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					                       Self-harm:
          short term treatment and
                management

          The treatment and management of
         self-harm in emergency departments



    November 2011


NICE clinical guideline 16
        What this presentation covers
Background
Epidemiology
Scope
Recommendations relevant to
emergency departments
Discussion
NICE pathways
NHS Evidence
Find out more
                 Definition and background

‘Self-harm’ refers to any act of self-poisoning or
self-injury.


Methods can be divided into:
• self-poisoning
• self-injury.


People who survive a medically serious suicide
attempt may have poorer life expectancy.
                                    Epidemiology
• Self-harm is common, especially among younger
  people

• For all age groups annual prevalence is approximately
  0.5%

• Self-harm increases the likelihood that the person will
  eventually die by suicide by between 50 and 100 fold

• Psychiatric problems such as borderline personality
  disorder, depression, bipolar disorder, schizophrenia
  and drug and alcohol-use disorders are
  associated with self-harm.
                                                   Scope

The guideline covers:

• all people aged 8 years and over who have carried out
  an act of intentional self-harm, regardless of whether
  the behaviour is accompanied by a mental illness

• the acute care of self-harm in people with learning
  disabilities, but not repetitive self-injurious behaviour,
  such as head banging

• guidance about care provided by primary, community
  and secondary health and social care services.
                             Key priorities for
                              implementation
• Respect, understanding and choice
• Staff training
• Activated charcoal
• Triage
• Treatment
• Assessment of needs
• Assessment of risk
• Psychological, psychosocial and
  pharmacological interventions
          Treating and managing self-
      harm in emergency departments
The emergency department provides the main services
for people who self-harm.


Emergency department staff should:
 • quickly assess risk and emotional, mental and
   physical state
 • try to encourage people to stay and organise a
   psychosocial assessment for them.
                    Respect, understanding
                                and choice
People who have self-harmed should be treated with the
same care, respect and privacy as any patient.


Take full account of the likely distress associated with
self-harm.


All staff caring and providing treatment for people who
self-harm should have regular clinical supervision in
which the emotional impact upon staff members can
be discussed.
                                      Staff training

Clinical and non-clinical staff in any setting should have
appropriate training.

Involve people who self-harm in the planning and
delivery of staff training.

Make training available in the assessment of mental
health needs and the preliminary management of mental
health problems.
                              Service planning
Involve people who self-harm in planning and evaluating
services.

Integrate physical and mental healthcare services – joint
plan by emergency departments, PCTs and local mental
health services.

Consider integrating mental health professionals into the
emergency department.

Psychiatric services available 24 hours a day – liaison
between emergency department and local mental
health services.
                            Activated charcoal


Ambulance and emergency department services that
may deal with people who have self-harmed by poisoning
should ensure activated charcoal is immediately
available at all times.


All healthcare professionals able to offer activated
charcoal should know how and when it should be
administered.
                                              Triage

Offer preliminary psychosocial assessment at triage.

Assessment should determine:
 • mental capacity
 • willingness to remain for further assessment
 • level of distress
 • possible mental illness.


Consider introducing the Australian Mental Health
Triage Scale so patients are seen in a
timely manner.
                         Waiting for physical
                                  treatments
Offer a person who has to wait for treatment an
environment that is safe, supportive and minimises any
distress.


Do not delay psychosocial assessment until after medical
treatment is complete.


Provide clear and understandable information about
the care process.
            People who wish to leave
      before assessment or treatment

If a person wishes to leave before psychosocial
assessment:

 • assess mental capacity and the presence of mental
   illness before the person leaves the service

 • if they have diminished capacity and/or significant
   mental illness, refer for urgent mental health
   assessment.
                                         Treatment

Offer treatment for the physical consequences of self-
harm, regardless of willingness to accept psychosocial
assessment or psychiatric treatment.


Offer adequate anaesthesia and/or analgesia throughout
the process of suturing or other painful treatments.


Provide full information about the treatment options and
ensure the person can give informed consent.
                    Treatment for ingestion
Consider gastrointestinal decontamination only if the
patient presents early, is fully conscious, has a protected
airway, and is at risk of significant harm from the
ingested substance.

Offer activated charcoal as early as possible, within
1 hour, unless contraindicated.

Consider activated charcoal between 1 and 2 hours, to
reduce absorption, especially if the ingested
substance delays gastric emptying, such as
tricyclic antidepressants.
                     Collecting samples and
                         interpreting results


Collect samples of blood, ingested substances, and
other samples if the NPIS requires them.

Consult TOXBASE to select and interpret assays (if in
doubt, check with local laboratory; if still in doubt, consult
with the NPIS [National Poisons Information Service]).
                           Information service

Emergency department staff should have easy access to
TOXBASE, be fully trained in its use, and know how and
when to contact the NPIS.

For poisons considered in this guideline:
 • consult TOXBASE in conjunction with this guideline
 • if in doubt, consult the NPIS.

For all other poisons:
  • consult TOXBASE
  • if the poison is an unusual one, pass the
    data to the NPIS.
                    Paracetamol screening

Measure plasma paracetamol concentrations in patients:
 • conscious with a history of paracetamol overdose, or
   suspected paracetamol overdose
 • with a presentation consistent with opioid poisoning
 • unconscious with a history of collapse, if drug
   overdose is a possible diagnosis.

Measure plasma paracetamol concentrations and
take samples no earlier than 4 hours and no later
than 15 hours after ingestion.
                        Management of
                paracetamol overdose: 1

Offer activated charcoal as recommended, and then use
TOXBASE to guide further management.


Use intravenous acetylcysteine depending on plasma
concentration levels, except:
 • for people who abuse intravenous drugs where
   intravenous access may be difficult
 • for people with needle phobia.
In these cases, consult TOXBASE.
                        Management of
                paracetamol overdose: 2

If the patient has an anaphylactoid reaction to
acetylcysteine, consult TOXBASE, then the NPIS.

In cases of staggered ingestion of paracetamol,
investigate for ingestion of other poisons, and
consult TOXBASE, then the NPIS.
                Benzodiazepine overdose


If benzodiazepine overdose is confirmed, investigate the
possibility of mixed overdose as soon as possible, and
especially if clinical progress suggests that the patient
may later need admission to intensive care.
                                    Flumazenil: 1
Consider flumazenil:

 • if the patient is unconscious or shows marked
   impairment of consciousness, with evidence of
   respiratory depression likely to lead to admission to
   intensive care with endotracheal intubation

 • only after a comprehensive assessment has been
   undertaken that includes a full clinical and
   biochemical assessment of the patient’s respiratory
   status, and his or her ability to protect his or her
   own airway.
                                   Flumazenil: 2

Do not use flumazenil if:

 • the patient has co-ingested proconvulsants,
   including tricyclic antidepressants

 • the patient has a history of epilepsy

 • the patient is benzodiazepine-dependent.
                                     Flumazenil: 3
When using flumazenil:
 • ensure resuscitation equipment is immediately
   available
 • use small doses
 • give slowly
 • use the minimum effective dose only for as long as it
   is clinically necessary
 • warn the patient of the risk of re-sedation,
   particularly if the patient expresses the desire to
   leave the treatment setting.
               Poisoning with salicylates



Following gut decontamination with activated charcoal,
where this is indicated by this guideline, the further
treatment of self-poisoning with salicylates should follow
the current guidance outlined in TOXBASE.
                               Opioid overdose
Use naloxone to diagnose and treat suspected opioid
poisoning with impaired consciousness and/or respiratory
depression
When administering naloxone:

 • Use minimum effective dose
 • If patient is dependent on opioids, give slowly and
   prepare for agitation
 • If there are long-acting opioids present (such as
   methadone), consider intravenous infusion
 • Monitor vital signs and oxygen saturation until
   patient is conscious and breathing
   adequately without naloxone.
                         Medical and surgical
                                management

• Do not delay treatment because injury is self-inflicted

• Take account of the distress involved in self-harm
  and in seeking treatment

•   Explain the treatment options to the service user
    and discuss treatment preferences fully

• Always use anaesthesia and/or analgesia if
  treatment may be painful.
               Superficial wound closure

For superficial uncomplicated injuries of 5 cm or less in
length, offer:
  • tissue adhesive as first-line treatment, or
  • skin closure strips if the service user prefers.


For superficial uncomplicated injuries greater than 5 cm
in length, or deeper injuries of any length, assess and
explore the wound and follow good surgical practice.
                        Advice for people who
                        repeatedly self-poison

Do not offer harm minimisation advice on self-poisoning,
there are no safe limits.

Consider discussing the risks of self-poisoning with
service users (and carers, where appropriate) who are
likely to use this method of self-harm again.

Also see NICE clinical guideline 133, ‘Self-harm: longer term
management’
                     Advice for people who
                      repeatedly self-injure
Consider giving advice and instructions on:
 • self-management of superficial injuries, including
   providing tissue adhesive
 • harm minimisation issues and techniques
 • appropriate alternative coping strategies
 • dealing with scar tissue.

Discuss with a mental health worker which service users
should be offered this advice.

Voluntary organisations may have suitable
materials.
                      Assessment of needs

Offer an assessment of needs.

This should be comprehensive and include:
 • evaluation of social, psychological and motivational
   factors specific to the act of self-harm
 • current suicidal intent and hopelessness
 • a full mental health and social needs assessment.
                             Assessment of risk

Assess risk for all people who have self-harmed.

Include identification of:
 • the main clinical and demographic features known to
   be associated with risk of further self-harm and/or
   suicide
 • key psychological characteristics associated with
   risk, in particular depression, hopelessness and
   continuing suicidal intent.
       Special issues for children and
                        young people
Children and young people should be triaged, assessed
and treated in a separate children’s area.

Staff should be trained in the assessment and early
management of mental health problems in children.

All children or young people who have self-harmed
should normally be admitted to a paediatric ward
overnight and assessed fully the next day.
       Special issues for older people

All people aged older than 65 years should be assessed
by mental healthcare practitioners experienced in the
assessment of older people. Attention should be paid to
the potential presence of depression, cognitive
impairment and ill health.

All acts of self-harm with this age group should be
regarded as evidence of suicidal intent.
         Psychological, psychosocial and
           pharmacological interventions


After psychosocial assessment, decide whether referral
is needed for further treatment and help:

 • based on a comprehensive psychiatric, psychological
   and social assessment, including an assessment of
   risk

 • not solely on the basis of having self-harmed.
                                       Discussion

• How does care provided by our emergency
  department for people who self harm compare with the
  guidance?

• What staff training is needed to support this guidance?

• What changes do we need to make?

• Who is leading on this review and action plan?
    NICE Pathway
    The NICE self-harm
    pathway covers:
•    planning of services
•    general principles of
     care
•    assessment, treatment
     and management
•    longer-term treatment
     and management.


     Click here to go to
      NICE Pathways
          website
NHS Evidence
Visit NHS Evidence
for the best available
evidence on all
aspects of self-harm



  Click here to go to
  the NHS Evidence
       website
                                    Find out more

Visit www.nice.org.uk/guidance/CG16 for:

  • the guideline

  • ‘Understanding NICE guidance’

  • slide set for primary care

  • slide set for ambulance staff
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