Uncompleted Suicide Attempts

In 2001, suicide resulted in the loss of 30,000 lives in the United States.^1,2 It was the 11th-leading cause of death that year. Of the deaths, firearms were the leading cause at 55%.^1,2 Of the more than 30,000 deaths, firearm involvement claimed more than 17,000 lives, suffocation claimed more than 6,000 lives and poisoning/ingestion resulted in more than 5,000 deaths.² In 2002, suicide attempts resulted in more than 130,000 hospitalizations, and more than 100,000 suicidal individuals were evaluated in emergency departments and subsequently released.^2,3 In 2002, there were more than 500,000 emergency department visits for self-inflicted wounds. In general, suicides are more likely to occur in the spring and are less frequent during the winter.^1,2

Following is a discussion of uncompleted suicide attempts, with a review of gender comparison, methods and potential complications of suicide attempts. By being provided an overview of suicide techniques, including the effects of failed attempts, providers may be more prepared to manage such cases, which may lead to a reduction in patient morbidity and mortality.

Gender Comparison
Suicide attempt rates and successes differ by gender. For males, suicide is the eighth-leading cause of death.^1,4 Men are four times more likely to die from suicide than women.^1,2,4 Of the completed male suicides reported in 2001, more than half involved a firearm.^1,4 Although females attempt suicide three times more often than males, female attempts are less likely to be completed.^1,2,5 This is partially due to the nature of the attempt. For example, a female may pursue ingestion, whereas a male may use a firearm.^1,2,5

Youth and Young Adults
Suicide attempts and completions vary by age. Suicide is the third-leading cause of death for individuals between ages 15 and 24 and ranks second for those aged 25 to 34.^1,5 In 2001, for the 15-24 age group, more than 75% of completed suicides involved males and over half involved a firearm.^1,5 In general, the rate of completed suicides among the youth has increased since 1950.^1,2,3,5 In 1950, the completion rate was 2.7 per 100,000; in 1994, the rate was 11.0 per 100,000. For individuals between ages 10-14, the rate of completed suicides has increased more than 120% since 1950.^1,5,6,7

The Elderly
Suicide rates increase with age.¹ In 2001, more than 5,300 individuals over age 65 committed suicide.^1,5,6 Of this group, 85% were male; 15% were female. Firearms were involved in more than 70% of these cases.^1,5,6 Numerous contributing factors may be present including depression, divorce, living alone, bipolar disorder and dysthymic disorder (daily depressed mood lasting for more than two years, but not as acute as severe depression).^4,8 Elderly suicide victims are also frequently observed to be mildly or moderately depressed a few weeks prior to attempting suicide (see Table I on page 74).^1,8

Suicide Risk Factors
Several factors have been identified that place an individual at risk for suicide.1 For example, widowed and divorced individuals have a higher rate, with nearly 30 per 100,000 individuals attempting suicide.¹ Married individuals have the lowest rate. Family history, lack of access to mental health resources and substance abuse have also been identified as risk factors.^1,9-13 Table II provides additional examples.

The presence of alcohol and/or substance abuse, especially in combination with a depressive disorder, has been associated with an increased likelihood that suicide may be considered.¹⁵ One study reviewed nontraffic-related fatalities that were associated with alcohol intoxication. More than 20% were attributed to suicide.^1,6 Providers are encouraged to thoroughly assess any patient who appears to be under the influence of an intoxicating substance (e.g., alcohol or illegal drugs) for potential suicidal thoughts or intent.^14,15,16

Attempted Suicides
Reports on suicide attempt rates vary. In general, there may be anywhere from 8-25 attempts made for each completed suicide.^1,2,17 The number of attempts tends to be higher for females and younger individuals, while completed suicides are more common among males and the elderly.^1,2,17 The female to male ratio of attempts has been reported at 3:1.^1,2,17 Survivors of an initial suicide attempt are likely to attempt again in the future, with a 10% increase in completion.^1,8,16

Mechanisms of Suicide Attempts
In the United States, drug overdoses are the most common type of suicide attempt; firearms are the most common method of completed suicide for both sexes.¹ For males, the second most common method is hanging; for females, it is self-poisoning.^1,2 Literature and the Internet are replete with examples of how to attempt suicide.^1,2,18-20 Table III provides examples of suicide methods.

The Scene
Prehospital management of the suicidal patient is influenced by a variety of factors. Scene dynamics, the method of the suicide attempt and provider discretion determine the sequence of events. Provider discretion allows the healthcare provider to draw upon various factors, such as scene dynamics, past experiences and local protocols, when determining which management options to pursue. In all cases, the EMS crew's safety must be the first priority. Once this is ensured, patient safety becomes the next priority. Until the crew and patient are safe, patient assessment and management may need to be delayed.^14,21

If it is either suspected or confirmed that a suicide attempt is involved (e.g., suicide note discovered), attempt to preserve the scene. Depending on the situation, you may want to avoid touching or moving certain items. If law enforcement is present, work with them to help preserve scene integrity. Any items discovered on scene that could be implicated in a suicide attempt should not be moved unless it directly impacts or influences patient care. If possible, ask law enforcement if the item can be transported to the hospital. For example, if you suspect that the opened pill bottle is involved in the suicide attempt, consider transporting it with the patient. If a firearm is present and the patient appears to be the victim of a self-inflicted gunshot wound (GSW), consider leaving the gun on scene, but make relevant mental and written notes, such as whether the weapon was a handgun or rifle.^14-16,21

The following provides summaries of management options for select suicide attempts. The focus will pertain to the situation in which a suicide attempt was initiated, but was not completed. Remember that these calls may not only be a situation that requires management of the patient's physical injuries; you may also need to provide initial emotional and/or psychological support to the patient, family or friends who are present until patient care has been transferred.^14,21

Patient Assessment
Consider scene safety on all calls including suicide attempts. If the individual attempted suicide and did not succeed, he may resist any efforts to help him. The suicidal patient may also have homicidal thoughts.¹⁴ Maintain an awareness of the scene, including knowing where the closest exit is in the event that rapid departure is needed.

Once you enter the scene and locate the patient, the initial assessment can begin even before patient contact is established. For example, as you approach, note the patient's overall appearance. Does he appear to be conscious? Is he coherent? Are there any immediate life threats, such as massive hemorrhage? Does the patient appear to be cooperative, or is he displaying signs of potential agitation like clenched fists, yelling or pacing?

If a weapon is found on scene, ask law enforcement for assistance securing it. This is especially important if the weapon is still in the patient's possession or close to the patient. In a GSW, law enforcement may request that the patient's hands be "bagged" or "brown bagged," which involves placing a (paper) bag over the patient's hands to preserve any evidence of gunpowder residue.

Once patient contact is established, several components of the assessment can be determined. Is the patient's skin warm, pink and dry, or is it cool, moist and pale? Is the patient tachycardic? Does he have radial pulses (perfusion status)? Does the patient appear to be coherent? A quick neurological exam can be accomplished using the AVPU method to determine if the patient is: Alert, responsive to Verbal stimuli, responsive to Painful stimuli or Unresponsive. Other assessment guides, such as the Glasgow Coma Scale (GCS), may also be used.^15,16,21

A complete head-to-toe assessment is indicated for any patient who attempted suicide. The DCAP BTLS approach shown in Table IV may be helpful. Manage immediate life-threatening findings as they are identified. In cases where the exact mechanism or cause is not clear, any physical findings noted on the patient may provide insight as to what is causing his condition. For example, a needle mark may indicate an overdose; a bleeding chest wound may indicate a penetrating injury.

Obtain a complete set of vital signs during the patient assessment, including heart rate, respiratory rate and blood pressure. Skin temperature, texture and color should also be noted. If available, cardiac monitoring and pulse oximetry may be applied.^15,16,21,22

Prehospital Management of the Uncompleted Suicide Attempt
When responding to an uncompleted suicide attempt, you must be aware of your affect and demeanor. If the patient perceives that you have a negative or unbecoming demeanor, this may not be well received. It is possible that this perception may negatively influence the patient's already-low self-esteem and contribute to future suicide attempts. During each contact with a patient who has attempted suicide, you will need to be conscious of your mannerisms, as well as how you approach each patient.

The treatment will be influenced by numerous factors. Scene dynamics, the mechanism(s) involved, local protocols, the patient's overall condition and provider discretion all need to be considered. The following provides treatment overviews for specific examples of uncompleted suicide attempts.

Penetrating & Blunt Trauma in Suicide Attempts
Firearms are the most common mechanism of completed suicides.^1,2 In cases of uncompleted suicide by firearm, injuries can present as subtle as a small wound to the chest or as graphic as massive facial trauma. Blunt trauma, such as intentional motor vehicle collisions or a jump from a great height, can also be a suicide attempt. In suicide attempts that involve blunt or penetrating trauma, you will need to treat the patient's injuries while also providing emotional support.^{10,15,16,21,22} Table V summarizes the general management options of blunt and penetrating trauma.

If the patient cuts him/herself, there may be a variety of lacerations, including hesitation marks-partial-thickness lacerations that are often parallel to each other. The lacerations tend to run across (perpendicular to) the wrist versus parallel to the vessels, tendons and ligaments. These marks are a strong indicator that the patient did try to harm him/herself.^19,23 Control bleeding lacerations with direct pressure and/or pressure points, as needed. Any puncture or open wounds should be managed as penetrating trauma.

Hangings
Hangings are either complete or incomplete. A complete hanging occurs when the entire body is suspended and the feet do not touch the floor. An incomplete hanging occurs when a part of the body is in contact with the ground after the patient hangs.^24,25

The mechanisms involved in a hanging will depend on its nature. For example, in a judicial hanging, the drop is at least as long as the patient is tall. Because the patient does not touch the floor, a judicial hanging is considered to be complete. In a complete hanging, the patient's head is distracted from the neck and torso. As a result, the upper cervical spine breaks and the spinal cord is transected, resulting in a nonsurvivable injury.^24,25

In hangings that are not complete, several events occur. Once the patient is hanging, venous blood flow is impaired, leading to cerebral stagnation and hypoxia. This results in loss of consciousness. The patient's muscle tone relaxes, allowing for arterial and airway obstruction. An increase in carotid pressure may lead to arterial spasm. Together, these events lead to reductions in cerebral blood flow. The end result is death that occurs secondary to cerebral hypoxia and ischemic neuronal death.^24,25

Management of a hanging victim who is still alive may prove to be challenging. If bystanders are available, try to determine the amount of time that the patient has been hanging. Hangings of a shorter duration tend to be correlated with better patient outcomes.²⁴ If possible, when lowering the patient to the ground, take cervical immobilization precautions. Providers are encouraged to consult their local protocols regarding the use of cervical spinal precautions in hangings.^16,21

Depending on the severity of hypoxia and/or injuries sustained during the hanging attempt, the patient's level of consciousness can vary. Assess the patient's neurological status while maintaining ABCs. Airway management may range from basic to endotracheal intubation.

The specific treatment provided to hanging victims varies with each case. Administer oxygen and consider IV fluids. Medication administration will be influenced by the patient's overall condition. For example, if the patient is experiencing seizure activity, anti-seizure medication (e.g., benzodiazepine) may be indicated. If the patient is agitated or uncooperative, physical or chemical restraints may be needed to restrict patient movement. Conduct frequent re-assessment of the patient's neurologic status and vital signs.^16,21

Ingestion and Injection
Several factors influence the management of a suicide attempt involving an ingestion or injection. For example, what substance was ingested? How much? How long ago was the substance ingested/injected? Was more than one substance involved (i.e., polypharmacological overdose)? Are alcohol or other substances suspected? Are illegal substances involved? What was the route? If the substance was taken orally, did the patient vomit following ingestion? Did the patient "shoot up" using an intravenous route? Table VI provides examples of prehospital treatment to consider.^15,21

Management of a suicide attempt by oral ingestion may involve inducing vomiting or inserting a gastric tube. If the patient is conscious and alert, and depending upon what substance is suspected of being involved, vomiting may be indicated, which can be accomplished with syrup of ipecac. If absorption is desired, administer activated charcoal. Gastric tube placement may be used to remove stomach contents.²¹

Managing a suicide attempt that involved an intravenous injection may be complex. It may not be possible to determine exactly what chemicals/solutions/substances were involved. In such cases, depending on the patient's condition, intervention will be influenced by factors including local protocols and proximity to a hospital.²¹

Carbon Monoxide
Carbon monoxide (CO) is an odorless, tasteless gas. Sources include propane grills, spray paint, solvents, degreasers, paint removers and automobile emissions. Excessive exposure to CO can result in death and has been used successfully in suicide.^26,27 A suicidal patient might lock himself in a running car that is parked in an enclosed garage, taking additional steps to promote success by attaching a hose to the exhaust pipe of the car and running the hose inside the car through a partially opened window.

Symptoms associated with CO poisoning are extensive and overlap with other medical conditions, including overdose and hypoxic conditions.^26,27 Major symptoms associated with high CO exposure include headache, dizziness, nausea, flu-like symptoms, shortness of breath on exertion, impaired judgment, chest pain, confusion, vomiting, depression, abdominal pain, drowsiness, visual changes, seizures, walking problems and unconsciousness.

Cases involving a running motor vehicle present unique challenges. For example, gaining access to the patient may be difficult due to a locked garage or automobile. If the car is running inside a closed garage, the elevated temperature of the car may be transferred and elevate the patient's body temperature, which may influence the effectiveness of the treatment provided.

Prehospital treatment of the suicidal patient suffering from CO poisoning will vary. After ensuring provider safety, remove the patient from the source, such as a running car. Secure the patient's ABCs. For possible CO poisoning, high-flow, high-concentration oxygen is indicated. Intubation and intravenous access may also be required. An altered mental status will require you to consider potential causes and provide treatment accordingly.^21,26,27

Altered Mental Status
An individual who attempted suicide but not completed it may experience altered mental status, or AMS. Because of this, managing the patient may not always be straightforward. You will need to consider the potential cause of the altered mental status, in addition to the mechanism of the suicide attempt, when determining patient care. The mnemonic AEIOU-TIPS provides a summary of the common causes of altered mental status: Alcohol, Epilepsy/Electrolyte Imbalance, Overdose, Uremia, Trauma, Infection/Insulin, Psychiatric and Sepsis. In an effort to rule out potential causes of AMS, and depending on local protocols, the patient with an altered mental status may be a candidate for various interventions. For example, naloxone (Narcan) may be administered to counter opiates. Thiamine, a vitamin for dextrose metabolism, may be given in combination with dextrose. Dextrose, D50, is used for hypoglycemia. In all cases of altered mental status, oxygen should be administered.^21,22

Depending upon the patient's level of consciousness, cooperation and condition, chemical or physical restraints may be necessary when trying to assess or manage the patient. For example, if the patient has an injury, restraints can be used to restrict movement. This helps ensure the patient's safety, as he is less likely to further harm himself, and it may also help the EMS crew as they attempt to assess and manage the patient. In the prehospital setting, consider restraining any unconscious patient prior to intervening. In the event that the patient regains consciousness and is not cooperative, you will not have to struggle (as much) with the patient to continue assessment and treatment. There are several types of physical and chemical restraints available. You are encouraged to become familiar with your EMS system's approved restraint devices prior to using them.^16,21

Uncompleted Suicide and EKG Changes
Following an uncompleted suicide attempt, cardiac arrhythmias may be present. In certain cases, such as acute tricyclic antidepressant overdose, the patient may experience life-threatening EKG changes that warrant treatment in the field. In other cases, EKG changes may not be present and you may need to monitor the patient for any changes.^21,22 Each scenario is unique.

Conclusion
By having a basic understanding of some of the methods involved in suicide attempts, you will be better prepared to respond to such calls. The ability to provide appropriate treatment may be key in reducing morbidity and mortality associated with suicide attempt scenarios.

References

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