia…
- BMI <17.5
- Body dysmorphia - over-valued ideas
- Self -induced weight loss - purging, vomiting
- Endocrine disorders - amenorrhoea
Signs of anorexia…
- Reduced muscle mass
- Brittle hair and nails
- Bradycardia
- Hypotension
- Hypothermia
- Peripheral cyanosis
- Atrophy of breasts
- Eroded tooth enamel
Common problems associated with anorexia…
- Dental caries
- Renal calculi
- Hypotension
- Amenorrhoea
- Infertility
Management of anorexia…
- Psychological =CBT/ family therapy
- Medical= fluoxetine
- Education about nutrition/ diet to combat over-valued ideas
- Weight restoration = managed by dietician - aiming for 0.5kg/ week in outpatient setting, 1kg/ week in inpatient
Inpatient setting indicated for: failure of O/P tx, severe weight loss, medical problems, psyhosis
- Refusal to eat - may need NG tube feeding under restraint
How is risk of refeeding syndrome managed…
- Check U&Es regularly
- Tapered increase of daily calorie intake (increase by 200-300kCal every 3-5 days)
What is bulimia nervosa?
Recurrent episodes of binge eating followed by purging, with marked body image distortion
Diagnostic criteria for bulimia…
- Persistent preoccupation with eating
- Irresistible cravings for food
- Binge eating episodes
- Vomiting, purging (laxatives, diuretics)
- Morbid fear of becoming fat
Signs of bulimia…
- Dental erosions
- Duodenal ulcer
- Oesophageal erosions
- Electrolyte imbalances
- Cardiac arrhythmias
Management of bulimia…
Medical = high-dose SSRI e.g.fluoxetine Psychotherapy = CBT - 10-20 sessions
SCOFF questions used for screening eating disorders…
S = do yo make yourself Sick? C = do you think you have a lack of Control with food? O= have you lost more than One stone in last 3 months? F = do you feel you look Fat, when you're not? F = do you think your life is controlled by Food?
Three main priorities of dealing with overdose patient…
- Resuscitate the patient
- Reduce drug absorption
- Use specific antidote if available
MATTERS structure for history taking in overdose…
Medication taken Amount of drug taken Time - all at once/ staggered Toxicology of drug Emesis - were they sick Reasons for taking Signs and symptoms
Basic investigations during overdose…
Bloods: - FBC, U&Es, LFTs, clotting - Toxicology screen ABG Urine sample for toxicology analysis ECG
General management of overdose patients…
- If ingestion <1hr - 50g activated charcoal can be used (does not work for lithium, iron, ethylene glycol)
- Refer to TOXBASE for appropriate guidelines - if specific antidote available follow protocol
Most poisoning cases do not have specific antidote so supportive care is required:
- Maintain airway - ET intubation if GCS<8
- Manage hypotension with fluid boluses
- Poisoning expert needed for arrhythmia control
- AEDs for convulsions
- Cooled IV fluids for hyperthermia - may need dantrolene
Most patients can be managed in ED, but more severely ill patients need escalation to ICU
*All patients will require psychiatry review when well enough
Specific antidotes for specific drug overdoses…
Benzodiazepine = Flumazenil B-blockers = Atropine, Glucagon Digoxin = Digibind Ethylene glycol= Ethanol, Fomepizole Iron = Desferrioxamine Methanol = Ethanol, Fomepizole Opiates = Naloxone Paracetamol = N-Acetylcysteine TCAs= Sodium bicarbonate Warfarin = Beriplex, Vitamin K
Signs of benzodiazepine overdose…
- Drowsiness
- Slurred speech
- Hypotonia
More severe sx are only seen when mixed with other depressants e.g. alcohol:
- Respiratory depression
- Hypotension
- Coma
Management of benzodiazepine overdose…
Normally supportive care is sufficient
Flumazenil - only used in severe/ iatrogenic overdose: 0.2mg boluses up to maximum of 3mg
*Risk of seizures with flumazenil
Signs of amphetamine/cocaine overdose…
Everything is elevated/ increased:
- Agitation
- Tremor
- Dilated pupils
- Hypertension
- Tachycardia
- Hyperthermia
*MI may be seen in significant cocaine overdose
Management of cocaine/ amphetamine overdose…
Supportive care for symptoms:
- Seizures = 10mg diazepam IV
- Hypertension = GTN 1-2mg
- Hyperthermia = cooled IV fluids
- Arrhythmias - narrow complex tachycardia (SVT) -diazepam/ verapamil
Signs of TCA overdose…
TCA has anticholinergic effects:
- Dry mouth
- Blurred vision
- Retention
- Constipation
- Dilated pupils
- Ataxia
What ECG changes may be seen in TCA overdose…
Prolonged PR interval
Prolonged QRS duration leading to VT (broad complex tachycardia)
Management of TCA overdose…
IV Sodium bicarbonate - important for managing acidosis which will then control ventricular arrhythmia / seizures
Signs of ethylene glycol overdose…
Stage 1: Intoxication, N+V, haematemesis, convulsions, coma
Stage 2: tachypnoea , tachycardia, heart failure
Stage 3: AKI from acute tubular necrosis
Management of ethylene glycol overdose…
Fomepizole = 1st line
Ethanol = 2nd line
*Dialysis may be required in some cases
How do fomepizole and ethanol work in ethylene glycol overdose?
Both compete with ethylene glycol for break down by alcohol dehydrogenase, preventing production of toxic metabolites
What are the risk factors for lithium toxicity?
- Dehydration
- Renal failure
- NSAIDs
- Diuretics
Signs of lithium toxicity…
Initial symptoms:
- Coarse tremor
- Hyperreflexia
- N+V
- Thirst
- Acute confusion
Late symptoms:
- Ataxia
- Seizures
- Coma
Management of lithium toxicity…
Mild-moderate toxicity = IV fluids
Severe toxicity = dialysis
What is the max dose of paracetamol in a day ?
4g/day = 8x 500mg tablets (2x500mg tablets QDS)
What is considered a single dose and staggered dose?
Single dose = all tablets taken within 1 hr period
Staggered dose = tablets taken >1 hr period
Signs of paracetamol overdose…
Within first 24 hrs = generally well, N+V
48 hrs = hepatorenal failure: RUQ pain, jaundice, hypoglycaemia, encephalopathy
Lactic acidosis later on
When is significant paracetamol toxicity considered unlikely?
- Asymptomatic
- Undetectable plasma paracetamol
- Normal LFT/INR >24hrs after last dose
Management of paracetamol OD…
Presenting within 8 hours of ingestion:
- If presenting within 1 hr - activated charcoal can be used
- Paracetamol levels can only be taken 4hrs post-ingestion; during this time manage conservatively
- If >100mg/kg start NAC regime
Presenting >8hrs of ingestion:
- NAC regime started immediately if it is suspected patient has OD > 150mg/kg
- Take Paracetmol levels anyway - if they return as normal, NAC can be suspended
Staggered OD:
- Measure paracetamol levels from 4 hours after most recent dose
- Start NAC regime immediately - before blood results return
*All patients should also receive 10mg Vitamin K
NAC regime for parcetamol OD…
BAG 1: 150mg/kg NAC in 200ml 5% glucose over 1 hr
BAG 2: 50mg/kg NAC in 500ml 5% glucose over 4 hrs
BAG 3: 100mg/kg NAC in 1000ml 5% glucose over 16 hrs
What should be given for anaphylactoid reaction to NAC?
Patients may develop a small rash:
Chlorphenamine - anti-histamine
KCH criteria for liver transplantation from paracetamol poisoning…
Arterial pH <7.3 OR All 3 of: - PT time> 100 seconds (sign of liver failure) - Creatinine > 300umol/L - High grade encephalopathy
Signs of opiate overdose…
- Pinpoint pupils
- Respiratory depression
- Myoclonic jerks
- Coma
Management of opiate overdose…
Naloxone 400mcg IV- repeat 400mcg boluses every 2-3 mins up to total max dose of 4mg in severe toxicity
Naloxone has short half life so IV infusion should be set up following the IV boluses:
2/3 of dose require to rouse patient in 500ml normal saline
*take care in highly opioid dependent patients as it may induce severe withdrawal reaction
Signs of salicylate poisoning…
- Tinnitus
- Deafness
- Hyperventilation - due to metabolic acidosis
- Sweating
- Tachycardia
Management of salicylate poisoning…
Haemodialysis - commonly used now
Urinary alkinisation with sodium bicarbonate now rarely used (promotes salicylate excretion via urine)
Signs of digoxin toxicity…
- N+V
- Xanthopsia - yellow colour vision (Van Gogh)
- Delirium
- Bradycardia
- ECG changes= prolonged PR and QRS, reverse tick sign (down-sloping) of ST segment
Management of digoxin toxicity…
- Digibind
Signs of iron toxicity…
- GI upset = abdo pain, N+V
- Severe signs = metabolic acidosis, reduced GCS, convulsions, GI bleed
Management of iron toxicity…
*Important to know what specific formulation of iron they were taking to calculate accurate iron conc
Antidote = IV desferrioxamine infusion when iron conc >5mg/L
