Eduovisual
CCS Integrated Cases
CCS case: suicidal patient in the emergency department
— Suicide is a top-10 cause of US death; #2 in ages 10–34
— ED visits for suicidal ideation (SI) or self-harm have risen sharply; ~10% of completed suicides occurred within weeks of an ED visit
— Roughly half of patients who die by suicide deny SI at their last clinical contact — absence of stated intent does not exclude risk
— Universal screening recommended by The Joint Commission for all ED and inpatient adults and adolescents ≥12, regardless of chief complaint
— Use a validated tool: Columbia Suicide Severity Rating Scale (C-SSRS), ASQ (Ask Suicide-Screening Questions) for pediatrics/adolescents, or PHQ-9 item 9
— Heightened suspicion in: overdose/ingestion, single-vehicle MVC, "accidental" firearm injury, lacerations to forearms/neck, vague "I just need a place to stay," recent psychiatric discharge (<30 days), military/veteran status, recent loss, chronic pain, terminal diagnosis
— Male sex (4× higher completion), age >65, white or Native American, social isolation, prior attempt (#1 predictor), family history of suicide
— Active substance use, command auditory hallucinations, hopelessness scores, access to firearms
— Recent improvement in depression after weeks of severe symptoms is a classic trap — energy returns before mood, enabling action
— Cases typically open in ED setting: overdose, self-inflicted laceration, family-brought-in "he said he wants to die"
— The clock starts immediately — safety, then workup, then disposition
— Expect to demonstrate: 1:1 sitter order, removal of belongings, medical clearance labs, psychiatric consult, and a disposition decision (involuntary hold vs voluntary admit vs safety-planned discharge)
Board pearl: A prior suicide attempt is the single strongest predictor of future completed suicide — ask about it explicitly in every SI workup, even when not volunteered.
— Direct: "I want to kill myself," brought by family or police after voicing intent, found with suicide note
— Post-attempt: acetaminophen/SSRI/benzodiazepine ingestion, wrist lacerations, hanging marks, GSW, CO exposure, jumping
— Disguised: vague somatic complaints, requests for refills of lethal medications, intoxication with no clear plan, "I just want to sleep forever"
— Sex (male), Age (<19 or >45), Depression, Previous attempt, Ethanol/substance use, Rational thought loss (psychosis), Social supports lacking, Organized plan, No spouse, Sickness (chronic illness)
— Better: ask the 5 Ps — Plan, Preparation, Practiced (rehearsed), Past attempts, Prevention (what stops them)
— "Are you thinking of killing yourself?" — asking does NOT increase risk
— Differentiate ideation → intent → plan → preparation → access to means
— Lethality of plan: firearm > hanging > jumping > CO > overdose > cutting
— Access: "Do you own a gun? Where is it now?"
— Protective factors: children at home, religious beliefs, reasons for living, future-oriented statements
— Family, friends, outpatient psychiatrist, pharmacy records, prior ED notes
— HIPAA permits gathering (but not disclosing) collateral when patient is at risk to self
— Look for recent stressors: job loss, breakup, legal trouble, anniversary of loss, recent discharge from psychiatric hospital
— Alcohol disinhibits and is present in ~30–40% of completed suicides
— Look at home meds: opioids, TCAs, benzos, lithium, acetaminophen stockpiles
— Recent SSRI initiation in adolescents (FDA black box re: SI in <25y)
Key distinction: Passive SI ("I wish I wouldn't wake up") vs active SI ("I'm going to take my pills tonight") vs intent with plan and access — escalating risk requires escalating disposition. Always document which category and the exact words used.
— Affect: tearful, flat, agitated, eerily calm (post-decision calm is ominous)
— Cooperativeness, eye contact, psychomotor activity
— Hygiene/grooming changes suggesting protracted depression
— Smell of alcohol, pupillary changes (miosis = opioid; mydriasis = anticholinergic/sympathomimetic/SSRI)
— Neck: ligature marks, petechiae, hoarseness (attempted hanging)
— Wrists/forearms/thighs: fresh and healed lacerations, hesitation marks
— Abdomen: surgical scars, signs of acetaminophen-induced hepatic tenderness
— Skin: track marks, transdermal patches (fentanyl), pill fragments in mouth
— Pupils, mucous membranes, bowel sounds: toxidrome recognition
— Bradycardia + hypotension + miosis → opioid → naloxone
— Tachycardia + hyperthermia + mydriasis → anticholinergic/sympathomimetic
— Wide QRS, hypotension, seizure → TCA → sodium bicarbonate
— Tachypnea, AGMA → salicylate or toxic alcohol
— Hypoxia disproportionate to exam → CO poisoning → 100% FiO2, co-oximetry
— GCS, orientation, ability to engage in conversation
— Mini mental status: appearance, behavior, speech, mood/affect, thought process/content, perceptions (hallucinations), insight, judgment
— Cognitive capacity assessment: can the patient understand the consequences of refusing care? This determines whether involuntary hold is needed
— Vitals q15min, continuous pulse oximetry, cardiac monitor
— Two large-bore IVs, point-of-care glucose
— 1:1 constant observation (sitter)
— Remove belts, shoelaces, sharps, medications, phone chargers — search bag/clothing
— Place in paper/safe gown, locked-down room with no ligature points
CCS pearl: Order "1:1 sitter, suicide precautions, search and remove belongings" within the first set of orders. Forgetting this is a common CCS failure — and a real-world sentinel event.
— Goal: rule out medical mimics of psychiatric symptoms and identify ingestions before psychiatric disposition
— Routine "panels" are low-yield in alert, cooperative patients with known psych history and normal vitals — but on Step 3 CCS, most ED suicidality cases warrant a focused workup
— CBC, BMP (electrolytes, BUN/Cr, glucose)
— LFTs (acetaminophen toxicity, alcohol use)
— Acetaminophen and salicylate levels — mandatory in any suspected overdose; acetaminophen is silently lethal in the first 24h
— Ethanol level
— Urine drug screen (opioids, benzos, cocaine, amphetamines, cannabis)
— Urine pregnancy (β-hCG) in all women of reproductive age — changes medication choices and disposition
— TSH (hypothyroidism mimics depression; hyperthyroidism mimics anxiety/agitation)
— VBG/ABG with co-oximetry if altered or suspected CO/methemoglobin
— Lithium level if on lithium (toxicity → tremor, ataxia, AMS)
— Digoxin, valproate, carbamazepine, phenytoin levels if relevant
— Osmolar gap and anion gap if toxic alcohol suspected
— Creatine kinase if down/found unresponsive (rhabdo from prolonged immobility)
— Troponin and ECG if sympathomimetic ingestion or TCA overdose
— QRS >100 ms → sodium channel blockade (TCA, bupropion, diphenhydramine) → NaHCO3
— QTc >500 ms → torsades risk (citalopram, methadone, antipsychotics) → Mg, avoid QT-prolonging agents
— Head CT if AMS, focal deficit, head trauma, age >65, anticoagulation, or unwitnessed event
— CXR if aspiration concern, hanging attempt (look for pulmonary edema, pneumomediastinum)
— C-spine imaging after hanging attempts
Board pearl: Always check acetaminophen and salicylate levels in any suicidal patient with possible ingestion, even when they deny taking them — concealment is common, and acetaminophen toxicity is asymptomatic in the window where NAC is most effective.
— Draw level at ≥4 hours post-ingestion; plot on Rumack–Matthew nomogram
— Level above treatment line → N-acetylcysteine (NAC) IV: 150 mg/kg over 1h, then 50 mg/kg over 4h, then 100 mg/kg over 16h
— Unknown ingestion time, staggered ingestion, or extended-release → treat empirically with NAC and trend LFTs/INR
— Transfer to liver transplant center if King's College criteria met (pH <7.3, or INR >6.5 + Cr >3.4 + grade III/IV encephalopathy)
— Mixed respiratory alkalosis + anion gap metabolic acidosis is classic
— Trend levels q2h until decreasing; tinnitus, hyperthermia, AMS
— Urine alkalinization with NaHCO3 infusion (target urine pH 7.5–8); hemodialysis if level >100 mg/dL, AMS, pulmonary edema, renal failure, or refractory acidosis
— Calculate osmolar gap (measured − calculated; calc = 2Na + glucose/18 + BUN/2.8 + EtOH/4.6)
— Gap >10 with AGMA → methanol/ethylene glycol → fomepizole + dialysis
— Calcium oxalate crystals in urine, retinal findings (methanol "snowfield vision")
— C-SSRS to quantify ideation severity and behavior subtype
— SAFE-T (Suicide Assessment Five-step Evaluation and Triage)
— Document MSE, risk/protective factors, level of acute and chronic risk, and rationale for disposition
— New-onset psychosis, focal neuro signs, first psychotic break in older adult → MRI brain
— Suspected NCSE in unexplained AMS → EEG
— Cognitive screening (MoCA) in elderly to differentiate pseudodementia of depression from neurodegenerative disease
— Four elements: communicates a choice, understands information, appreciates situation, reasons about options
— Capacity is decision-specific — a patient may have capacity to refuse a blood draw but not to leave AMA when actively suicidal
Step 3 management: A patient with active SI and a plan lacks capacity to refuse psychiatric evaluation — invoke emergency hold (state-specific 5150/Section 12/etc.) and document the four capacity elements and the imminent risk.
— High acute risk: current SI with intent, plan, or recent attempt; access to lethal means; severe psych symptoms (psychosis, command AH); poor impulse control (intoxication, agitation) → inpatient psychiatric admission, involuntary if needed
— Moderate acute risk: SI with no specific plan or intent, recent stressors, prior attempts, multiple risk factors → psychiatric consult; admit if protective factors weak or follow-up uncertain; intensive outpatient (IOP/PHP) if robust supports
— Low acute risk: passive ideation only, no plan/intent, strong protective factors, engaged in care → safety plan + outpatient follow-up within 24–72h
— Reassess vitals and mental status q1h once stable; q15min if intoxicated or agitated
— Order psychiatry consult as soon as medical clearance trajectory is clear
— Continue 1:1 observation throughout
— Means restriction counseling with family: lock or remove firearms (single most evidence-based intervention to reduce suicide death), secure medications in lockbox, alcohol removal
— Step 1: Warning signs
— Step 2: Internal coping strategies
— Step 3: Social contacts/settings for distraction
— Step 4: People to ask for help
— Step 5: Professionals/agencies to contact (988 Suicide & Crisis Lifeline)
— Step 6: Means restriction
— A safety plan is not a "no-suicide contract" — contracts are ineffective and not evidence-based
— Risk assessment with reasoning
— Capacity determination
— Disposition rationale (why admit vs discharge)
— Follow-up plan with named provider and timeframe
CCS pearl: On CCS, order "psychiatry consult" and "safety plan / means restriction counseling" — both score. Discharging a moderate-risk patient without documented outpatient follow-up within 7 days is a likely deduction.
— Pharmacotherapy in the ED for suicidal patients targets acute agitation, intoxication reversal, and specific toxidromes — not initiation of long-term antidepressants
— Antidepressants typically started by inpatient psych or outpatient provider, not ED, because they take 4–6 weeks to work and carry early SI risk in <25y (FDA black box)
— Verbal de-escalation first — quiet room, calm voice, validate
— Offer PO before IM if cooperative: olanzapine 5–10 mg ODT, risperidone 1–2 mg, or lorazepam 1–2 mg
— IM options if refusing or severely agitated:
— Haloperidol 5 mg + lorazepam 2 mg + diphenhydramine 50 mg IM ("B-52") — classic, monitor QTc
— Olanzapine 10 mg IM — avoid combining with IM benzo (respiratory depression)
— Droperidol 5 mg IM — fast, watch QTc
— Ketamine 4–5 mg/kg IM for severe/dangerous agitation, last line
— Acetaminophen → NAC (see chunk 5)
— Opioids → naloxone 0.04–0.4 mg IV, titrate to respirations not consciousness; redose or infusion for long-acting agents
— Benzodiazepines → supportive care; avoid flumazenil in chronic users (seizures)
— TCA → sodium bicarbonate IV bolus 1–2 mEq/kg for QRS >100 ms, seizure, or hypotension; goal pH 7.45–7.55
— Beta-blocker → glucagon, high-dose insulin/dextrose
— Calcium channel blocker → calcium, glucagon, HIE therapy
— Salicylates → bicarb infusion, dialysis if severe
— Toxic alcohols → fomepizole 15 mg/kg load
— Sulfonylurea → octreotide + dextrose
— Iron → deferoxamine
— Discharge with large supplies of TCAs, lithium, or opioids
— Bupropion in those with seizure risk or eating disorders
— Prescribing >1-week supply of any potentially lethal med at discharge
Step 3 management: When prescribing or refilling at discharge for a recently suicidal patient, write small quantities (7-day supply), avoid TCAs, and document means restriction counseling — this is testable and a real-world safety practice.
— Activated charcoal 1 g/kg PO within 1 hour of ingestion in alert, cooperative patients with intact airway; not useful for lithium, iron, alcohols, hydrocarbons, caustics
— Gastric lavage rarely indicated; whole-bowel irrigation for sustained-release products, body packers, iron
— Hemodialysis: "I STUMBLED" — Isopropyl, Salicylates, Theophylline, Uremia, Methanol, Barbiturates (long-acting), Lithium, Ethylene glycol, Depakote (severe)
— Usually benign in pure ingestion; watch QTc (citalopram, escitalopram)
— Serotonin syndrome with co-ingestants: hyperthermia, clonus (lower > upper), hyperreflexia, agitation, autonomic instability → benzos, cooling, cyproheptadine if severe
— Distinguish from NMS (rigidity, hyporeflexia, slower onset, antipsychotic exposure)
— Acute: GI predominant; chronic: neuro predominant (tremor, ataxia, confusion, seizures)
— Indications for HD: level >4 mEq/L acute or >2.5 with symptoms or renal failure
— IV normal saline; avoid thiazides, NSAIDs, ACEi
— QT prolongation, anticholinergic effects, sedation, EPS
— Supportive care; bicarb if QRS widening; magnesium for QT/torsades
— "3 Cs": Cardiotoxicity (wide QRS, RAD, terminal R in aVR), Convulsions, Coma
— NaHCO3 bolus + infusion; lipid emulsion for refractory hypotension; avoid class IA/III antiarrhythmics, flumazenil, physostigmine
— NAC most effective <8h post-ingestion but give regardless of delay
— Continue NAC until level undetectable AND LFTs improving AND INR <2
— Refer to transplant center early if any concerning trajectory
— 0–1h: ABCs, charcoal if eligible, labs drawn, ECG, IV access × 2, 1:1 sitter
— 1–4h: trend labs, specific antidote initiated, psych consult notified
— 4–6h: acetaminophen level interpretable, decision on NAC
— 6–24h: ICU vs floor vs psych admit, ongoing antidote, repeat ECG, reassess mental status
Board pearl: Wide QRS in an overdose patient = sodium channel blockade until proven otherwise → give sodium bicarbonate before waiting for tox screen results.
— Highest completion rate of any age group (men >85)
— Methods more lethal (firearms predominate); fewer warning signs
— Often present with somatic complaints, "failure to thrive," refusing food/meds
— Often visited PCP within 30 days — missed opportunity
— Recent widowhood, social isolation, new functional dependence
— Chronic pain, terminal illness, recent diagnosis of dementia/cancer
— Polypharmacy with access to lethal medications (digoxin, opioids, sedatives)
— Comorbid depression often underdiagnosed; rule out pseudodementia (cognitive complaints from depression, reversible with treatment)
— Avoid benzodiazepines if possible (Beers Criteria) — falls, delirium
— If antipsychotic needed for agitation: lower doses (haloperidol 0.5–1 mg, olanzapine 2.5 mg); black box warning for increased mortality in dementia-related psychosis
— Avoid TCAs, paroxetine, anticholinergics
— Preferred antidepressants: sertraline, escitalopram, mirtazapine (latter for poor appetite/sleep)
— Lithium: avoid or use with caution; dose by GFR, levels q3–5d
— Gabapentin, pregabalin, duloxetine: renal dose adjust
— Avoid NSAIDs in lithium users
— Avoid duloxetine in significant hepatic disease
— Reduce doses of TCAs, mirtazapine, sertraline (modestly)
— Acetaminophen toxicity threshold is lower in chronic alcohol use, malnutrition, and chronic liver disease — treat at lower nomogram cutoff
— Lower threshold to admit elderly suicidal patients given lethality
— Coordinate with caregivers, home health, APS if neglect/abuse concerns
— Means restriction is paramount: remove firearms from the home, lockbox medications
Key distinction: Younger patients more often present with attempts that are interrupted or non-lethal; elderly more often present with completed or near-lethal first attempts — never label elderly self-harm as a "gesture."
— Suicide is a leading cause of maternal mortality in the year postpartum
— Screen with EPDS (Edinburgh Postnatal Depression Scale); item 10 covers SI
— Postpartum psychosis (1–2/1000) is a psychiatric emergency with infanticide and suicide risk — hospitalize, treat with antipsychotic ± mood stabilizer ± ECT
— Pharmacology: sertraline preferred in pregnancy/lactation; avoid paroxetine (cardiac malformations); avoid valproate (NTDs, teratogenic); lithium acceptable with monitoring (Ebstein anomaly risk small)
— Brexanolone or zuranolone for postpartum depression
— Always check β-hCG before imaging or teratogenic medications
— Screen ages ≥12 in ED with ASQ
— SSRI black box warning for SI in patients <25 — fluoxetine and escitalopram are FDA-approved for adolescent depression
— Common precipitants: bullying (including cyber), LGBTQ+ identity stressors, family conflict, academic pressure, recent peer suicide (contagion)
— Means restriction counseling with parents before discharge — firearms, medications, alcohol
— Mandatory reporting if abuse/neglect contributing
— Disposition: lower threshold to admit; if discharged, outpatient follow-up within 72h, written safety plan signed by parent and patient
— Suicide rate ~1.5× civilian; firearms predominate
— Screen for combat exposure, TBI, PTSD, MST (military sexual trauma)
— Veterans Crisis Line: 988, press 1
— Coordinate with VA — they have specific safety planning protocols and Caring Contacts programs
— 4× higher attempt rate than peers
— Family rejection is a major modifiable risk factor; supportive family contact lowers risk
— Use chosen name and pronouns; avoid outing patient to family without consent unless required for safety
Step 3 management: A pregnant patient with active SI on valproate should have valproate stopped and switched (after psychiatry input) to a safer agent like lamotrigine or lithium — and folate supplementation if continuing pregnancy. Document teratogenicity counseling.
— Hanging: anoxic brain injury, cervical spine injury, laryngeal fracture, post-obstructive pulmonary edema, delayed airway edema (admit even if appears well)
— Overdose: aspiration pneumonia, rhabdomyolysis, AKI, hepatic failure (acetaminophen), arrhythmia, ARDS
— Firearm: hemorrhagic shock, TBI, vascular injury — high mortality
— Jumping: polytrauma, spinal injury, solid organ injury
— Cutting: tendon/nerve/vascular injury (wrist), hemorrhage, infection
— CO poisoning: delayed neuropsychiatric syndrome (2–40 days post-exposure)
— NAC anaphylactoid reaction: slow infusion, give antihistamine, do not stop indefinitely
— Naloxone-precipitated withdrawal and acute pulmonary edema
— Sodium bicarbonate: alkalemia, hypokalemia, hypocalcemia, hypernatremia
— Restraints: rhabdomyolysis, positional asphyxia, aspiration, DVT, dehumanization
— Antipsychotic-related: NMS, EPS, QT prolongation, dystonia
— Elopement from ED while on suicide watch → sentinel event; mitigated by 1:1 sitter, locked rooms, removal of clothing
— In-hospital suicide: ligature points (door hinges, IV poles), hoarded medications, sharp objects — environmental rounds and ligature-resistant fixtures
— Boarding in ED for psychiatric beds (median >12 h in many systems) — increases agitation, missed care; consider telepsychiatry consults
— Risk of completed suicide is highest in the week after psychiatric discharge and within 30 days of an ED SI visit
— Mitigated by Caring Contacts (postcards/calls), early follow-up <7 days, safety plan in hand, lethal means restriction confirmed
— Patient suicide: notify and support family; clinician postvention (peer support, M&M); avoid documentation changes after the fact
— Cluster suicide (contagion) — adhere to safe messaging guidelines
Board pearl: Hanging patients with normal initial exam can still develop delayed laryngeal edema and post-obstructive pulmonary edema — admit for observation, even if alert.
— Hemodynamic instability or vasopressor requirement
— Intubation/respiratory failure (depressed mental status, aspiration, ARDS)
— Serious arrhythmia or significant QRS/QTc prolongation requiring monitoring
— Severe metabolic acidosis, ongoing seizures, status epilepticus
— Hepatic failure trajectory (rising INR, encephalopathy)
— Ongoing NAC infusion with abnormal LFTs/coagulopathy
— Dialysis requirement (lithium, salicylate, toxic alcohols)
— Hypothermia/hyperthermia requiring active management
— Psychiatry: every patient with SI, attempt, or self-harm — usually after medical stability
— Toxicology / Poison Control (1-800-222-1222): any significant ingestion, unfamiliar agent, mixed overdose
— Hepatology/transplant: acetaminophen with INR >2 at 24h, encephalopathy, acidosis
— Trauma surgery: GSW, jumping, hanging with c-spine concern, deep lacerations
— ENT: laryngeal injury after hanging
— Social work: housing, IPV, child welfare, financial barriers to follow-up
— Ethics: contested capacity, family disagreement about involuntary hold
— Medical floor with sitter: stable post-ingestion needing monitoring (e.g., acetaminophen NAC course) before psychiatric transfer
— Step-down/telemetry: QTc concern, ongoing antidote, moderate vitals abnormality
— Psychiatric inpatient (voluntary): medically clear, willing
— Psychiatric inpatient (involuntary hold): medically clear, refusing, meets state criteria for danger to self
— Medical-psychiatric unit if both active needs
— Hour 1: stabilize, labs, consults paged
— Hour 4–6: disposition trajectory clear
— Hour 12–24: psych bed sought; while boarding, continue 1:1, reassess MSE q4–8h, treat agitation, treat comorbid withdrawal
— Day 2–3: transfer to psych or admit medically
CCS pearl: Do not "advance the clock" past 24 hours in CCS without re-evaluating the patient, repeating vitals, and updating orders — including continued 1:1 sitter. Forgetting to re-order observation after admission is a common miss.
— ≥2 weeks of SIGECAPS + functional impairment
— Highest lifetime suicide risk among mood disorders
— Treatment: SSRI/SNRI + therapy; ECT for severe, catatonic, or treatment-resistant; ketamine/esketamine for treatment-resistant with SI
— Suicide risk higher than MDD; especially in mixed states and depressive phases
— Antidepressant monotherapy can precipitate mania — always pair with mood stabilizer
— Lithium uniquely reduces suicide risk (independent of mood effect)
— Screen with MDQ; ask about prior manic/hypomanic episodes before starting antidepressants
— Recurrent SI, self-injurious behavior (cutting, burning), unstable relationships, identity disturbance
— Chronic suicidality with acute fluctuations; differentiating chronic baseline vs acute-on-chronic is the key disposition skill
— Dialectical behavior therapy (DBT) is first-line; avoid prolonged hospitalizations which can reinforce regression
— Avoid benzodiazepines (disinhibition)
— 5–10% lifetime suicide rate; highest early in illness, post-discharge, with command AH
— Clozapine is the only antipsychotic with FDA approval for suicide risk reduction in schizophrenia — monitor ANC for agranulocytosis
— Alcohol, opioids, stimulants — all increase suicide risk acutely (disinhibition) and chronically
— Co-occurring SUD doubles risk; integrated dual-diagnosis treatment
— Especially with combat trauma, MST, childhood abuse
— Treat with SSRI/SNRI + trauma-focused CBT or EMDR; prazosin for nightmares
— Highest mortality of any psychiatric disorder; ~half from suicide
— Refeeding syndrome risk on admission
Key distinction: Acute-on-chronic SI in BPD often resolves within hours with validation, safety planning, and DBT skills referral — repeated brief admissions can be iatrogenic. In contrast, a first SI episode in MDD warrants lower threshold for inpatient stabilization.
— Hypothyroidism: fatigue, depression, cognitive slowing → check TSH
— Hyperthyroidism: anxiety, agitation, insomnia → TSH, free T4
— Cushing syndrome: depression in 60%, plus weight gain, striae, hypertension
— Addison disease: depression, weakness, hypotension, hyperpigmentation
— Hypoglycemia: agitation, AMS — always check glucose
— Hyponatremia, hypercalcemia: AMS, depression, psychosis
— Stroke, especially left frontal: post-stroke depression and SI
— Traumatic brain injury: doubles suicide risk; CTE in repeated injury
— Huntington disease: SI even before motor symptoms; family history of dementia/chorea
— Multiple sclerosis: depression in 50%, SI risk elevated
— Epilepsy: post-ictal depression, levetiracetam-induced mood symptoms
— Dementia: especially early, with insight preserved
— HIV with CNS involvement
— Neurosyphilis: classic mimic, "the great masquerader"
— Autoimmune encephalitis (anti-NMDA-R): young woman with psychiatric symptoms, seizures, autonomic instability — order anti-NMDA-R antibodies, consider teratoma workup
— Interferon (hepatitis C historical), isotretinoin (controversial), varenicline (black box removed but still considered), corticosteroids, levetiracetam, montelukast (FDA boxed warning)
— Withdrawal syndromes: alcohol, benzodiazepine, opioid withdrawal can present with severe agitation and SI
— Beta-blockers (less clear association)
— Chronic pain doubles suicide risk; opioid availability raises lethality
— Recent cancer diagnosis (especially lung, head/neck, pancreatic) — peaks in first 6 months
— Often mistaken for psychiatric agitation; look for waxing/waning, inattention, acute onset, medical trigger
— Treat underlying cause; haloperidol for severe agitation; avoid benzodiazepines except in alcohol/benzo withdrawal
Step 3 management: Before attributing new-onset psychiatric symptoms in a patient >50 or with atypical features to a primary psychiatric disorder, rule out medical mimics: TSH, B12, electrolytes, glucose, urinalysis, ± neuroimaging, ± RPR.
— Written Stanley-Brown Safety Plan in patient's hand
— Verified outpatient psychiatric appointment within 7 days (ideally <72h) — "warm handoff" if possible
— Means restriction documented: firearms secured/removed, medications in lockbox, alcohol restricted
— Family/support person informed and engaged
— 988 Suicide & Crisis Lifeline number provided
— Limited prescriptions: small quantities (≤7 days), avoid lethal-in-overdose agents
— Naloxone prescribed if opioid use history
— Usually deferred to outpatient or inpatient psychiatry, but if ED initiates: SSRI (sertraline 50 mg or escitalopram 10 mg) for MDD/anxiety
— Counsel: 4–6 weeks to full effect, possible early SI in <25y (FDA warning, monitor closely), sexual side effects, GI upset, discontinuation syndrome
— Avoid bupropion if seizure or eating disorder history
— Avoid TCAs as outpatient starter in suicidal patient (lethal in overdose)
— Lithium in bipolar and recurrent depression
— Clozapine in schizophrenia
— CBT for suicide prevention (CBT-SP) and DBT
— Means restriction (especially firearms — single biggest population-level effect)
— Caring Contacts (brief follow-up messages over months)
— Lethal means counseling with the patient and family
— Co-occurring SUD: refer to integrated dual-diagnosis program
— Naltrexone or acamprosate for AUD; buprenorphine or methadone for OUD
— Naloxone kit with training for patient and household
— Housing instability, IPV, food insecurity, unemployment — engage social work
— IPV screening (HITS, Partner Violence Screen) — suicide risk amplified
Step 3 management: A discharged ED patient with SI must leave with a named outpatient provider, an appointment date within 7 days, a written safety plan, and confirmed means restriction — without all four, disposition is unsafe.
— 24–72 hours: phone check-in by ED, primary care, or behavioral health team (Caring Contacts)
— Within 7 days: face-to-face outpatient psychiatric or behavioral health appointment
— 2 weeks: medication tolerance and early efficacy check if antidepressant started; reassess SI with C-SSRS
— 4–6 weeks: full antidepressant response assessment; titrate dose
— 3 months: stabilization phase — consider continued therapy weekly
— 6–12 months: maintenance; consider step-down to monthly visits
— Ongoing: relapse prevention plan, periodic SI re-screening at every visit
— SSRIs/SNRIs: PHQ-9 at baseline and each visit; suicide screen <25y at weekly intervals × 4 weeks per FDA
— Lithium: level + TSH + Cr q3–6 months; toxicity awareness with NSAID/diuretic/ACEi
— Lamotrigine: rash warning, slow titration
— Clozapine: ANC weekly × 6 months, then biweekly, then monthly; REMS registry
— Valproate: LFTs, CBC, level; avoid pregnancy
— CBT, DBT, IPT, problem-solving therapy — evidence-based for SI
— Intensive outpatient program (IOP, 3 days/week) or partial hospitalization (PHP, 5 days/week) for step-down from inpatient
— Peer support specialists (lived-experience model)
— Vocational rehabilitation, supported employment
— Substance use recovery groups (AA, NA, SMART Recovery)
— ED → outpatient handoff: closed-loop referral with confirmed appointment, records sent, patient confirmation
— PCP role: ongoing screening (PHQ-9 annually minimum, more often if risk factors), refill management, lethal means re-counseling
— Family/caregiver education: warning signs, when to return to ED, 988 line
— Repeat risk assessment each visit; document acute and chronic risk and rationale
— Update safety plan as life circumstances change
— Anniversary reactions: heightened vigilance around anniversaries of losses or prior attempts
CCS pearl: On CCS, after discharging a patient with SI history, place outpatient follow-up orders explicitly: "psychiatry follow-up in 5 days, PCP follow-up in 2 weeks, telephone check-in in 48 hours" — concrete cadence scores.
— A patient who is actively suicidal generally lacks capacity to refuse psychiatric evaluation, but capacity must be assessed and documented (understand, appreciate, reason, communicate)
— Involuntary hold statutes vary by state (CA 5150, MA Section 12, NY 9.39) — typically 72-hour observation
— Criteria: imminent danger to self/others or grave disability due to mental illness
— Patient retains rights: notification, legal counsel, judicial review, treatment refusal (except emergency medications)
— Permitted disclosures: emergency contact for safety, collateral history when patient at risk, mandatory reporting
— May receive collateral information without consent when needed for safety
— Disclosure to family for treatment planning is generally permitted; for non-safety information, obtain consent
— Child abuse/neglect (all states)
— Elder abuse (most states)
— IPV (varies by state; CA mandates reporting of injuries from weapons/assault)
— Tarasoff duty: warn/protect identifiable third parties if patient makes credible threats against them
— Medications during involuntary hold: emergency administration allowed for imminent danger; for ongoing treatment, requires consent or court order in many states
— ECT in incapacitated suicidal patients: requires surrogate consent or court order
— Adolescents: parental consent required, but adolescent assent and confidentiality protections vary; some states allow minors to consent to outpatient MH
— In-hospital suicide is a sentinel event requiring root cause analysis
— Environmental risk: ligature-resistant rooms, no loopable cords, breakaway curtain rods, locked sharps
— Hand-off between ED and inpatient psych: highest risk of dropped information; use structured tools (SBAR, I-PASS); confirm receipt
— Boarding patients: continue 1:1, reassess MSE q4h, treat agitation, prevent VTE, manage withdrawal
— Discharge without confirmed follow-up doubles 30-day suicide risk
— Closed-loop communication with outpatient provider is the standard
— Caring Contacts intervention is low-cost and evidence-based
Step 3 management: A 19-year-old refuses admission after a serious overdose, demanding to leave AMA. You may not let him sign out AMA — actively suicidal patients lack capacity for that decision; place an emergency hold, document four capacity elements absent, and notify on-call psychiatry.
— SAD PERSONS: Sex (male), Age, Depression, Prior attempt, Ethanol, Rational thought loss, Social supports lacking, Organized plan, No spouse, Sickness
— #1 risk factor: prior attempt
— #1 modifiable intervention at population level: firearm access restriction
— Highest-risk window: 7 days post-psychiatric discharge
— Lithium and clozapine: only agents with proven suicide-specific mortality reduction
— SSRIs in <25y: FDA black box for emergent SI in early weeks
— Citalopram max dose: 40 mg (20 mg if >60y or hepatic impairment) — QTc
— Bupropion: avoid in seizure/eating disorder; no sexual side effects (favored switch)
— Mirtazapine: weight gain, sedation — useful for depressed insomniacs
— APAP → NAC; opioid → naloxone; benzo → flumazenil (rarely used); TCA → bicarb; β-blocker → glucagon; CCB → calcium/insulin/glucagon; methanol/ethylene glycol → fomepizole; iron → deferoxamine; sulfonylurea → octreotide; methemoglobinemia → methylene blue; salicylate → bicarb + HD; digoxin → digoxin-specific Fab
— Cholinergic (SLUDGE/DUMBELS): organophosphate → atropine + pralidoxime
— Anticholinergic ("hot, dry, red, blind, mad"): supportive, physostigmine if severe
— Sympathomimetic: cool, benzos
— Opioid: miosis, hypoventilation, ↓RR — naloxone
— 988 = Suicide & Crisis Lifeline (US, since 2022)
— 1-800-222-1222 = Poison Control
— Veterans Crisis Line = 988, press 1
— ECT response rate in severe depression with SI: ~70–90%
— Highest completion: elderly white males
— Highest attempt rate: young women
— Highest method lethality: firearms (~85% fatal)
— Native American/Alaska Native youth: highest among ethnicities
Board pearl: When a stem mentions a patient with severe depression whose mood suddenly improves, suspect a finalized suicide plan — energy and motivation return before mood; this is when patients act.
— "After 4 weeks on sertraline, the patient reports feeling more energetic and sleeping better, although still feels life is not worth living…"
— Answer: Admit / increase monitoring — this is the high-risk window, not improvement to celebrate
— "Patient swallowed 30 acetaminophen tablets 2 hours ago, now alert, requests to leave AMA"
— Answer: Emergency hold, draw level at 4 hours, start NAC if indicated — not "discharge per patient request"
— "Found down, no history available, ECG shows QRS 130 ms, RAD, terminal R in aVR"
— Answer: TCA overdose → sodium bicarbonate — even before tox screen returns
— "Patient ingested unknown pills 12 hours ago, now nausea and RUQ pain"
— Answer: Check APAP level, start NAC empirically, LFTs, INR; consider transplant center if criteria met
— "3 weeks postpartum, mother believes baby is possessed and considers harming herself and infant"
— Answer: Emergency psychiatric admission, separate from infant, antipsychotic ± mood stabilizer ± ECT
— "22-year-old with multiple ED visits for superficial cutting, currently calm, denies plan, has outpatient DBT therapist"
— Answer: Safety plan, contact therapist, discharge with close follow-up — not admission, which can reinforce regression
— "Suicidal patient at home, owns a firearm" — Answer: Counsel patient and family to remove firearm from home (not just lock it)
— Patient with bipolar disorder, recurrent SI, on quetiapine — best add-on? Lithium
— Treatment-resistant schizophrenia with persistent SI — answer: clozapine with ANC monitoring
— Newly discharged psychiatric inpatient — when to follow up? Within 7 days, ideally with telephone outreach <72 hours
Key distinction: When the stem asks "next best step," prioritize safety > diagnosis > definitive treatment — 1:1 sitter, means restriction, and emergency hold beat ordering more labs.
Every ED suicide case is solved by stabilizing the medical threat, restricting means, completing a structured risk assessment, and engineering a safe disposition with explicit follow-up — never by accepting a suicidal patient's request to leave.
— On arrival: ABCs, 1:1 sitter, search and remove belongings, paper gown, ligature-safe room, IV × 2, monitor, glucose, ECG
— Labs: CBC, BMP, LFTs, acetaminophen and salicylate levels, ethanol, UDS, β-hCG, TSH ± lithium/AED levels
— Antidotes: NAC for APAP, naloxone for opioids, bicarb for TCA/wide-QRS, fomepizole for toxic alcohols, dialysis per ISTUMBLED
— Stratify acute vs chronic risk; prior attempt is the strongest predictor
— Admit (often involuntarily) for active SI with plan/intent, psychosis, or weak supports
— Discharge only with safety plan + named follow-up within 7 days + means restriction + 988 number
— Lithium (bipolar) and clozapine (schizophrenia) are the only agents with suicide-specific mortality benefit; firearm restriction has the largest population-level effect
— High-risk subgroups: elderly males, post-discharge week, postpartum psychosis, BPD acute-on-chronic, recent improvement in MDD
— Mimics to rule out before labeling primary psychiatric: thyroid, glucose, sodium/calcium, stroke, infection, medication effects, delirium
— Actively suicidal patients lack capacity to refuse psychiatric evaluation → emergency hold, document four capacity elements, notify psychiatry, never sign AMA
— Closed-loop outpatient handoff prevents the dominant post-ED mortality window
Board pearl: Safety first, capacity always, means restriction every time — and never let a suicidal patient leave the ED without a name, a number, and a date.