Pediatric emergency medicine trisk 1044

In the event that an ED physician is evaluating and managing a truly
homicidal patient, the ED physician has a duty to both warn the potential
victim (typically via contacting local police) and to take actions to protect
the potential victim from harm (e.g., by psychiatrically hospitalizing the
patient). This duty was established in the landmark case of Tarasoff vs. the
University of California and has withstood numerous court challenges. This
duty to warn and protect the potential victim supersedes the physician’s duty
to maintain patient confidentiality.

SUICIDE ATTEMPTS
Goals of Emergency Evaluation and Treatment
The goals of emergency evaluation and treatment of patients presenting in
the wake of a suicide attempt are to identify and treat any potential medical
sequelae of the attempt, to maintain the patient’s safety in the ED, and to
establish an adequate disposition plan.
CLINICAL PEARLS AND PITFALLS


Suicide is the final common pathway for various situations in which
the child experiences a pervasive sense of helplessness, with a
perceived absence of alternative solutions. To the distressed child,
suicide appears to be the only solution to his or her problems and
the family’s problems. Most suicide attempts occur in depressed
children; others occur with children experiencing major losses, such
as serious illness or death in the family or in children with
depression with associated impulsivity. A small but significant
percentage of suicide attempts occur in psychotic children and
adolescents ( Table 126.9 ).
Children have differing conceptions of death at various ages. Up
to age 5, death is seen as a reversible process in which the activities
of life still occur. From 5 to 9 years, the irreversibility of death is

beginning to be understood, but death is personified rather than
seen as an independent event. It is not until about age 9 that death
is seen as irreversible in the adult sense of being both final and
inevitable. Even then, however, the child may imagine his or her own
death as being reversible. Under such circumstances, a suicide
attempt may have a different meaning than for an adult, where
suicide corresponds to a definite end of one’s life.
While it is common for psychiatric symptoms to be present for
weeks to months before an attempt and the vast majority of patients
who suicide meet criteria for a psychiatric or substance abuse
diagnosis at the time of their death, the time between a patient
deciding to kill themselves and carrying out the act is often quite
short and often occurs in the midst of an acute crisis. Studies of
survivors of potentially lethal attempts suggest that close to 25% act
on their decision within 5 minutes, another nearly 25% act between
5 and 19 minutes, while another nearly 25% act between 20 minutes
and 1 hour. This means that effective prevention efforts include the
strategies of identifying and treating psychiatric disorders prior to the
development of suicidal ideation as well as efforts to restrict access
to the most lethal and common means of suicide attempts.
Emergency physicians must provide clear guidance around
means restriction including firearms and potentially dangerous
medications. Over 80% of pediatric patients who suicided by firearm


use a family member’s firearm. Of those, over two-thirds used guns
that were unlocked and the remainder either knew how to open the
gun safe or were able to break in. In one study, nearly a quarter of
children whose parents believed they had never handled their
firearms were mistaken. Removal of firearms (and potentially

dangerous medications) from the home—at least temporarily—is
ideal; safe storage is a minimum.
The dichotomy sometimes drawn between suicide “attempts” and
suicide “gestures” is ill conceived, and the lethality of attempt does
not always correlate with lethality of intent. As a corollary, minimizing
a suicidal act as “just cry for help” by not responding adequately only
invites a potentially far-more-lethal “scream for help.”
Suicidal ideation is common enough that EDs could consider
screening all teens for suicidal ideations or attempts, especially ones
engaging in any high-risk behaviors or with other identifiable risk
factors. Several screening tools, such as the Risk of Suicide
Questionnaire (RSQ) and briefer two- and four-question screening
tools are effective and accurate in screening for suicidality in
patients presenting with nonpsychiatric complaints. Other wellvalidated pediatric suicide screening tools include the “Ask SuicideScreening Questions” (ASQ,
) and the Columbia Suicide Severity
Rating Scale (C-SSRS, ). The AACAP
Suicide Resource Center can be accessed at
/>Suicide_Resource_Center/Home.aspx


TABLE 126.9
POTENTIAL SOURCES OF ADOLESCENT SUICIDE ATTEMPTS
Developmental stress—identity crisis
Dependence/independence
Accepting disappointments/limitations
Planning for future
Body changes and self-image
Physical growth
Onset of puberty
Awareness of sexuality/need to look attractive

Peer pressures
Friendships and competition with peers of same gender
Dating, romantic involvements, dealing with sexuality
Rejection by special person or peer group
School pressures
Academic competition
Personal need to succeed
Meeting parental expectations
Family pressures
Parent–child expectations/problems
Parental impairment (medical, psychiatric, drug or alcohol)
Parental conflict or divorce
Financial/job-related crises
Societal influences
Mobility and social isolation
Romanticizing of violence and suicide
Lack of confidence in secure future
Adolescent depression
Physiologic vulnerability
Situational stresses
Sexual orientation and/or gender identity