Suicide AttemptMANAGEMENT

PSYCHIATRIC PRESENTATIONS · 12 SECTIONS

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734 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Acute anxiety Acute psychosis Agitation-behavioral emergency Anorexia Nervosa (Medical Complications)Bipolar disorder Bipolar Disorder (Depressive Episode)Bipolar Disorder (Manic Episode)Bulimia Nervosa (Medical Complications)Catatonia Conversion disorder Dementia and behavioral crisis Factitious Disorder Failure to Cope (Social)Failure to Thrive Generalized Anxiety Disorder Homicidal Ideation Major Depressive Disorder Major depressive episode Malingering Neuroleptic malignant syndrome Panic Attack Post-Traumatic Stress Disorder (Acute)Schizophrenia Exacerbation Suicidal Ideation Suicidal ideation and attempt Suicide Attempt

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp60

Immediate medical priorities

›Airway and breathing threats

›Compromised airway from ingestion or trauma

›Depressed gag reflex

›Altered mental status with inability to protect airway

›Stridor or secretion burden from caustic ingestion

›Oxygenation failure

›SpO2 < 90% on room air

›Cyanosis or diaphoresis

›If unable to protect airway, proceed to rapid sequence intubation

›Class I recommendation

›Succinylcholine preferred unless hyperkalemia risk

›Circulation threats

›Hemodynamic instability from ingestion, hemorrhage, or trauma

›SBP < 90 mmHg

›HR > 120 or HR < 50

›Arrhythmia from TCA, QT-prolonging agents, or cardiac toxins

›Obtain two large-bore IVs immediately

›IV fluid resuscitation for hypotension

›Blood products if hemorrhage from self-inflicted wound

›Continuous cardiac monitoring mandatory for all intentional ingestions

›AHA scientific statement guideline

›Detect QRS widening, QTc prolongation, dysrhythmia

Toxicologic stabilization

›Identify ingested agent immediately

›Collateral from family, EMS, pill bottles

›Quantity taken versus prescribed

›Time of ingestion

02History/hx76

Attempt characterization

›Details of the attempt

›Method used

›Ingestion, cutting, hanging, firearm, jumping, drowning

›Method predicts future risk and lethality

›Timing

›When the attempt occurred

›Time elapsed since attempt

›Intent to die

›Patient's expected outcome at time of attempt

›Perception of lethality may differ from actual lethality

›Planning versus impulsivity

›Premeditation markers

›Suicide note written

›Affairs arranged or possessions given away

›Researched methods in advance

›Precautions against discovery

›Isolation during attempt

›Steps taken to avoid rescue

›Impulsive trigger

›Precipitating event immediately before attempt

›Acute intoxication at time of attempt

›Current suicidal ideation

›Ongoing wish to die after medical stabilization

›Active plan or intent persisting

›Regret at being alive or rescued

›Access to lethal means

›Firearms in the home

03Physical Exam/exam64

Vitals and general appearance

›Hemodynamic stability snapshot

›Blood pressure

›Hypotension from hemorrhage or toxidrome

›Hypertension from stimulant ingestion or agitation

›Heart rate

›Tachycardia from stimulant, pain, or hemorrhage

›Bradycardia from opioid, beta-blocker, or calcium channel blocker overdose

›Respiratory rate

›Depression from opioid or sedative overdose

›Tachypnea from metabolic acidosis or pain

›Temperature

›Hyperthermia from serotonin syndrome or stimulants

›Hypothermia from prolonged outdoor exposure or CNS depression

›Oxygen saturation

›Room air value before supplemental oxygen

›Trend over time

›Mental status

›Level of consciousness

›GCS score documented

›Coma or obtundation from CNS depressants

›Orientation and cognition

›Delirium versus encephalopathy

›Acute psychosis or disorganization

Toxidrome-directed exam

›Neurological exam

›Pupillary size and reactivity

›Miosis: opioid, clonidine, cholinergic

04Differential Diagnosis/ddx35

Psychiatric and behavioral differentials

›True suicide attempt with intent to die

›ICD-10 T14.91XA intentional self-harm

›Clear intent and plan documented

›Distinguishes from non-suicidal self-injury

›Non-suicidal self-injury (NSSI)

›Self-harm without intent to die

›Affect regulation function

›May coexist with suicidal ideation

›ICD-10 Z91.5 personal history of self-harm

›Suicidal ideation without attempt

›Active ideation with plan but no action taken

›Requires same psychiatric risk stratification

›Disposition depends on severity and protective factors

Medical differentials and mimics

›Accidental overdose or ingestion

›Substance use disorder context

›Unintentional overdose especially with opioids

›Pediatric accidental ingestion

›Differentiating clue: stated lack of intent to die

›Collateral history critical

›Psychotic self-harm

›Command auditory hallucinations directing self-injury

›ICD-10 F20 schizophrenia spectrum association

›May be more medically severe due to disorganized behavior

›Delirium or acute intoxication mimicking suicidal behavior

›Altered behavior without clear suicidal intent

›Metabolic derangement

05Laboratory Tests/lt49

Toxicology screen

›Serum acetaminophen level mandatory in all intentional ingestions

›Asymptomatic in early stages of serious toxicity

›Level interpreted on Rumack-Matthew nomogram relative to time of ingestion

›Draw no earlier than 4 hours post-ingestion for accuracy

›Treatment threshold: level above nomogram line for hepatotoxicity

›NAC initiated if above treatment line

›Serum salicylate level

›Often co-ingested

›Severe toxicity at levels > 3.6 mmol/l (50 mg/dL equivalent)

›Clinical severity does not correlate perfectly with level

›Serum ethanol level

›Acute intoxication quantification

›Guides reassessment timeline

›Legal threshold for reference

›Urine drug screen

›Qualitative detection for opioids, benzodiazepines, stimulants, cannabis

›Immunoassay with significant false positive and negative rates

›Confirmatory GC-MS when medically significant

Metabolic and organ function

›Comprehensive metabolic panel

›Liver function tests

›AST and ALT for acetaminophen hepatotoxicity baseline

›Repeat at 24 hours if acetaminophen involved

›Renal function

›Creatinine for dosing adjustments

›Electrolyte abnormalities from toxidrome or dehydration

›Blood glucose

06Diagnostic Tests/dt65

Scoring Systems

›Columbia Suicide Severity Rating Scale (C-SSRS)

›Validated structured tool for suicidal ideation and behavior

›Passive ideation: wish to be dead

›Active ideation: thoughts of killing oneself

›Ideation with method

›Ideation with intent to act

›Ideation with plan

›Suicidal behavior: past or current attempt

›Stratifies patients into low, moderate, or high risk categories

›Used to guide disposition decisions

›VA/DoD 2024 CPG endorses structured risk stratification

›SAD PERSONS mnemonic (historical, limited predictive value)

›Sex, Age, Depression, Previous attempt, Ethanol, Rational thinking loss, Social support lacking, Organized plan, No spouse, Sickness

›Not validated as a standalone disposition tool

›Should not replace comprehensive psychiatric evaluation

›Patient Health Questionnaire-9 (PHQ-9)

›Depression severity screening adjunct

›Item 9 screens for suicidal ideation

›Score 0-27; score >= 10 moderate-severe depression

›USPSTF endorses depression screening in adults using validated tools

›JAMA 2023 guideline

MRI

›MRI brain indications in suicide attempt

›Limited acute role in most presentations

›Not routinely indicated

›Availability and time constraints in acute setting

›Problem-solving indications

07Disposition/dispo52

Admission and psychiatric hospitalization

›Psychiatric hospitalization indications

›High lethality attempt with clear intent to die

›Firearm use, hanging, high jump

›Premeditated plan with precautions against rescue

›Ongoing suicidal ideation after medical stabilization

›Active plan or intent persisting

›Refusal to engage in safety planning

›Psychotic features or command hallucinations

›Antipsychotic initiation or optimization required

›Mixed-state bipolar disorder requiring mood stabilization

›Lack of safe discharge environment

›No social support or unsafe home

›Access to lethal means cannot be secured

›When in doubt, inpatient psychiatric care is the prudent option

›AFP 2021 recommendation

›Medical admission criteria

›Hemodynamic instability requiring resuscitation

›ICU level monitoring for severe toxidrome

›Vasopressor requirement

›Acetaminophen hepatotoxicity requiring NAC infusion

›Serial LFT and INR monitoring

›Surgical wound management

›Deep laceration with tendon, nerve, or vascular repair

›Need for antidote or ongoing antidotal therapy

›NAC, digoxin Fab, lipid emulsion therapy

Observation and intermediate care

›Observation indications

08Treatment/t116

Medical stabilization and antidotes

›Acetaminophen overdose: N-acetylcysteine (NAC)

›Indications

›Level above Rumack-Matthew treatment line

›History of large ingestion when level unavailable

›IV protocol: 3-bag regimen

›Bag 1: 150 mg/kg in 200 mL D5W over 60 minutes

›Bag 2: 50 mg/kg in 500 mL D5W over 4 hours

›Bag 3: 100 mg/kg in 1000 mL D5W over 16 hours

›Oral protocol alternative: 140 mg/kg loading dose

›Maintenance 70 mg/kg every 4 hours for 17 doses

›IV preferred in vomiting or altered mentation

›Opioid overdose: naloxone

›Acute reversal

›0.4-2 mg IV/IM/intranasal

›Repeat every 2-3 minutes up to 10 mg if no response

›Continuous infusion for sustained opioid effect

›Two-thirds of effective reversal dose per hour

›Titrate to adequate ventilation without full reversal

›Duration of action of naloxone (60-90 minutes) may be shorter than opioid

›Observation period mandatory even after initial response

›TCA overdose: sodium bicarbonate

›Indications for sodium bicarbonate

›QRS > 100 ms on ECG

›Ventricular arrhythmia

›Hypotension refractory to fluids

›Dosing

›1-2 mEq/kg IV bolus

›Repeat boluses to maintain pH 7.50-7.55

›Continuous infusion: 150 mEq in 1 L D5W

›Target arterial pH 7.50-7.55

›Alkalemia narrows QRS and reduces arrhythmia risk

›Avoid hyperventilation alone as substitute

Decontamination

›Activated charcoal

›Indications

›Toxic ingestion within 1-2 hours of presentation

›Cooperative patient with intact airway

›Agent adsorbed by charcoal (not iron, lithium, alcohols)

›Dose

›Adults: 50 g PO or via nasogastric tube

›Children: 1 g/kg up to 50 g

›Contraindications

›Unprotected airway

›Bowel obstruction or perforation

›Caustic ingestion

›Gastric lavage

›Very limited contemporary role

›Consider within 1 hour of life-threatening ingestion

›Requires protected airway in altered mental status

›Not routinely recommended over activated charcoal alone

›Position statement from AACT and EAPCCT

Wound management

›Laceration repair

›Wound irrigation and exploration first

›Tendon involvement assessed prior to closure

›Neurovascular exam distal to wound

›Wound closure technique based on depth and location

›Staples or sutures for scalp and extremities

›Tissue adhesive for superficial linear wounds

›Tetanus prophylaxis per wound type and immunization history

›Vascular injury management

›Direct pressure for hemorrhage control

›Tourniquet for life-threatening extremity hemorrhage

›Surgical consultation for arterial injury

›Repair versus ligation decision

›Operating room preparation if hemodynamically unstable

Psychiatric pharmacotherapy initiated in ED

›Acute agitation management

›Benzodiazepines first line for agitation

›Lorazepam 1-2 mg IV or IM

›Diazepam 5-10 mg IV

›Antipsychotics for psychosis-driven agitation

›Haloperidol 5 mg IM

›Olanzapine 10 mg IM

›Avoid olanzapine with benzodiazepine in same encounter if possible

›Ketamine for severe agitation unresponsive to above

›1-2 mg/kg IM or 0.5-1 mg/kg IV

›Agitation safety considerations

›QTc monitoring when antipsychotics used

›AHA 2017 guideline for continuous cardiac monitoring

›Respiratory monitoring with benzodiazepine use

›Resuscitation equipment at bedside

›Anti-suicidal pharmacotherapy (inpatient initiation)

›Lithium: reduces suicide attempts and all-cause mortality

›Unipolar and bipolar mood disorders

›AFP 2021 and Pharmaceuticals 2025 systematic review

›Clozapine: reduces suicidal behavior in schizophrenia and schizoaffective disorder

›REMS monitoring program for agranulocytosis required

›Pharmaceuticals 2025 systematic review

›Ketamine IV: rapid reduction of suicidal ideation within 24 hours

›0.5 mg/kg IV over 40 minutes

›Duration of effect 1-6 weeks

›Intranasal esketamine (Spravato): FDA-approved for MDD with acute suicidal ideation

›84 mg intranasally under supervision

›REMS program required

Safety planning intervention

›Safety Planning Intervention (SPI) components

›Warning signs recognition

›Thoughts, images, moods, behaviors that precede crisis

›Internal coping strategies

›Things patient can do alone to distract

›Social contacts who provide distraction

›People and settings that provide distraction

›Contacts who can help when in crisis

›Family or friends to call

›Professional and agency contacts

›Clinician, ED, crisis line numbers

›Means restriction

›Steps taken to limit access to lethal means

›SPI with follow-up reduces repeat ED visits compared to usual care

›JAMA Psychiatry 2018 Stanley et al: Class I evidence level

›Lethal means counseling

›Firearm counseling

›Temporarily remove from home or store locked and unloaded

›NEJM 2024 Carter and Cunningham: firearms 85-90% fatal per attempt

›VA/DoD 2024 CPG endorses lethal means restriction

›Medication security counseling

›Prescribe limited quantities at discharge

›Lockbox for remaining home medications

›Family or caregiver holds medications when possible

09Special Populations/sp66

Pregnancy

›Pregnancy-specific considerations

›Prevalence and risk

›Suicidal ideation occurs in approximately 5-14% of pregnant individuals

›Postpartum period carries elevated risk especially first 3 months

›Medication safety in overdose management

›NAC is safe in pregnancy for acetaminophen toxicity

›Naloxone safe in pregnancy for opioid reversal

›Imaging in pregnancy

›CXR with abdominal shielding when clinically indicated

›CT only when maternal benefit outweighs fetal radiation risk

›Fetal monitoring

›Viable gestation: fetal heart rate monitoring during resuscitation

›Maternal hemodynamic stability prioritized

›Psychiatric medication safety

›SSRIs generally considered low risk in pregnancy for moderate-severe depression

›Lithium: Category D historical classification; benefits may outweigh risks in severe bipolar

›Avoid benzodiazepines in third trimester when possible (neonatal withdrawal)

›Social and safety context

›Intimate partner violence screening

›Social support assessment critical

Geriatric

›Older adult specific features

›Epidemiology

›Older adults have higher case fatality ratio per attempt than younger adults

›Men over 65 have highest completion rate of any demographic

›Method lethality

›More likely to use highly lethal methods

›Less likely to make last-minute interventions or alert others

›Atypical presentations

›Social withdrawal and hopelessness may be primary symptoms

›Physical illness and pain as predominant precipitants

›Medical complexity

›Polypharmacy increases overdose lethality risk

›Chronic pain: OR 2.15 for lifetime suicide attempt per Lancet 2022

›Pharmacokinetic differences

›Reduced renal clearance: adjust NAC and antibiotics

›Increased drug sensitivity: lower benzodiazepine doses

›Cognitive assessment

›Dementia as risk factor for self-harm

›Cognitive status affects capacity determination for involuntary hold

Pediatrics

›Pediatric-specific considerations

›Epidemiology

›Second leading cause of death ages 10-34 in United States

›AAP Pediatrics 2023 guideline: suicide risk assessment mandatory in pediatric ED

›Age-specific risk factors

›LGBTQ+ youth have 3-4 times higher suicide attempt rate

›Bullying, cyberbullying, school stressors as precipitants

›Social media exposure associated with increased ideation in adolescents

›Assessment approach

›Interview adolescent alone AND with caregiver separately

›C-SSRS validated in pediatric population

›Pediatrics 2023: ED psychiatry consultation mandatory for all pediatric attempts

›FDA black box warning

›Antidepressants increase suicidality risk in under 25 years

›Especially first weeks of treatment or dose change

›Close monitoring required when initiating antidepressants

›Lethal means counseling with caregivers

›Firearms secured: same-day lock purchase or removal from home

›All medications secured by parent or guardian

›Internet access to methods counseling

›Post-discharge follow-up

›Telephone follow-up after ED discharge reduces repeat suicidal behavior

›Pediatrics 2023 guideline: formal outpatient mental health within 24-72 hours

›Weight-based dosing for toxicology management

›NAC: 150 mg/kg loading dose (same weight-based as adult)

›Activated charcoal: 1 g/kg PO up to 50 g

›Naloxone: 0.01 mg/kg IV for children, then titrate

10Background/b81

Epidemiology

›Global and national burden

›Approximately 700,000 deaths by suicide annually worldwide

›Leading cause of death in young people globally

›Lancet 2022 Knipe et al review

›United States: approximately 49,000 suicide deaths per year

›Over 1.3 million attempts per year

›Male to female completion ratio approximately 3:1

›Female to male attempt ratio approximately 2:1

›Firearms account for approximately 55% of US suicide deaths

›85-90% case fatality rate per firearm attempt

›NEJM 2024 Carter and Cunningham

›High-risk populations

›Veterans and military

›Suicide rate 1.5 times higher than civilian population

›Higher firearm access contributes to lethality

›LGBTQ+ individuals

›Up to 4-fold higher attempt rate than heterosexual peers

›Individuals with chronic medical illness

›Chronic pain OR 2.15 for lifetime attempt per Lancet 2022

›New terminal diagnosis as precipitant

›Post-psychiatric hospitalization

›Highest risk period is first weeks after discharge

›Lancet 2016 Turecki and Brent

Pathophysiology

›Neurobiological mechanisms

›Serotonergic dysregulation

›Reduced serotonin turnover in brainstem and prefrontal cortex

›Associated with impulsivity and aggression

›HPA axis dysregulation

›Elevated cortisol in suicidal individuals

›Blunted dexamethasone suppression test

›Prefrontal cortex dysfunction

›Impaired decision-making and impulse control

›Reduced executive function under stress

›Stress-diathesis model

›Diathesis (predisposition)

›Genetic vulnerability

›Childhood adversity and epigenetic changes

›Underlying psychiatric disorder

›Stressor (precipitant)

›Acute life event triggering crisis

›Intoxication lowering threshold

›Model explains why not all at-risk individuals attempt

›Clinical utility: identify and reduce modifiable stressors

›Genetic and epigenetic factors

›Heritability of suicidal behavior estimated at 30-55%

›NEJM 2020 Fazel and Runeson

›Serotonin transporter gene (5-HTTLPR) associations

›Interaction with adverse life events

›Epigenetic changes from early adversity

›Altered stress response programming

Therapeutic Considerations

›Evidence base for ED interventions

›Safety Planning Intervention (SPI) with telephone follow-up

›Reduces suicide attempts at 6 months vs usual care

›JAMA Psychiatry 2018: 45% reduction in suicidal behavior

›Class I evidence level for brief ED intervention

›Caring contacts: brief follow-up calls or texts post-discharge

›Reduces attempts at 1 year

›AFP 2025 Arnold: VA/DoD 2024 CPG endorses caring contacts

›Collaborative assessment and management of suicidality (CAMS)

›Collaborative therapeutic approach

›Evidence for outpatient setting

›Pharmacological evidence base

›Lithium: most robust evidence for suicide prevention across mood disorders

›Reduces attempts and all-cause mortality

›Pharmaceuticals 2025 systematic review: 10-year evidence review

›Clozapine: FDA-approved indication for reducing suicidal behavior in schizophrenia

›Requires REMS enrollment for agranulocytosis monitoring

›Pharmaceuticals 2025 systematic review

›Ketamine and esketamine: rapid anti-suicidal effect within hours

›IV ketamine 0.5 mg/kg: effect within 24 hours, lasting 1-6 weeks

›Intranasal esketamine FDA-approved for MDD with acute suicidal ideation

›SSRIs: first line for underlying depression in adults 25 and older

›Reduce suicidal ideation overall in adults

›FDA black box warning for increased suicidality under 25

›Lethal means restriction as treatment

›Firearm access restriction: strongest modifiable risk reduction intervention

›Each 10% increase in household firearm ownership associated with 3.1% increase in male suicide rate

›NEJM 2024 Carter and Cunningham

›Medication dispensing limitations

›Blister packs and limited supply prescriptions reduce overdose deaths

›UK paracetamol pack size restriction reduced overdose mortality

11Patient Discharge Instructions/pdi37

copy discharge instructions

›What happened today

›You were treated in the emergency department after a suicide attempt

›Your physical injuries have been assessed and treated

›Your mental health team has completed an assessment today

›It is very common to feel overwhelmed or hopeless at times

›These feelings can improve with the right support and treatment

›Reaching out for help is a sign of strength

›Your safety plan

›Warning signs to watch for in yourself

›Your team has reviewed personal warning signs with you

›Early warning signs are easier to manage before crisis escalates

›What to do when warning signs appear

›Use distraction and self-soothing strategies discussed today

›Contact a trusted person from your support list

›Call or text 988 (Suicide and Crisis Lifeline) anytime

›Text HOME to 741741 (Crisis Text Line) if you prefer text

›Firearms and medications at home

›Firearms should be removed from the home or stored locked and unloaded

›Ask a trusted family member to hold your medications for you

›Only keep small quantities of medications accessible

›Your follow-up appointment

›Mental health follow-up is scheduled within 24-72 hours

›Keeping this appointment is critical to your safety

›Call your mental health provider if you are struggling before that appointment

›Continue any prescribed medications as directed

›Do not adjust doses or stop medications without speaking to your doctor first

›Return to the emergency department immediately if

12References/r33

Guidelines and key sources

›Primary guidelines

›VA/DoD Clinical Practice Guideline: Assessment and Management of Patients at Risk for Suicide 2024

›Bahraini et al. VA/DoD CPG 2024

›Comprehensive risk stratification and management framework

›American Academy of Pediatrics: Suicide and Suicide Risk in Adolescents

›Hua LL, Lee J, Rahmandar MH, Sigel EJ. Pediatrics 2023

›Mandatory ED psychiatry consultation and follow-up standards

›American Family Physician: The Suicidal Patient - Evaluation and Management

›Norris DR, Clark MS. AFP 2021

›Stanley B, Brown GK et al. Safety Planning Intervention with follow-up vs usual care

›JAMA Psychiatry 2018

›45% reduction in suicidal behavior with SPI and follow-up

Key evidence sources

›Landmark reviews

›Fazel S, Runeson B. Suicide. NEJM 2020

›Comprehensive risk factor model and predisposing-precipitating framework

›Turecki G, Brent DA. Suicide and suicidal behaviour. Lancet 2016

›Pathophysiology, genetic risk, and stress-diathesis model

›Knipe D et al. Suicide and self-harm. Lancet 2022

›Adverse childhood experiences data: OR 30.15 for attempt with 4+ ACEs

›Carter PM, Cunningham RM. Clinical Approaches to the Prevention of Firearm-Related Injury. NEJM 2024

›Firearms 85-90% fatal per attempt; lethal means restriction evidence

›Waszak PM et al. Anti-suicidal effects of lithium, ketamine, and clozapine. Pharmaceuticals 2025

›10-year systematic review of pharmacotherapy for suicidality

›Mann JJ, Michel CA, Auerbach RP. Improving suicide prevention through evidence-based strategies. Am J Psychiatry 2021

›Toxicology references

›Manini AF et al. Validation of the prognostic utility of the ECG for acute drug overdose. J Am Heart Assoc 2017

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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