Level 2 of 6Must-remember

Self-harm and suicide risk

Assess, manage and stay safe — enough on its own

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The card — assess, manage, caution

Assessment— look, ask, measure

Establish what, when, how, why and what else: the agent, formulation, strength, count the missing blisters; the exact time and whether a single act or staggered; and alcohol above all, since mixed ingestion is the rule.
Take a collateral history — it is not optional: the person who found the patient, the family and the general practitioner frequently reverse the impression given by the patient, because accounts are often incomplete and sometimes deliberately minimised.
Capillary glucose is mandatory in every patient with altered consciousness or behaviour: hypoglycaemia is free to exclude and causes irreversible injury if missed, and it is produced by insulin, sulphonylureas, β-blockers, ethanol, quinine and salicylates — all commonly taken deliberately.
Examine fully undressed, looking for what has not been disclosed; actively seek the second, unreported act — a patient who cut their wrists may also have swallowed a packet an hour earlier and said nothing.
On the neck: a ligature mark, petechiae above the line, subconjunctival and facial petechiae, hoarseness, stridor, tenderness or surgical emphysema.
On the forearms, thighs, abdomen and axillae: old parallel scars indicating undisclosed repeated self-cutting, fresh cuts under sleeves, cigarette burns; at the wrists and hands, a laceration that looks superficial may have divided a tendon or the median or ulnar nerve — each must be tested individually.
Also check: injection sites in the antecubital fossae, groins and between the toes; the mouth and pharynx for corrosive burns; pupils; respiratory rate; GCS itemised as E, V and M; and a rectal core temperature with a low-reading thermometer.
Physical red flags needing immediate medical priority: reduced conscious level or absent gag/cough reflex; respiratory rate below 8 or a rising PaCO₂; any stridor, voice change, neck swelling or surgical emphysema after hanging; uncontrolled haemorrhage; penetrating wound of neck, chest or abdomen; seizures; arrhythmia or refractory hypotension; hypoglycaemia; hypothermia or hyperthermia; ingestion of a corrosive or of an agent needing extracorporeal removal.
Measure medical severity and suicidal intent as two independent things — they correlate poorly: a patient may take four tablets believing them lethal, having written a note and locked the door (intent total, toxicity nil), while another takes sixty and telephones a friend immediately.
Judge intent from preparation, precautions against discovery, the note, the patient's belief about lethality, and the answer to 'would you do it again?' — never from the tablet count.
Ask directly about suicide — it does not increase the risk of it occurring; patients are often reluctant to volunteer these thoughts without prompting, and failure to enquire removes the only opportunity to prevent it.
Escalate the questions gently: from 'things must have felt very bad for you to do this', through 'have you felt life is not worth living?' and 'did you want to die when you took them?', to 'are you still having those thoughts now?', 'have you thought about how you would do it?' and 'is there anything that has stopped you?' — the more specific and detailed the plan, the more serious the risk.
Psychiatric red flags: a violent or high-lethality method (hanging, drowning, jumping, firearm); a clearly pre-planned act not intended to be discovered; persistent intent now with a specific plan and access to means; clinical depression; psychosis of any kind, especially command hallucinations; profound hopelessness; and intent that hardens rather than softens as the patient sobers and realises they have survived.
Screen the mental state: depression (persistent low mood, anhedonia, reduced self-esteem, pessimism, guilt, loss of interest, and the somatic features), psychosis with specific enquiry about command hallucinations to self-harm, and alcohol or substance misuse quantified as units per typical week and corroborated.
Exclude delirium, hypoglycaemia and hypoxia before accepting a psychiatric explanation — hallucinations in non-auditory modalities, especially visual but also taste and smell, suggest an organic cause; a hypoglycaemic or hypoxic patient who climbs off the trolley is ill, not absconding.
In an older person an overdose is rarely a gesture: intent is more often unambiguous, planning more thorough, physiological reserve lower, and the same ingested dose more toxic because of reduced renal and hepatic clearance and polypharmacy. In a pre-pubertal child, a wish to die is always a serious presentation however trivial the act.

Management— do this, in order

The physical problem is treated first and completely: the need for psychiatric assessment must never delay urgent medical or surgical treatment, and the psychiatric assessment itself may have to be deferred until the patient is well enough to be interviewed.
Airway, breathing, circulation, disability and exposure, as in any resuscitation: loss of the cough or gag reflex is the prime indication for intubation, and the recovery position and suction are used while awaiting it unless the cervical spine is immobilised.Doctor / Nurse
Hypoglycaemia: 50% glucose 50 mL IV, or 20% glucose 100 mL, or 10% glucose 250 mL (all about 25 g), repeated to effect; in a child 10% glucose 2 mL/kg IV or IO repeated as needed — never 50% glucose in a child.Doctor / Nurse
Malnourished or alcohol-dependent: thiamine 100 mg IM or slow IV before or with glucose.Doctor / Nurse
Opioid toxicity (respiratory rate below 8, cyanosis, unresponsive): naloxone 0.4–2 mg IV repeated every 2–3 minutes to restore ventilation, with an infusion if a long-acting opioid; child 0.01 mg/kg IV or IO, and if no response 0.1 mg/kg — observe for at least 3–4 hours after the last dose.Doctor / Nurse
Seizures: a benzodiazepine first line — lorazepam 4 mg IV or diazepam 10 mg IV in an adult; in a child lorazepam 0.1 mg/kg IV (maximum 4 mg), or diazepam 0.3 mg/kg IV or 0.5 mg/kg PR, or buccal midazolam 0.3 mg/kg.Doctor / Nurse
Hypotension: crystalloid bolus then agent-specific therapy; in a child 0.9% sodium chloride 10–20 mL/kg boluses, reassessed after each.Doctor / Nurse
Decontamination: activated charcoal 50 g orally within 1 hour for suitable agents with the airway protected; child 1 g/kg.Doctor / Nurse
Paracetamol poisoning: intravenous acetylcysteine, standard regimen 150 mg/kg over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours; the same weight-based regimen in children with fluid volumes reduced to avoid hyponatraemia.Doctor / NurseNot available at your setup — Infusion pump.
Take a timed paracetamol level in every deliberate self-poisoning where the agent is not certain, whatever the patient says: valid only at 4 hours or more post-ingestion for a single acute overdose, interpreted on the treatment nomogram; in staggered or unknown-time ingestion the nomogram does not apply and treatment is given on history and biochemistry.
After hanging or strangulation treat the airway as a time bomb: laryngeal and supraglottic oedema worsens over the first several hours, so a patient talking normally on arrival may be stridulous later — humidified oxygen, upright posture, early airway expertise, cervical spine immobilisation and imaging, observation for delayed pulmonary oedema, and admission is mandatory.
For corrosive ingestion: keep nil by mouth, give no charcoal, do not induce vomiting, do not pass a blind nasogastric tube, provide analgesia and an intravenous proton pump inhibitor, secure the airway early if there is any stridor or oropharyngeal oedema, and arrange endoscopy.Doctor / Nurse
For self-inflicted wounds: direct pressure, elevation and early transfusion planning rather than watching the haemoglobin fall; every tendon and nerve tested individually before repair.Not available at your setup — Blood & blood products.
Make the environment safe as a prescribed intervention: search the patient and belongings with dignity and remove tablets and blister strips, blades, razors and glass, syringes, lighters, belts, cords, scarves, shoelaces, drawstrings and plastic bags, and any chemical or pesticide container; prescribe the level of observation in unambiguous words such as 'continuous observation within arm's reach at all times, including in the bathroom'.
For the disturbed patient, establish control of the situation rapidly, then determine and remedy the cause: ensure adequate personnel before beginning, attain a safe quiet environment, de-escalate verbally — sit down, use the patient's name, offer food, water, a blanket, a telephone call — and only then consider emergency sedation.
Emergency sedation in an adult: haloperidol 0.5–5 mg IM or orally (start at 0.5–2 mg in the elderly, frail, intoxicated or medically unwell); lorazepam 1–2 mg IM or orally, usual maximum 4 mg daily; diazepam 5–10 mg IV given slowly; promethazine 25–50 mg IM, often combined with haloperidol. Treat acute dystonia with procyclidine 5–10 mg IM or IV.Doctor / Nurse
Every patient receives a full psychosocial assessment with two defined aims — to establish the short-term risk of suicide, and to identify treatable problems, medical, psychiatric or social.
Nobody is discharged without a plan: if hospitalisation is not indicated a treatment plan must be formulated and instituted, or an adequate referral made — a named service, a date, and a crisis contact the patient can use immediately; dispense only three days' supply of essential medication.

Caution— what harms

Never let the need for psychiatric assessment delay urgent medical or surgical treatment.
Never give 50% glucose to a child — use 10% glucose 2 mL/kg IV or IO.
Avoid flumazenil after benzodiazepine overdose, particularly where a mixed ingestion or a proconvulsant is possible.
Never assume a low-risk score means safe to discharge: all these instruments have high sensitivity and very low specificity, roughly half of those who go on to die by suicide are classified as low risk, and a score may structure enquiry but must never be used to authorise discharge.
Never judge intent from the tablet count — medical severity and suicidal intent correlate poorly.
Never send home the composed survivor of a high-lethality method: hanging, drowning, jumping and firearm attempts are more likely to be associated with serious psychiatric disorder, and the survivor is at high risk regardless of how physically unharmed they appear.
Never discharge on a normal saturation alone: pulse oximetry detects hypoxaemia but not hypercapnia, and a normal saturation on oxygen does not exclude ventilatory failure.
Never treat a normal MCV and GGT as excluding alcohol excess — they are abnormal in only about half of problem drinkers.Not available at your setup — Liver function tests.
Never discharge the hanging survivor early: admission is mandatory because laryngeal and supraglottic oedema progresses over hours and pulmonary oedema may be delayed.
Never stack sedatives in an already-poisoned patient: sedation adds a respiratory depressant to one still being absorbed — use the lowest effective dose, and after any parenteral sedation give continuous pulse oximetry, respiratory rate, blood pressure and conscious level with oxygen, suction and a bag-valve-mask to hand, nursing the patient in the recovery position, never prone. Deaths after rapid tranquillisation are airway deaths.
Never start an antidepressant reflexly after an act of self-harm: the diagnosis is often not yet established, the effect takes weeks, and the dispensed tablets become the means for the next attempt.
Never grant an immediate re-prescription on discharge: give only three days' supply of essential medication and ask the patient to obtain further supplies from their general practitioner or outpatient clinic.
Never moralise, lecture, or tell the patient they were lucky or have wasted anyone's time — staff attitude is among the most modifiable determinants of whether this patient ever seeks help again.
Never label the confused older patient as self-harming before delirium is excluded, and never assume malingering in a patient with risk factors.

Refer / escalate

Refer to psychiatry for clinical depression, psychotic illness of any kind, a clearly pre-planned attempt not intended to be discovered, persistent suicidal intent, or a violent method used — and admit for an acute psychiatric disorder, a high short-term risk of suicide, a need for temporary respite from intolerable circumstances, or a requirement for further assessment of mental state; transfer physically for airway compromise after hanging, uncontrolled haemorrhage, corrosive ingestion needing endoscopy, or poisoning needing extracorporeal removal.

The card — assess, manage, caution

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