Improve your care of self-inflicted injuries

You come on shift to the following scenario in your busy emergency department (ED):

• In your major trauma room, an 82-year-old recently widowed man is in critical condition with a self-inflicted gunshot wound to the head.

• In the very next bed, a distraught 16-year-old who took a handful of acetaminophen capsules when her boyfriend broke up with her awaits gastric lavage and a chat with the social worker.

Such cases are becoming increasingly common. A new report from the Atlanta-based Centers for Disease Control and Prevention says that an estimated 264,108 persons were treated in EDs for nonfatal self-inflicted injuries in 2000. (For information on how to access, see resources at the end of this article.) Here are ways to improve care of patients with self-inflicted injuries:

• Determine suicide risk. The report showed that 60% of self-inflicted injuries were listed as probable suicide attempts, 10% were noted to be possible suicide attempts, and 30% were of unknown intent. The patient’s intent is key, says Kathleen A. Loeffler, RNC, research nurse at Harborview Injury Prevention and Research Center in Seattle. She says to keep in mind that patients who present with self-inflicted injury may not want to die, but actually need help with an acute stressor in their lives. "A teen-ager trying to cope with a recent sexual assault is far different than a chronic paranoid schizophrenic with command hallucinations or a client with chronic major depression," she says.

She points to the following risk factors associated with deliberate self-harm and suicide: known psychiatric diagnoses, substance abuse, interpersonal conflict (particularly a broken relationship, separation, or divorce), family stress, recent illness or death of a loved one, and personal loss of money, employment, or status.

• Identify patient at risk for self-harm. Loeffler says the report underscores that deliberate self-harm is a significant health problem in the United States, particularly among young women. (See table, below.)


Key stats for self-inflicted injuries

The rate for females was higher than that of males.
Poisonings comprised 65% of self-inflicted injuries; 24% involved trauma with a sharp instrument; and 1% were attributed to a firearm.
By age, rates were higher among adolescents ages 15-19 and young adults 20-24, with highest rate in females ages 15-19.
Females attempt and repeat harmful behavior more often, but boys and older children use more lethal methods of self-inflicted injury.

Victims of violence, abuse, or neglect (especially children and adolescents); homeless adults; and runaway youths also are vulnerable to acts of deliberate self-harm, says Loeffler. "A prior episode of self-inflicted injury increases a patient’s risk, as does behavior and attention problems in younger populations," she says.

Have psychiatric evaluation

• Ensure all patients are evaluated promptly. The study’s authors recommend prompt, thorough evaluation by a psychiatrist for all patients who present with self-inflicted injury. Loeffler says the exam should include the following:

  • identification of all acute and chronic comorbid psychiatric conditions;
  • investigation of all circumstances and motivations surrounding the deliberate self-harm event;
  • assessment of short-term suicide risk;
  • long-term treatment of chronic psychiatric issues;
  • practical help with immediate precipitating factors;
  • arrangement of rapid, systematic follow-up.

• Take steps to prevent other episodes. Loeffler recommends taking the following steps to prevent other incidents of deliberate self-harm:

  • aiding patients in problem solving the life stressors that precipitated the incident;
  • providing appropriate referrals for domestic violence, mental health, and financial services;
  • showing a compassionate, nonjudgmental attitude.

She adds that the treatment for patients with self-inflicted injury depends upon the intent, risk for suicide, precipitating events, and patient history. "Ethical dilemmas may arise with patients who refuse help, are hostile, in denial, or noncompliant with medication and treatment," she says. "Voluntary or involuntary hospitalization may be required."

Loeffler recommends asking these questions of patients at risk for self-harm:

  1. Have you ever thought about or actually hurt yourself?
  2. Are you in a situation where someone is hurting you?
  3. What is your current living situation? Who do you rely on for support?
  4. Have you ever been treated for depression or any other mental health issue?
  5. Do you presently take any psychiatric medication? Are you following the prescribed treatment plan?
  6. Do you have any acute stressors in your life? Change in a relationship or job, or recent death of a loved one?
  7. Do you use alcohol or other drugs? How often and how much?

"Our two best hopes to reduce the incidence of deliberate self-harm is to adequately treat known psychiatric disorders and help our patients develop more effective coping skills," Loeffler says.

Source and resource

For more information on management of self-inflicted injuries, contact:

Kathleen A. Loeffler, RNC, Research Nurse, Harborview Injury Prevention and Research Center, 325 Ninth Ave., Seattle, WA 98104-2499. Telephone: (206) 521-1520. Fax: (206) 521-1562. E-mail: loeffler@u.washington.edu. The complete report, Nonfatal Self-Inflicted Injuries Treated in Hospital Emergency Departments — United States, 2000, can be downloaded at no charge at www.cdc.gov/mmwr/PDF/wk/mm5120.pdf.