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 to 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 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 minutes, another nearly 25% act between and 19 minutes, while another nearly 25% act between 20 minutes and 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, https://www.nimh.nih.gov/research/research-conducted-at-nimh/asqtoolkit-materials/index.shtml ) and the Columbia Suicide Severity Rating Scale (C-SSRS, http://cssrs.columbia.edu/ ) The AACAP Suicide Resource Center can be accessed at https://www.aacap.org/aacap/families_and_youth/resource_centers/ 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 ... 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... screening for suicidality in patients presenting with nonpsychiatric complaints Other wellvalidated pediatric suicide screening tools include the “Ask SuicideScreening Questions” (ASQ, https://www.nimh.nih.gov/research/research-conducted-at-nimh/asqtoolkit-materials/index.shtml