Level 1 of 6Core
Self-harm and suicide risk
The core to-do list — diagnose and manage, at a glance
Diagnose— recognise it
- Establish what, when, how, why and what else: the agent, formulation and strength — count the missing blisters; the exact time and whether single or staggered; and alcohol above all, since mixed ingestion is the rule. A collateral history from the person who found the patient, the family and the GP is not optional — it frequently reverses the impression given by the patient.
- Capillary glucose is mandatory in every patient with altered consciousness or behaviour: hypoglycaemia is free to exclude, causes irreversible injury if missed, and is produced by insulin, sulphonylureas, beta-blockers, ethanol, quinine and salicylates — all commonly taken deliberately.
- Examine fully undressed, actively seeking the second, unreported act — a patient who cut their wrists may also have swallowed a packet an hour earlier and said nothing. Neck: ligature mark, petechiae above the line, hoarseness, surgical emphysema. Forearms, thighs, abdomen: old parallel scars, fresh cuts, cigarette burns. Wrists: a superficial-looking laceration may have divided a tendon or the median or ulnar nerve — test each individually. Also injection sites, corrosive mouth burns, pupils, respiratory rate, GCS itemised as E, V and M, and a rectal core temperature.
- Physical red flags needing immediate medical priority: reduced conscious level or absent gag/cough reflex; respiratory rate below 8 or rising PaCO₂; any stridor, voice change, neck swelling or surgical emphysema after hanging; uncontrolled haemorrhage; penetrating neck, chest or abdominal wound; seizures; arrhythmia or refractory hypotension; hypoglycaemia; hypothermia or hyperthermia; corrosive ingestion or an agent needing extracorporeal removal.
- Medical severity and suicidal intent are two independent measurements — they correlate poorly: one patient takes four tablets believing them lethal with a note and a locked door (intent total, toxicity nil); another takes sixty and phones a friend. Judge intent from preparation, precautions against discovery, the note, the belief about lethality, and 'would you do it again?' — never from the tablet count. Asking directly about suicide does not increase the risk; failure to enquire removes the only opportunity to prevent it.
- Psychiatric red flags: a violent or high-lethality method (hanging, drowning, jumping, firearm) — the survivor is at high risk however composed and physically unharmed; a pre-planned act not intended to be discovered; persistent intent now with a specific plan and access to means; clinical depression; psychosis, especially command hallucinations; profound hopelessness; intent that hardens as the patient sobers. Exclude delirium, hypoglycaemia and hypoxia before accepting a psychiatric explanation — non-auditory hallucinations suggest an organic cause, and a hypoglycaemic patient climbing off the trolley is ill, not absconding. In an older person an overdose is rarely a gesture; in a pre-pubertal child a wish to die is always serious.
Manage now— 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. Airway, breathing, circulation, disability, exposure: loss of the cough or gag reflex is the prime indication for intubation; recovery position and suction while awaiting it unless the cervical spine is immobilised.Doctor / NurseNot available at your setup — Endotracheal intubation kit.
- 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. Thiamine 100 mg IM or slow IV before or with glucose in the malnourished or alcohol-dependent.Doctor / Nurse
- Opioid toxicity (RR below 8, cyanosis, unresponsive): naloxone 0.4–2 mg IV repeated every 2–3 minutes to restore ventilation, with an infusion for a long-acting opioid; child 0.01 mg/kg IV/IO, and if no response 0.1 mg/kg — observe at least 3–4 hours after the last dose. Seizures: lorazepam 4 mg IV or diazepam 10 mg IV in an adult; child lorazepam 0.1 mg/kg IV (max 4 mg), diazepam 0.3 mg/kg IV or 0.5 mg/kg PR, or buccal midazolam 0.3 mg/kg. Hypotension: crystalloid bolus then agent-specific therapy (child 0.9% sodium chloride 10–20 mL/kg boluses).Doctor / Nurse
- Decontamination and paracetamol: activated charcoal 50 g orally within 1 hour for suitable agents with the airway protected (child 1 g/kg). 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; in staggered or unknown-time ingestion the nomogram does not apply and treatment is given on history and biochemistry. Acetylcysteine: 150 mg/kg over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours (same weight-based regimen in children with reduced fluid volumes).Doctor / Nurse
- After hanging or strangulation, treat the airway as a time bomb: laryngeal and supraglottic oedema worsens over the first several hours — 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 — admission is mandatory. Corrosive ingestion: nil by mouth, no charcoal, no induced vomiting, no blind nasogastric tube; analgesia and an IV proton pump inhibitor, early airway if any stridor, arrange endoscopy. Self-inflicted wounds: direct pressure, elevation, early transfusion planning; every tendon and nerve tested individually before repair.Doctor / Nurse
- Make the environment safe as a prescribed intervention: search the patient and belongings with dignity and remove tablets and blister strips, blades, razors, glass, syringes, lighters, belts, cords, scarves, shoelaces, drawstrings, plastic bags and any chemical or pesticide container; prescribe the level of observation in unambiguous words — 'continuous observation within arm's reach at all times, including in the bathroom'.
- Emergency sedation in an adult if de-escalation fails: haloperidol 0.5–5 mg IM or orally (start 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 slowly; promethazine 25–50 mg IM, often with haloperidol; procyclidine 5–10 mg IM/IV for acute dystonia. Never stack sedatives in an already-poisoned patient — after any parenteral sedation: continuous oximetry, RR, BP and conscious level, bag-valve-mask to hand, recovery position, never prone. Deaths after rapid tranquillisation are airway deaths.Doctor / Nurse
- Every patient receives a full psychosocial assessment with two aims — the short-term risk of suicide, and treatable problems, medical, psychiatric or social. Nobody is discharged without a plan: a named service, a date, and a crisis contact the patient can use immediately; dispense only three days' supply of essential medication, never an immediate re-prescription, and never start an antidepressant reflexly — the dispensed tablets become the means for the next attempt. Never use a risk score to authorise discharge — roughly half of those who die by suicide are classified as low risk; and never moralise or tell the patient they were lucky.Doctor / Nurse
| Problem | Adult | Child |
|---|---|---|
| Hypoglycaemia | 50% glucose 50 mL / 20% 100 mL / 10% 250 mL IV (≈25 g) | 10% glucose 2 mL/kg IV/IO — never 50% |
| Opioid toxicity | Naloxone 0.4–2 mg IV q2–3 min | 0.01 mg/kg; if no response 0.1 mg/kg |
| Seizures | Lorazepam 4 mg IV or diazepam 10 mg IV | Lorazepam 0.1 mg/kg (max 4 mg); diazepam 0.3 mg/kg IV / 0.5 mg/kg PR; buccal midazolam 0.3 mg/kg |
| Charcoal (within 1 h) | 50 g orally, airway protected | 1 g/kg |
| Paracetamol poisoning | Acetylcysteine 150 mg/kg/1 h → 50 mg/kg/4 h → 100 mg/kg/16 h | Same regimen, reduced fluid volumes |
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 — admit for an acute psychiatric disorder, high short-term suicide risk, need for temporary respite, or further mental state assessment; transfer physically for airway compromise after hanging, uncontrolled haemorrhage, corrosive ingestion needing endoscopy, or poisoning needing extracorporeal removal.
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