 Welcome to emergency medicine video. This segment is about the suicidal patient who discuss the approach and the management of the patient in the emergency department We'll discuss how to approach the history physical How to assess risk and determine disposition of the patient First history we'll divide this up into the event or the attempt past history including medical and psychiatric and Concurrent psychiatric illness if the patient has had a suicidal attempt We sometimes need to address the injury from the attempt first Whether this is toxicological effect from meds overdose or trauma We need to make sure the patient is stable before we assess the psychiatric component of the attempt Once they're stable, we can clarify more about the attempt We need to find out whether there is a particular trigger or a stressor that made the patient attempt that particular day What were they planning and how far did they go with the planning? How long have they been thinking about this plan and organizing it? If they did not attempt what stopped them What was going through their mind during the attempt? Past history include a path of medical history and past psychiatric history Past medical history that's relevant include a thyroid issues and any other significant medical history For previous psychiatric history. We need to know about previous suicidal attempt and the methods previous mood disorder including bipolar and depression anxiety disorder psychosis and substance abuse Family history of psychiatric illness is also helpful For concurrent psychiatric illness. We want to ask the ones that we just mentioned If the patient have not made a suicidal attempt But has presented with features of these psychiatric illness. It is also important for us to assess their suicidal risk Asking them whether they have ever thought of harming themselves will not increase the risk of suicide What about physical exam? First, we have to assess the injury that has been caused by the suicidal attempt There are also medical conditions that mimic psychiatric conditions Hypothyroid can look like depression Delirium can look like psychosis Conditions such as PE Asthma can look like panic attack or anxiety Therefore based on the patient's presenting symptoms the appropriate physical examination should be done Likewise, sometimes lab work is also ordered in the workup of the patient For example a TSH might be ordered to roll out a hypothyroid In some cases a delirium workup Or a workup for PE including chest x-ray ECG and so on Next we'll talk about the risk assessment of the patient Are we worried that they are going to harm themselves if released from the hospital? This is a tricky area There are a few factors that make us worry more increasing age being of the male gender and previous attempt As for the plan or attempt What kind of plans have they thought about? Have they thought about how they're going to carry it out with what means? Do they have ready access to lethal weapons such as firearms? If they have attempted but survived What do they think of the lethality of their attempt? Did they think that they were going to die? What about their support system? The lack of a support system is a risk factor It increased also in those who live alone Do they express hopelessness And symbols of hopelessness such as giving away their possessions and writing goodbye letters If they had attempted those who had no regret for the attempt are at higher risk And so are those with no future oriented goals or plans The more concrete the plan the more organized it is And the further down the patient has to carry out the plan. We are more worried about them All of these discussed here will increase the patient's risk for suicide That leads us into disposition Those who've had sustained injuries from the attempt will likely need to be admitted Once their medical conditions are being stabilized and treated that can delve into their psychiatric risk Then we can ask them the questions that we've outlined before to assess their risk For the patient with low risk It's essential for us to set up a good follow-up for the patient We need to ensure that a good support system is in place And the patient should have a future oriented plan They need to feel like they would be safe enough to go home Depending on your institution, you might still wish to discuss with the psychiatric team about low risk patients High risk patient should have psychiatric evaluation If the patient does not consent, depending on where you work, there are different ways to detain a patient without their consent In Ontario, we use a Form 1 under the Ontario Mental Health Act It allows us to detain the patient for a maximum of 72 hours without their consent in a psychiatric facility The criteria for this certification includes threat to themselves Attempt to hurt self Or another person Or unable to care for themselves Different jurisdictions will have different forms that might include different criteria and you should follow your local practice In cases that are ambiguous, again, it's best to speak to your psychiatric consultants In summary, we discuss how to assess the suicidal patient in the emergency department We talk about history, including present and previous history Physical examination that may target some medical mimics How to assess for risk and how to disposition the patient in the emergency department We hope you find that useful. Thank you for watching