Approach to the Critical Patient

Immediate medical priorities

Airway and breathing threats

Circulation threats

Toxicologic stabilization

Identify ingested agent immediately

TCA overdose emergency actions

Opioid overdose

Acetaminophen overdose

Psychiatric safety priorities

One-to-one observation for all patients with suicide attempt

Psychiatric consultation for all suicide attempt presentations

Involuntary hold consideration

History

Attempt characterization

Details of the attempt

Planning versus impulsivity

Current suicidal ideation

Precipitants and context

Precipitating events

Substance use at time of attempt

Recent psychiatric history

Risk factor inventory

Predisposing factors

Demographic and social risks

Physical Exam

Vitals and general appearance

Hemodynamic stability snapshot

Mental status

Toxidrome-directed exam

Neurological exam

Skin and mucous membranes

Cardiac exam

Trauma and wound exam

Lacerations and self-inflicted wounds

Evidence of other mechanism

PITFALLS in physical exam

Differential Diagnosis

Psychiatric and behavioral differentials

True suicide attempt with intent to die

Non-suicidal self-injury (NSSI)

Suicidal ideation without attempt

Medical differentials and mimics

Accidental overdose or ingestion

Psychotic self-harm

Delirium or acute intoxication mimicking suicidal behavior

Domestic violence or assault

Factitious disorder or malingering

Laboratory Tests

Toxicology screen

Serum acetaminophen level mandatory in all intentional ingestions

Serum salicylate level

Serum ethanol level

Urine drug screen

Metabolic and organ function

Comprehensive metabolic panel

Arterial blood gas or venous blood gas

Cardiac and hematologic labs

Complete blood count

Coagulation panel

Beta-hCG in females of reproductive age

Diagnostic Tests

Scoring Systems

Columbia Suicide Severity Rating Scale (C-SSRS)

SAD PERSONS mnemonic (historical, limited predictive value)

Patient Health Questionnaire-9 (PHQ-9)

MRI

MRI brain indications in suicide attempt

CT

CT head indications

CT chest and abdomen

Ultrasound

FAST exam for traumatic mechanism

Vascular ultrasound

Bedside cardiac POCUS

Disposition

Admission and psychiatric hospitalization

Psychiatric hospitalization indications

Medical admission criteria

Observation and intermediate care

Observation indications

Involuntary hospitalization

Discharge criteria

Prerequisites for safe discharge

Treatment

Medical stabilization and antidotes

Acetaminophen overdose: N-acetylcysteine (NAC)

Opioid overdose: naloxone

TCA overdose: sodium bicarbonate

Decontamination

Activated charcoal

Gastric lavage

Wound management

Laceration repair

Vascular injury management

Psychiatric pharmacotherapy initiated in ED

Acute agitation management

Agitation safety considerations

Anti-suicidal pharmacotherapy (inpatient initiation)

Safety planning intervention

Safety Planning Intervention (SPI) components

Lethal means counseling

Special Populations

Pregnancy

Pregnancy-specific considerations

Geriatric

Older adult specific features

Pediatrics

Pediatric-specific considerations

Background

Epidemiology

Global and national burden

High-risk populations

Pathophysiology

Neurobiological mechanisms

Stress-diathesis model

Genetic and epigenetic factors

Therapeutic Considerations

Evidence base for ED interventions

Pharmacological evidence base

Lethal means restriction as treatment

Patient Discharge Instructions

copy discharge instructions

What happened today

Your safety plan

Your follow-up appointment

Return to the emergency department immediately if

References

Guidelines and key sources

Primary guidelines

Key evidence sources

Landmark reviews

Toxicology references

Coding standards