The most common place you will see a patient who has self-harmed is in ED, where they have been referred to the psychiatry team but need to be medically cleared. Rarely this could occur on the ward but the format is still vastly the same. Here are some tips on how to manage this.
History
- Ensure you are non-judgemental & are an active listener
- Empathise with the situation that has led them to this moment
- Use this opportunity to enquire what was mentally & physically occurring at this moment (were they intoxicated?)
- Screen them for what they expected from the attempt (did they think it could kill them? was it a suicide attempt?)
- Screen them for whether they would harm themselves again. To what degree?
- Look for multiple methods – it is possible they took an overdose & physically harmed themselves with an implement whilst also intoxicated
- Look for any other recreational drug use & alcohol consumption
- Look for any other psychiatric disease (particularly as this may have medical complications)
- Psychosis
- Affective disorders
- Personality disorders
- What is their social set up? Domestic violence? Are there any children involved? Is a safeguarding referral required?
Examination
- A full exam is ideal
- Assess the wounds
- Hopefully, ED will have managed the wounds with stitches or other as required. However, look for any issues such as infection (including of old wounds)
- Identify risk factors to suggest a tetanus booster or PEP might be required
- Consider a neurological exam – hve a low threshold. Definitely required where the wound has occurred in an area at risk of nerve damage
Investigations
- Usual bloods – FBC, U&Es, LFTs, Coagulation
- Consider GGT and alcohol level to look for alcohol use
- Regardless of risk factors or lack thereof – include paracetamol, salicyclate levels and CK
- ECG particularly in mixed overdose or antidepressants/antipsychotics or others which can cause arrhythmias. Or if any cardiovascular symptoms
- Urine dip & pregnancy test
- Consider a CT scan if there’s any neurology or features to suggest this is organic such as acute onset
Management
- Beyond medically clearing them, consider whether a safeguarding referral may be required
- Remember you cannot discharge as an FY1 – always get a second opinion from seniors
By Dr Sevgi Kozakli (FY4)
Edited by Dr Akash Doshi (CT2)
