SELF-HARM: SUMMARY OF MANAGEMENT AND TREATMENT
Advice for healthcare professionals in any setting
General
principles
Always treat people with care and respect
Ensure privacy for service user
Take full account of the likely distress associated with self-harm
If it is not possible to give people their choice,
explain why and write it in the notes
Offer the choice of male or female staff for assessment and
treatment
Always ask the service user to explain why they have selfharmed in their own words
Remember, when people self-harm often, the reason
for each act may be different on each occasion; don’t
assume it’s done for the same reasons
Involve service user in clinical decision-making; provide
information about treatment options
Relatives,
carers and
friends
Include family or friends if the
service user wants their
support during assessment
and treatment
Psychosocial assessment usually needs some time with service user alone
Relatives/carers may need emotional support
Self Harm: NICE guideline (January, 2004)
Page 1 of 15
SELF-HARM: SUMMARY OF MANAGEMENT AND TREATMENT
Consent
Always assess mental capacity
interview relatives/friends to help assessment
Assume mental capacity unless evidence to the
contrary
Obtain fully informed consent before each treatment
or procedure is started
including taking to hospital
If mentally incapable always act in the person’s best
interest even if against the person’s wishes
includes taking to hospital when person has refused
Always attempt to gain consent for each and every
new treatment.
Remember, capacity changes over time.
The mental health act can be used to treat the
physical consequences of self-harm
Specific issues
regarding
treatment and
care
When
physical
treatments are
offered
Ambulance staff and primary care practitioners involved in the treatment of
self-harm should ensure that activated charcoal is always available for
immediate use
Always offer necessary physical treatments even if the person doesn’t
want psychosocial or psychiatric assessment
Always use proper anaesthesia if treatment is painful
Offer sedation if treatment may evoke distressing memories of previous
sexual abuse, such as when repairing harm to the genital area
Self Harm: NICE guideline (January, 2004)
Page 2 of 15
SELF-HARM: SUMMARY OF MANAGEMENT AND TREATMENT
Activated
charcoal
Primary care, ambulance and
emergency department staff involved
in the treatment of self-harm by
poisoning should offer activated
charcoal appropriately within 2 hours
of ingestion
Know how to administer it
Know for which poisons activated charcoal should and should not be
used
Know the potential dangers and contraindications of giving activated
charcoal
Know that it’s important to encourage and support service users when
offering activated charcoal
Self Harm: NICE guideline (January, 2004)
Page 3 of 15
SELF-HARM: SUMMARY OF MANAGEMENT AND TREATMENT
The management of self-harm in primary care
Urgently establish physical risk
and mental state in a respectful
and understanding way
If in doubt about whether to refer –
Discuss with the emergency consultant
Self-injury
If there is significant
risk to the service user
refer to A&E urgently
Assess risk of further self-harm Especially
consider depression, hopelessness and
suicidal intent
if can’t get to A&E quickly (remote areas) Discuss with
emergency consultant. Consider initiating treatment
and collect samples as necessary (for self-poisoning)
Tell the ambulance crew what
treatment you have given
Arrange for appropriate chaperone when service
user going in ambulance to A & E if
•
•
•
There is a risk of further self-harm
Person is reluctant to attend
Service user is very distressed
Inform other
relevant staff
and
organisations
of the outcome
of this
assessment
Self-poisoning
Refer to A&E urgently unless you
are sure this isn’t necessary
(always do so if you have given
activated charcoal)
Remember – many people
aren’t sure what drugs they’ve
taken.
Offer activated charcoal as early as
possible
If within two hours of ingestion, the service user is fully
conscious, service user able to protect his or her own
airway, substance ingested indicates use of activated
charcoal
Tell patient activated charcoal is unpleasant and
encourage them whilst they are taking it
Self Harm: NICE guideline (January, 2004)
Page 4 of 15
SELF-HARM: SUMMARY OF MANAGEMENT AND TREATMENT
When urgent
referral to the
emergency
department is not
necessary
Base decision on risk and needs assessment,
including:
Does the person need
urgent referral to
secondary mental
health services?
•
Social and psychological aspects of episode
of self-harm
•
mental health and social needs
•
hopelessness
•
suicidal intent
Send full details of assessments and treatment to
the appropriate secondary mental health team as
soon as possible
Prescribing to
service users at
risk of selfpoisoning
When prescribing
drugs to:
•
•
•
Self Harm: NICE guideline (January, 2004)
people who
have
previously
self-poisoned
Always prescribe those drugs which are the
least dangerous in overdose
Prescribe fewer tablets at any one time
people who
are at risk of
doing selfpoisoning
Consider alternatives to co-proxamol
people who
live with
someone at
risk of selfpoisoning
Page 5 of 15
SELF-HARM: SUMMARY OF MANAGEMENT AND TREATMENT
The assessment and initial management of self- harm by ambulance personnel
Urgently establish physical risk and mental state in respectful and understanding way
Selfinjury
Selfpoisoning
Unless the service user’s clinical condition requires urgent attention, record all relevant information at
the scene:
home environment, social/family support network and history leading to self-harm.
Pass information to A&E staff on arrival
If within two hours of
ingestion, the service
user is fully conscious,
service user able to
protect his or her own
airway, substance
ingested indicates use of
activated charcoal
Obtain all
substances
and/or
medications
found at the
scene.
Give them to
A&E staff on
arrival
Offer activated charcoal as
early as possible
Tell patient activated charcoal
is unpleasant and encourage
them whilst they are taking it
Consider IV naloxone:
• Follow JRCALC
guidelines
• Pay attention to the
need for repeat doses
• Monitor vital signs
frequently
Self-poisoning with
opioids
If unsure if pre-hospital
treatment needed or
ingestion of unusual
substance
If person is likely to
refuse treatment
assess
mental
capacity
provide information about
the potential consequences
of not receiving treatment
Self Harm: NICE guideline (January, 2004)
Consult TOXBASE
continue to try to
gain valid
consent and
follow guidance
on consent
Page 6 of 15
If consent
is withheld
follow
guidance
on consent
Take straight to A&E,
even if they have
responded well to
initial treatment
Consider service
user’s preference if
more than one A & E
nearby
Ignore preferences if
this increases risk
If the service user does
not require treatment at
A&E
consider taking the
person to an alternative
appropriate service.
Must be agreed with
alternative service and
the service user
SELF-HARM: SUMMARY OF MANAGEMENT AND TREATMENT
The treatment and management of self-harm in emergency departments
Triage
Take account of
emotional distress as well
as physical
Remember, some people who self-harm may not
show distress even when severe
•
Offer psychosocial
assessment at triage to
determine
People waiting
for physical
treatments
Don’t delay psychosocial
assessment until after
medical treatment
Provide verbal and written
information about the care
process
Self Harm: NICE guideline (January, 2004)
•
•
EXCEPT WHEN:
• Service user needs life-saving treatment
• Patient is unconscious
• Patient incapable of assessment (e.g. intoxicated)
Must be in a language service user understands
Provide a safe, supportive environment where people can wait
People who wish to leave
before assessment and/or
treatment
•
mental capacity
willingness to remain for further
psychosocial assessment
distress levels
presence of mental illness
Service user may need supervision
to ensure safety
If person wants to leave before a
psychosocial assessment
Assess for: mental capacity/ mental illness
If mental capacity diminished, and/or
significant mental illness
refer for urgent mental health assessment
Page 7 of 15
Record assessment in the notes
prevent the person leaving
SELF-HARM: SUMMARY OF MANAGEMENT AND TREATMENT
Medical and surgical management of self-harm
General
treatment
for
ingestion
Only offer gastrointestinal
decontamination if
person:
• presents early
• is fully conscious
• has a protected
airway
• is at risk of significant
harm from the
ingested substance
Offer activated charcoal,
unless contraindicated,
as early as possible and
within 2 hours after
ingestion
If consciousness is
impaired, and patient
cannot adequately protect
their own airway, and there
is considerable risk from
the ingested substance
Collecting
samples
and
interpreting
results
Information and
laboratory
services
available to
clinicians
treating selfpoisoning
Collect samples
•
•
•
Blood
Ingested
substances
Other samples if
NPIS require them
Tell patient
activated charcoal
is unpleasant and
encourage them
whilst they are
taking it
Consider giving
activated charcoal via a
nasogastric tube in
conjunction with
endotracheal intubation
only
Beware:
increased
risk of
aspiration
pneumonitis
Consult TOXBASE to select
and interpret assays:
Don’t offer multiple doses of activated
charcoal, unless specifically
recommended by TOXBASE or the
NPIS
•
Don’t use emetics, including ipecac
•
Don’t use cathartics
•
Don’t use gastric lavage, except on
the advice of NPIS or a poisons
treatment centre
Consult TOXBASE to interpret
assay results:
•
If in doubt check with
local laboratory
•
if in doubt check with
local laboratory
•
Still in doubt consult
with NPIS
•
Still in doubt consult
with NPIS
Use TOXBASE as the
primary source of information
about the treatment of
poisoning
Except in the use of activated
charcoal for self-poisoning
Contact the NPIS only after
consulting TOXBASE
In poisoning with unusual
substance, pass data to NPIS
Self Harm: NICE guideline (January, 2004)
•
Page 8 of 15
Consult TOXBASE for the
specific management and
treatment of overdose with
substances not covered in this
guideline
SELF-HARM: SUMMARY OF MANAGEMENT AND TREATMENT
For all conscious patients with a history of paracetamol
overdose, or suspected paracetamol overdose
Paracetamol
screening
Management
of paracetamol
overdose
Offer
activated
charcoal as
indicated
above
Use
TOXBASE to
guide further
management
Flumazenil in
benzodiazepine
overdose
Measure plasma paracetamol
concentrations
For patients with a presentation consistent with opioid
poisoning
For unconscious patients with a history of collapse where drug
overdose is a possible diagnosis
Use IV N-acetylcysteine1 (NAC)
In cases of
staggered ingestion
of paracetamol
Except:
• in patients who report previous
proper anaphylactic reactions
following administration of NAC
• for people who abuse
intravenous drugs where
intravenous access may be
difficult
• in people with needle phobia
in these cases consult
TOXBASE
If benzodiazepine poisoning
suspected and:
Patient unconscious or marked
impairment of consciousness and
respiratory depression present
If positive diagnosis, and improving
consciousness clinical priority and
respiration depressed, and
concomitant tricyclic antidepressant
poisoning excluded
Self Harm: NICE guideline (January, 2004)
If patient has
anaphylactoid
reaction to NAC
Consider flumazenil to aid diagnosis
•
•
•
Use small doses
Resuscitation equipment must be available
Check for other ingested substances
•
Then use flumazenil therapeutically
•
Page 9 of 15
use the minimum
effective dose for only
as long as is clinically
necessary
monitor and document
known side effects,
such as convulsions
Consult
TOXBASE,
then the
NPIS
SELF-HARM: SUMMARY OF MANAGEMENT AND TREATMENT
Treatment and
management of
poisoning with
salicylates
Treatment
of opioid
overdose
Use activated charcoal
as above
If opioid poisoning
suspected, and
•
•
Use TOXBASE for further
management
Use naloxone for diagnosis and treatment
Impaired
consciousness
and
Respiratory
depression
Use minimum effective dose
If patient dependent on opioids:
give slowly and prepare for
agitation
if long-acting opioids (e.g.
Methadone) present: consider IV
Infusion
Monitor vital signs and oxygen
saturation until patient conscious
and adequate breathing without
further naloxone
Giving advice to people who repeatedly
self-poison
•
•
Self Harm: NICE guideline (January, 2004)
Don’t offer harm minimisation advice regarding selfpoisoning – 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.
Page 10 of 15
SELF-HARM: SUMMARY OF MANAGEMENT AND TREATMENT
General
treatment for
self injury
Wound closure
Remember:
•
Explain the treatment
options to the service user
Don’t delay treatment because it is selfinflicted
•
Take account of the distress involved in
self-harm and in seeking treatment
•
Always use anaesthesia if treatment may
be painful
Discuss fully with the service
user his or her treatment
preferences
offer tissue adhesive
as the first-line
treatment
For superficial uncomplicated
injuries of 5cm or less in length
For superficial uncomplicated
injuries of greater than 5cm, or
deeper injuries of any length
Offering support
and advice for
people who selfinjure repeatedly
Offer skin closure strips if
service user prefers this
assess and explore the wound and follow
good surgical practice
Consider giving advice and instructions on
Self Harm: NICE guideline (January, 2004)
•
Self-management of superficial
injuries, including providing tissue
adhesive.
•
Harm minimisation issues and
technique
•
Appropriate alternative coping
strategies
•
Dealing with scar tissue
Page 11 of 15
Discuss with a mental health worker
which service users should be offered
this
Voluntary organisations may have
suitable materials
SELF-HARM: SUMMARY OF MANAGEMENT AND TREATMENT
Psychosocial Assessment
Assessment of
need (specialist
mental health
professionals)
Assess needs and risks as part of the therapeutic process to
understand and engage the service user
Offer needs assessment to all
people who self-harm.
Consider integrating needs and risk assessment.
Assessment of
risk (specialist
mental health
professionals)
Assess all people who selfharm for risk.
Include:
Include:
•
Social, psychological and motivational factors specific to the act
of self-harm
Identification of the main clinical and demographic features known
to be associated with risk of further self-harm and/or suicide
•
current intent
•
Identification of the key psychological characteristics associated
with risk:
hopelessness
•
mental health and social needs assessment
•
Depression
•
Hopelessness
•
continuing suicidal intent
Record assessment in notes
•
Share written assessment with service user
•
If disagreement consider service user recoding this in the notes
Record assessment in notes
Only use a standardised riskassessment scale to aid
identification of those at high
risk of repetition of self-harm
or suicide.
Self Harm: NICE guideline (January, 2004)
Page 12 of 15
Don’t use standardised riskassessment scales to identify
service users of supposedly
low risk who are not then
offered services
SELF-HARM: SUMMARY OF MANAGEMENT AND TREATMENT
Referral, Discharge and Admission following psychosocial assessment
Decide options jointly with the Service User
Discuss:
• Treatment
options
• Service users
preference
• Provide
relevant
written
information
Base decisions about referral,
discharge and admission on
comprehensive assessment
including needs and risks
If:
If not possible e.g.
• Reduced
mental
capacity
• Significant
mental
illness
•
Very distressed
Home considered
unsafe
Too difficult to
undertake
psychosocial
assessment
Re assess the
following day
Refer for further assessment and
treatment according to underlying
problems associated with self-harm
Self Harm: NICE guideline (January, 2004)
Consider offering an
intensive
therapeutic
intervention
combined with
outreach to people
who have selfharmed and are
deemed to be at
risk of repetition
Consider DBT
for people with
Borderline
Personality
Disorder
Page 13 of 15
Write explanation in
the notes
Do not refer only on
the basis that they
have self-harmed
Do not discharge
without a follow up
solely on the basis
of low risk and no
mental illness
Consider
admission
overnight
•
•
Explain to service
user
Intensive
intervention should
allow greater
access to a
therapist than
good standard
care, and outreach
should include
following up the
service user when
an appointment
has been missed.
The therapeutic
intervention plus
outreach should
continue for at
least 3 months
However, don’t
ignore other
psychological
treatments for
people with this
diagnosis, which are
outside the scope of
this guideline
SELF-HARM: SUMMARY OF MANAGEMENT AND TREATMENT
Undertake assessment
addressing:
Special issues for children and young people
Triage, assessment and treatment should
be undertaken by: paediatric nurses and
doctors trained to work with children and
young people who self-harm
All children and young people should be
admitted into a paediatric ward under the
overall care of a paediatrician
After admission, the paediatric team should
obtain consent for mental health assessment
from the child or young person’s parent, guardian
or other legally responsible adult
In A & E in a separate area for children and young people
Alternative placements may be needed, depending on:
•
Age
•
Circumstances of the child and their family
•
Time of presentation
•
Child protection issues
•
Physical and mental health of the child
•
Needs and risks for the
child (similar to adults)
•
The family
•
The social situation of
family and young
person
•
Child protection issues
Assessors should be
specifically trained and
supervised to work with
self-harm in this age group
For young people who
have self-harmed
several times:
Preferences of the child or young person
If you are involved with children or young people in the emergency treatment of self-harm,
you must understand how issues of capacity and consent apply to this group
Special attention should be given to:
During
admission,
the CAMHS
team should:
Confidentiality, Consent (including Gillick Competence), Child protection issues, The use
of the Mental Health Act and the Children Act
Self Harm: NICE guideline (January, 2004)
Page 14 of 15
Provide consultation for:
•
The young person
•
Their family
•
The paediatric team
•
Social services
•
Education staff
Before the child or young
person goes home advise
carers to remove all
means of self-harm,
including medication
Consider offering
developmental group
psychotherapy with other
young people; this should
include at least 6 sessions but
can be extended by mutual
agreement
SELF-HARM: SUMMARY OF MANAGEMENT AND TREATMENT
Special issues for older people
You must be experienced in assessing older adults who
have self-harmed to undertake assessment of this age
group.
Follow the same principles as for the assessment of adults, but also
include a full assessment with special attention to:
Be aware:
•
the possible presence of depression
•
cognitive impairment
•
physical ill health
•
their social and home situation
All acts of self-harm in people over the age of 65 years should be taken as
evidence of suicidal intent until proven otherwise
Always consider admission for:
•
mental health assessment
•
risk and needs assessment
•
monitoring changes in mental state and levels of risk
Self Harm: NICE guideline (January, 2004)
Page 15 of 15