Deliberate Self Harm

Last updated on 14th May 2014 by Calum Murray

Essential History

1. Patients presenting with self poisoning/deliberate self harm (DSH) do so either impulsively or as a genuine suicide attempt. From the initial presentation it is not always possible to distinguish between the two. Further history should be obtained and a thorough clinical assessment carried out.
2. Thorough history taking should include: quantity/type of substance taken (mixed overdoses are not uncommon), as well as timing of ingestion, reasons for taking the OD and whom the substance belonged to. It is also useful to include past hx, drug hx including allergies, family hx and social circumstances.
3. Essential additional history includes:
   1. Previous OD?
   2. History of depression?
   3. History of alcohol abuse?
   4. History of physical or sexual abuse?
   5. Social circumstances?

Poisons Information

1. Best source of information is TOXBASE (Requires Login) – click here to access 
2. For specialist input, more unusual ingestions, mixed ingestions and in particular for unstable patients you should contact the National Poisons Information Service in Edinburgh on 0844 892 0111

Psychiatric Assessment

1. Psychiatric assessment MUST precede discharge in all cases of DSH
2. Handling first DSH presentation well is essential in reducing long-term suicide risk. Someone with DSH has 10-15x (against general population) risk of successful suicide in the future.
3. For Mon-Fri 0900-1700 phone Crisis Assessment Treatment Service (CATS) on 34166 after medical treatment completed for same day assessment. At other times, referrals should be to on-call psychiatric SHO via switchboard.

Indications for Serum Paracetamol at 4 Hours

1. In any unconscious patient.
2. In anyone who has taken ‘white tablets’.
3. When you can’t be certain exactly what has been taken.
4. In any patient with a deliberate ingestion ofparacetamol

Indications for Serum Salicylate at 4 Hours

1. Salicylism e.g. tinnitus, sweating, nausea, vomiting.
2. Patient claims to have taken Aspirin OD – there is no need to measure salicylate in conscious overdose patients who deny taking salicylate-containing preparations and who have no features suggesting salicylate toxicity.
3. Measure serum salicylate 4 hours after ingestion, as result is not interpretable until this stage. Salicylates can form concretions within the stomach which delay absorption,
4. A repeat sample should be taken in ALL symptomatic patients and those with concentrations greater than 500 mg/L after a further 2 hours because of the possibility of continuing absorption. Under these circumstances, measurements should be repeated every 3 hours until concentrations are falling.
5. Although salicylate is an unusual cause of coma, it is reasonable to take a serum salicylate in unconscious patients with an unclear history.  

Links

• Toxbase (Requires Login)