Emergency Department Tips & Tricks for Managing the Suicidal Patient

Author: Erica Simon, DO, MHA (@E_M_Simon, EM Chief Resident at SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital)

An adolescent male with a chief complaint of suicidal ideation presents to the emergency department (ED). The 17 year-old patient is lead to a triage room where a nurse checks his vital signs, performs an EKG, and draws blood for initial screening labs. After handing the young man a set of hospital scrubs, the nurse exits, pulling the curtain to allow for limited privacy. Minutes later, a chilling scream echoes through the halls. Personnel rush to the triage center where an attending physician is struggling to remove a disposable latex tourniquet from the, now cyanotic, patient’s neck.

Believe it or not, this is a depiction of recent events witnessed in a community ED. As you stand ready to perform your medical screen and proceed to phone a friend in psychiatry, let’s take a minute to address a few pearls in approaching the suicidal patient.

Epidemiology of Suicidal Ideation

Today more than twelve million annual emergency department visits involve a diagnosis related to mental health or substance abuse; representing nearly one in every eight ED encounters.¹ Occurring at a rate of one suicide every thirteen minutes, intentional self-harm represents the leading cause of death among persons greater than 85 years of age. Among American Indians and Alaska natives ages 10-34, and in all U.S. citizens aged 15-34 years, suicide is the second leading cause of death.² Data currently identify males as four times more likely to commit suicide than females.² Costs associated with suicide, both medical and related to decreased work productivity, total nearly $51 billion annually.²

The Role of the Emergency Physician

This review will address patient stabilization and provide tips and tricks for use in interviewing and evaluating the suicidal patient. An in-depth discussion of toxic ingestions will be omitted as this content is addressed elsewhere:

FOAMED Resource Series Part IV: Toxicology
Brit Long, MD (@long_brit, EM Attending Physician, SAUSHEC)
http://www.emdocs.net/foamed-resource-series-part-iv-toxicology/

Stabilize the Patient

Current surveys suggest that approximately one million people in the U.S. engage in intentional self-harm behavior, and that for every death reported by suicide, approximately twelve individuals severely harm themselves.³ Of patients inflicting self-harm, nearly 650,000 are evaluated in the ED each year.⁴

Patients may present after a failed suicide attempt by gun-shot wound (mechanism in 59.6% of males having committed suicide⁴), suffering from the affects of an acute toxic ingestion (mechanism in 34.8% of females having committed suicide⁴), or actively bleeding from an arterial laceration (cutting, burning, and blunt trauma reported by males and females as common mechanisms of self-harm⁵); therefore, the emergency physician must stand ready to address the ABCs.

Transition the Patient to a Safe Environment

All patients who are hemodynamically stable upon presentation should be taken to an area of the ED that is free of all potentially dangerous medications and equipment. Patients should be searched for weapon/substances and be provided a set of scrubs or disposable clothing to discourage elopement. At no point in time should the patient be left unattended.⁶

 Perform an Assessment of Suicide Risk

Obtain an appropriate medical history centering on the identification of risk factors for suicide:

A few words on risk factors:

Adolescents: Adolescent patients are most likely to present with injuries secondary to self-harm (ratio of attempted to completed suicides reported as 200:1¹⁰). Although parental consent is typically required for the treatment of minors (defined as age <18 in the majority of states), evaluation following a serious suicide attempt is mandated according to the Emergency Medical Treatment and Active Labor Act.⁶

If and when present, parents and caregivers should be questioned regarding impulsive behavior, bouts of aggression, significant family stressors, and inter-personal conflicts, as these can be subtle signs of depression.¹¹

The elderly: Suicidal ideation is endorsed much less frequently in the elderly population,¹² however, completed suicides are much more likely to occur later in life (ratio of attempted to completed suicides reported as 4:1^12,13). Patients >65 years of age should be questioned specifically regarding: recent death of a loved one, perceived poor health, social isolation and loneliness, uncontrolled pain, and major changes in social roles as these are frequently associated with completed suicide.¹²

 Current psychiatric diagnosis: When controlled for other factors, a previous history of major depressive disorder is the most significant risk factor for completed suicide in males and females.¹¹ Patients with a history of military service should be questioned regarding post-traumatic stress disorder as these individuals are also at increased risk for suicide.¹¹

Substance abuse: Current data identify 19-27% of all suicides as associated with alcohol.¹⁴ Specifically, individuals over the age of 18 engaging in heavy episodic drinking (having ≥ 5 alcoholic drinks in a row on one occasion) are noted to have a suicide risk 1.2 times that of their non-drinking counterparts.¹⁵ Question patients regarding alcohol consumption.^11,14,15

 An assessment of thought content is particularly important in patients with a previous medical history of schizophrenia, mood disorder, bipolar disorder, and substance abuse as these conditions pre-dispose to episodes of psychosis.¹⁴ Patient reports of auditory hallucinations, persecutory delusions, or thoughts of external control or religious preoccupation require immediate hospitalization in order to prevent harm to self or others.^12,14

 Patients should be questioned regarding prescription drugs (dosing/compliance/regimen changes), the use of homeopathic remedies, and the use of over-the-counter medications. This information is vital if suspecting toxic ingestion, medication withdrawal, or mood alteration secondary to changes in pharmacotherapy.

In interviewing the patient, enquire as to weapons access as this is also an independent risk factor for completed suicide.⁸

Perform risk stratification:

If you attended a medical school in the U.S., chances are that you’ve had some exposure to the Modified Sad Persons Score:

Originally developed by Hockberger and Rothstein at the Harbor-UCLA Medical Center in 1988, this scoring tool was created to predict the need for hospitalization in individuals at risk for suicide. After analysis of 119 patients, Hockberger and Rothsetin identified a score ≥ 6 as having a sensitivity of 94% and a specificity of 71% for predicting the need for psychiatry directed hospitalization (P<0.001).¹⁴ While an excellent reminder of suicide risk factors, the authors’ score is limited in that it was designed to assess the decision-making of behavior of psychiatry personnel at one institution.

The Manchester Self-Harm Rule was published by Cooper et al.¹⁷ in 2006 as a mechanism to determine the risk of repeat self-harm or suicide in patients presenting to the ED with the chief complaint of self-injury. Demographic and clinical information from 9,086 patients presenting to 5 emergency departments in Manchester and Salford, England (2001-2007) were utilized to identify the following risk factors:

The Manchester Self-Harm Rule demonstrated 94% sensitivity in the detection of individuals who would perform repeated self-harm or suicide within six months following the initial ED encounter (patients who possessed one or more risk factors).¹⁷ Data utilized in developing the Manchester Self-Harm Rule was collected from an urban population with high rates of benzodiazepine use and abuse, thus limiting its generalizability.¹⁷ Ultimately, clinical judgement in the evaluation of the suicidal patient is paramount.

Performance of the Physical Exam (Secondary Examination in the Hemodynamically Unstable Patient)

Elements of the physical exam include an assessment of:

• The patient’s general appearance (emotional status, thought content, and affect).
• A complete physical examination of the head, body, and extremities with documentation of all visible injuries.

Actively search for signs and symptoms of acute ingestions, toxidromes, and withdrawal symptoms: diaphoresis, hyperthermia, hypopnea, or bradypnea, pinpoint or dilated pupils, hyper or hyporeflexia, clonus, tremor, or altered mental status.¹⁸

• Sympathomimetic toxidrome: agitation, delirium, hypertension, hyperthermia, nausea, and muscle rigidity.
• Anticholinergic toxidrome: mydriasis, urinary retention, tachycardia and hyperthermia.
• Serotonin syndrome: altered mental status, autonomic instability, myoclonus, and tremor.
• Neuroleptic malignant syndrome: lead pipe rigidity, hyperthermia, altered mental status.
• Monoamine oxidase inhibitor (MAOI) toxicity: severe hyperthermia, nausea, emesis, and cardiovascular collapse. Excessive ingestion of tyramine containing food stuffs during MAOI therapy may result in hypertensive crisis.
• Patients experiencing benzodiazepine, opiod, and alcohol withdrawal may present with agitation, hypertension, tachycardia, and GI upset.

Primary interventions should address airway, breathing and circulation. Benzodiazepines are the treatment of choice for agitation, anticholinergic toxicity, sympathomimetic toxicity, and serotonin syndrome. Dopamine agonists have been demonstrated to improve symptoms in neuroleptic malignant syndrome. Provide fluid resuscitation in the setting of seizure and muscular rigidity in order to avoid complications secondary to rhabdomyolysis.¹⁸

Evaluate for signs and symptoms of medical conditions, and their sequelae, that are commonly associated with psychiatric symptoms:

• Hypoglycemia (perform a bedside blood glucose assessment)
• Thyroid pathology (thyroid storm or myxedema coma)
• Cushing’s
• CVA/TIA
• Intracranial trauma
• Infectious etiologies: HIV, syphilis, meningitis/encephalitis
• Neoplasm (intracranial mass vs. hypercalcemia secondary to metastasis)
• Degenerative neurologic diseases (Alzheimer’s, Parkinson’s, Creutzfeld-Jacob, Multiple Sclerosis)¹⁹

Notes on the agitated patient: if the patient presents a risk to self or others, the utilization of chemical or mechanical restraints should be entertained, bearing in mind that this may worsen hyperthermia and rhabdomyolysis. See Dr. Lulla’s and Singh’s The Art of the ED Takedown for a quick refresher on these interventions: http://www.emdocs.net/the-art-of-the-ed-takedown/

 Pertinent Studies

Once a thorough history and physical examination are completed, clinical decision-making should be utilized to assess the need for advanced imaging and adjunct studies.

Imaging: A non-contrasted CT head à rule out intracranial mass/abscess, intracranial hemorrhage, hemorrhagic CVA, etc. Consideration should be made for additional imaging as required (CVA: CTA head/neck vs. MRI/MRA, etc.).

EKG: An EKG may be diagnostic in the hemodynamically unstable patient. Sodium channel blockade (tricyclic anti-depressant therapy) often manifests as a rightward axis in the terminal 40-msec of the QRS complex (terminal R wave in aVR).²⁰

Currently there are no data-driven consensus recommendations regarding the appropriateness of routine laboratory screening tests in patients with suicidal ideation. As previously mentioned, the history and physical exam should be utilized to direct evaluation for an underlying organic etiology of depression and suicidal ideation. Studies to consider include²¹:

• CBC
• CMP
• TSH, FT4
• RPR/VDRL, FTA-ABS
• HIV
• Serum ETOH
• Serum salicylates
• Serum acetaminophen

The use of urine drug screens (UDS) in the evaluation of suicidal patients is controversial, as numerous studies have demonstrated the results of these screens as having minimal impact on patient care. Given these findings, the American College of Emergency Physicians currently recommends against the routine use of UDSs in the suicidal population.²²

Disposition

After performance of patient stabilization, attainment of a history and physical, and assessment of imaging/laboratory studies as appropriate, medical clearance may be given, and consultation placed for specialist evaluation and treatment.

If the patient appears to be a risk to him/herself or others, or is gravely disabled (unable to provide for his/her basic needs), involuntary psychiatric detention should be pursued. Regulations regarding involuntary psychiatric holds are state specific, therefore the emergency physician must be apprised of local policies and procedures.⁸ Obtaining collateral information from family and friends will often facilitate this intervention.¹⁹

Contracts for safety: While some physicians may elect to create a contract for safety, allowing outpatient evaluation and treatment, this is not advised for the emergency physician. Contracts for safety do not substitute for adequate documentation regarding the risk of suicide, or free the physician of liability in cases of subsequent self-harm and suicide.⁸

Key Pearls

• Stabilize as appropriate => a number of patients will present after performing self-harm
• If the patient is hemodynamically unstable, consider an EKG to evaluate for sodium channel blockade (TCA overdose)
  • Quickly evaluate for signs/symptoms of toxic ingestions
• In the stable patient, perform an H&P focusing on risk factors for suicide
  • Question patients regarding substance abuse (specifically alcohol)
  • Question regarding access to weapons
  • Use friends/family to corroborate stories
• During the physical examination, evaluate for findings consistent with toxidromes or organic pathology
• After seeking out organic etiologies of suicidal ideation, medically clear the patient and consult a specialist
• Be familiar with state laws regarding emergency detention
• Avoid the use of safety contracts in the emergency setting

 References / Further Reading

1. Owens P, Mutter R, Stocks C. Mental health substance abuse-related emergency department visits among adults 2007. Statistical Brief #92. Agency for Healthcare Research and Quality. Available from: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb92.pdf
2. Centers for Disease Control and Prevention. Suicide: Facts at a glance. Available from: https://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf
3. Centers for Disease Control and Prevention. Web-based injury statistics query and reporting system (WISQARS). National Center for Injury Prevention and Control. Available from: http://www.cdc.gov/injury/wisqars/index.html
4. Chang B, Gitlin D, Patel R. The depressed patient and suicidal patient in the emergency department: Evidence-based management and treatment strategies. Emergency Medicine Practice. 2011; 11(9):1-24.
5. Kerr P, Muehlenkamp J, Turner J. Nonsuicidal self-injury: A review of current research for family medicine and primary care physicians. J Am Board Fam Med. 2010; 23(2):240-259.
6. Kennedy S, Baraff L, Suddath R, Asarnow J. Emergency department management of suicidal adolescents. Ann Emerg Med. 2004; 43:452-462.
7. Mendelson WB, Rich CL. Sedatives and suicide: The San Diego study. Acta Psychiatr Scan 1993;88:337–41.
8. Ronquillo L, Minassian A, Vilke G, Wilson M. Literature-based recommendations for suicide assessment in the emergency department: a review. J Emerg Med. 2012; 43(5):836-842.
9. American Foundation for Suicide Prevention. Suicide Statistics. 2016. Available from: https://afsp.org/about-suicide/suicide-statistics/
10. Tuzun B, Polat O, Vatansever S, Elmas I. Questioning the psychosocio-cultural factors that contribute to the cases of suicide attempts: an investigation. Forensic Sci Int 2000;113:297–301.
11. Schwab J, Warheit G, Holzer C. Suicidal ideation and behavior in a general population. Diseases of the Nervous System. 1972;33(11):745–748.
12. Mitchell A, Garand L, Dean D, Panzak G, Taylor M. Suicide assessment in hospital emergency departments: Implications for patient satisfaction and compliance. Top Emerg Med. 2005; 27(4):302-312.
13. Parkin D, Stengel E. Incidence of suicidal attempts in an urban community. British Medical Journal. 1965;2(54):133–138.
14. Canapary D, Bongar B, Cleary K. Assessing risk for completed suicide in patients with alcohol dependence: Clinicians’ views of clinical factors. Professional Psychology: Research and Practice. 2002;33(5):464–469.
15. Asteline R, Schilling E, James A, Glanovsky J, Jacobs D. Age variability in the association between heavy episodic drinking and adolescent suicide attempts: findings from a large-scale, school-based screening program. J Am Acad Child Adolesc Psychiatry. 2009; 48(3):262-270.
16. Hockberger RS, Rothstein RJ. Assessment of suicide potential by nonpsychiatrists using the SAD PERSONS score. J Emerg Med. 1988;6:99–107.
17. Cooper J, Kapur N, Dunning J, Guthrie E, Appleby L, Mackway-Jones K. A clinical tool for assessing risk after self-harm. Ann Emerg Med 2006;48:459–66.
18. Zosel A. General Approach to the Poisoned Patient. In Emergency Medicine: Diagnosis and Management. 7^th ed. Boca Raton: CRC Press, 2016: 292-298.e1.
19. Knoll, J. The Psychiatric ER Survival Guide. 2016. Upstate Medical University. Available from: http://www.psychiatrictimes.com/all/editorial/psychiatrictimes/pdfs/psych-survival2.pdf
20. Niemann J, Bessen H, Rothstein R, et al. Electrocardiographic criteria for tricyclic antidepressant cardiotoxicity. Am J Cardiol. 1986;57(13):1154-1159
21. Russinoff I, Clark M. Suicidal Patients: Assessing and Managing Patients Presenting with Suicidal Attempts or Ideation. 2004. Available from: http://www.ebmedicine.net/topics.php?paction=showTopic&topic_id=97
22. Lukens T, Wolf S, Edlow J, Shahabuddin S, Allen M, et al. Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006; 47(1):79-99.