This report describes a rare but life-threatening case of a suicide attempt initially considered as intentional overdose at the emergency department. Persistent altered mental status, despite normal toxicology investigations, led the attending team to order a head computed tomography scan, which revealed a bilateral penetrating nail gun injury with a right temporal hematoma for which a decompressive craniectomy was performed. Although voluntary intoxication is the most frequent form of suicide attempt, emergency physicians must be alert and maintain a broad differential diagnosis. Although rare, penetrating head injuries have increased in recent decades. As neurological symptoms can be minimal and penetration wounds small, this type of injury could potentially be overlooked.

Suicidal ideation and attempted suicide are important presenting complaints in the Emergency Department (ED). The Joint Commission established a National Patient Safety Goal that requires screening for suicidal ideation to identify patients at risk for suicide.

Given the emphasis on screening for suicidal ideation in the general hospital and ED, it is important for Emergency Physicians to be able to understand and perform suicide risk assessment.

A review of literature was conducted using PubMed to determine important elements of suicide assessment in adults, ages 18 years and over, in the ED. Four typical ED cases are presented and the assessment of suicide risk in each case is discussed.

The goal of an ED evaluation is to appropriately determine which patients are at lowest suicide risk, and which patients are at higher or indeterminate risk such that psychiatry consultation is warranted while the patient is in the ED. Emergency clinicians should estimate this risk by taking into account baseline risk factors, such as previous suicide attempts, as well as acute risk factors, such as the presence of a suicide plan.

Although a brief screening of suicide risk in the ED does not have the sensitivity to accurately determine which patients are at highest risk of suicide after leaving the ED, patients at lowest risk may be identified. In these low-risk patients, psychiatric holds and real-time psychiatric consultation while in the ED may not be needed, facilitating more expeditious dispositions from the ED.

Emergency physicians (EP), paramedics and the staff of the emergency room play an increasingly important role in the medical and psychological emergency treatment of patients after suicide attempts, as well as in the crisis intervention of persons with acute suicidal tendencies. This article aims to give an overview of the prevalence rates, methods of suicide or attempted suicide and the problems faced by EPs when treating these patients. In addition, concepts are presented which allow an adequate risk assessment of suicidality and the options for primary crisis intervention. Paramedics and intensive care clinicians are increasingly confronted with this complex process with social, personal and medical aspects. In order to treat people in suicidal crises and/or after a suicide attempt and to provide a safe and optimal care for this often heterogeneous group of patients, clear guidelines are a prerequisite. The first assessment of the acute danger of suicide is of particular importance due to the resulting consequences and a clear approach is demonstrated for dealing with suicidal people. Furthermore, the legal principles are presented.

Psychiatric emergency situations (PES) are common in the physician-based emergency medical system (EMS) in Germany. However, many emergency physicians (EP) feel insecure in assessing the necessity for treatment of these patients. The aim of this investigation was to evaluate whether a short, newly developed questionnaire (Indicator for Psychiatric Pharmacotherapy, IPP) is able to help EPs in deciding for or against pharmacological treatment.

The protocols of the EMS at the Saarland University Hospital were prospectively collected over a 1-year period and PESs were identified and analyzed in detail. The 7-item IPP, which focuses on the most relevant psychiatric symptoms, was to be completed for each PES.

Among all calls for an EP (2,114) 250 (11.8%) were classified as a PES. The most frequent diagnoses were alcoholic intoxication, state of agitation and suicide attempts. Of the IPP questionnaires 193 could be evaluated and in 31.2% of all PESs a specific psychiatric medication was administered. These patients scored significantly higher in the IPP compared to those who did not receive medication (8.0 ± 3.9 compared to 5.6 ± 3.2, p < 0.001). The IPP items "anxiety", "agitation/aggression", "mood" and "physical symptoms/disorders" had the highest impact on the administration of psychotherapeutic drugs.

The IPP can be a valuable tool to assess the necessity of pharmacological treatment for patients in PESs. The assessment of the symptom categories "anxiety", "agitation/aggression", "mood" and "physical symptoms/disorders" seems to be sufficient to estimate a need for treatment.

Guide the health professional to identify risk factors and forms of protection, together with handling such patient throughout a clinical interview within the emergency service context.

Selected literature revision so as to identify relevant and illustrative key cases.

The clinical interview is the best method to evaluate the suicidal risk and has two different aims: 1) emotional support and creation of a bond; 2) collecting information. There is a substantial amount of information to be collected during the clinical interview, such as: risk factors and protection, epidemiologic data, act characterization, psychical dynamics aspects, personal and familial historic patterns, identification models, data on physical wealth and social net support. Difficulties are to emerge throughout the clinical interview, but a trained and informed professional will be able to approach and adequately add the patient. Although several scales have been proposed, none of them have been efficient to deter the suicidal risk.

There is no method to predict who is to commit suicide, nevertheless, it is possible to evaluate the individual risk of each patient with regards to a detailed and empathic clinical interview. Prevent the patient to commit suicide is the preliminary and fundamental rule.

The treatment of acutely ill patients who presumably lack the insight or judgement to determine their need for medical treatment, is a difficult challenge for emergency physicians. We have carried out a study to assess the frequency and relevance of involuntary treatment and procedures in medical emergency services.

Retrospective chart analysis for a 1-year period was performed for all treatment protocols of a medical emergency service unit and for all court-ordered treatments of a guardianship court. Cases of involuntary treatment by emergency physicians were identified and analysed.

In 10.4% of all emergency calls analysed a relevant and acute psychiatric condition was found. In 0.3% of the cases or 4.8% of the psychiatric cases, involuntary inpatient commitment was chosen by the emergency physician.

Involuntary inpatient commitment by emergency physicians was only necessary in relatively few cases. Nevertheless, in order to be able to correctly consider treatment and management options, emergency physicians should be aware of the basic conditions for treatment without a patient's consent.