short term treatment and
The treatment and management of
self-harm in emergency departments
NICE clinical guideline 16
What this presentation covers
Recommendations relevant to
Find out more
Definition and background
‘Self-harm’ refers to any act of self-poisoning or
Methods can be divided into:
People who survive a medically serious suicide
attempt may have poorer life expectancy.
• Self-harm is common, especially among younger
• For all age groups annual prevalence is approximately
• 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.
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
• Respect, understanding and choice
• Staff training
• Activated charcoal
• Assessment of needs
• Assessment of risk
• Psychological, psychosocial and
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
• try to encourage people to stay and organise a
psychosocial assessment for them.
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
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
Clinical and non-clinical staff in any setting should have
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
Involve people who self-harm in planning and evaluating
Integrate physical and mental healthcare services – joint
plan by emergency departments, PCTs and local mental
Consider integrating mental health professionals into the
Psychiatric services available 24 hours a day – liaison
between emergency department and local mental
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
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
Waiting for physical
Offer a person who has to wait for treatment an
environment that is safe, supportive and minimises any
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
• 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
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
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
Collecting samples and
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]).
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.
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.
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.
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.
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.
• 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
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.
When using flumazenil:
• ensure resuscitation equipment is immediately
• 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.
Use naloxone to diagnose and treat suspected opioid
poisoning with impaired consciousness and/or respiratory
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
• 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
• 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
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
Advice for people who
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
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
• key psychological characteristics associated with
risk, in particular depression, hopelessness and
continuing suicidal intent.
Special issues for children and
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
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
• not solely on the basis of having self-harmed.
• How does care provided by our emergency
department for people who self harm compare with the
• 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?
The NICE self-harm
• planning of services
• general principles of
• assessment, treatment
• longer-term treatment
Click here to go to
Visit NHS Evidence
for the best available
evidence on all
aspects of self-harm
Click here to go to
the NHS Evidence
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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