Self-harm, suicide and brain death: the role of the radiologist

Suicide is a leading cause of death worldwide and takes many forms, which include hanging, jumping from a height, sharp force trauma, ingestion/poisoning, drowning, and firearm injuries. Self-harm and suicide are associated with particular injuries and patterns of injury. Many of these patterns are apparent on imaging. Self-harm or suicidal intent may be overlooked initially in such cases, particularly when the patient is unconscious or uncooperative. Correct identification of these findings by the radiologist will allow a patient's management to be tailored accordingly and may prevent future suicide attempts. The initial role of the radiologists in these cases is to identify life-threatening injuries that require urgent medical attention. The radiologist can add value by drawing attention to associated injuries, which may have been missed on initial clinical assessment. In many cases of self-harm and suicide, imaging is more reliable than clinical assessment. The radiologist may be able to provide important prognostic information that allows clinicians to manage expectations and plan appropriately. Furthermore, some imaging studies will provide essential forensic information. Unfortunately, many cases of attempted suicide will end in brain death. The radiologist may have a role in these cases in identifying evidence of hypoxic-ischaemic brain injury, confirming a diagnosis of brain death through judicious use of ancillary tests and, finally, in donor screening for organ transplantation. A review is presented to illustrate the imaging features of self-harm, suicide, and brain death, and to highlight the important role of the radiologist in these cases.

A Retrospective Analysis of the Clinical Use and Utility of Advanced Imaging in the Evaluation of Near-Hanging and Strangulation Injuries at a Canadian Level One Trauma Centre

INTRODUCTION

Computed tomography (CT) of the neck is highly sensitive and may effectively rule-out cervical spine, cerebrovascular, and aerodigestive injuries after blunt and penetrating trauma. However, CT may be overutilized in the evaluation of hanging or strangulation injuries. The objective of this study was to determine the diagnostic yield of CT imaging among patients evaluated for hanging or strangulation mechanisms at a Canadian level-1 trauma center.

METHODS

All adult patients evaluated for hanging or strangulation injuries over an eight-year period were reviewed. The primary outcome was the diagnostic yield of CT imaging for major aerodigestive, cervical spine, cerebrovascular, or neurological injuries. Multiple logistic regression were performed to determine predictive factors for the use of CT imaging and the identification of injury on imaging.

RESULTS

Among 124 patients evaluated for hanging or strangulation injuries during the study period, 101 (80%) were evaluated with CT of the head or neck. A total of 26 injuries were identified in 21 patients (18 anoxic brain injuries, 4 aerodigestive, 3 cerebrovascular, and 1 of cervical spine injury). The overall diagnostic yield of neck CT for cervical injuries was 7.8%, 4.7% for laryngeal-tracheal injuries, 3.5% for carotid and vertebral artery injuries, and 1.1% for cervical spine injury. The diagnostic yield of CT head for anoxic brain injury was 22.8%. Factors predicting the use of CT imaging were abnormal physical exam findings (RR 1.7 95% CI [1.2, 2.3]) and transfer accepted by the trauma team leader (RR 1.3 95% CI [1.1, 1.5]).

CONCLUSION

CT imaging is often used in the evaluation of patients presenting with hanging or strangulation mechanisms. Seven cerebrovascular, aerodigestive, or cervical spine injuries were identified on imaging during the study period, representing a diagnostic yield of 7%. No injuries were identified among patient with a normal GCS or physical exam. Factors predicting the use of CT imaging included transfer accepted by the trauma team leader and abnormal physical exam findings. The variable clinical presentation of near-hanging and strangulation injuries and the relatively low diagnostic yield of CT imaging should prompt the development of tools and institutional protocols to guide the evaluation of hanging and strangulation injuries.

Radiographers' experiences and educational needs in relation to caring for suicidal patients during radiology examinations

INTRODUCTION

Researchers have explored the experiences, attitudes, and educational needs of several healthcare professional groups in relation to caring for suicidal patients. However, radiographers have not been included in these studies. Radiographers are likely to encounter these patients when they present for diagnostic imaging following suicide attempts.

METHODS

An online questionnaire exploring radiographers' experiences and educational needs in caring for suicidal patients was circulated to radiographers working in 23 acute hospitals across Ireland and posted to a Facebook page targeting Irish-based radiographers. Closed-ended questions were used to capture respondents' demographics and five-point Likert scale questions to establish their confidence levels in imaging suicidal patients. Open-ended questions were used to explore their experiences and educational needs. Quantitative data was analysed using descriptives statistics, and qualitative data thematically analysed.

RESULTS

One hundred and four radiographers responded to the questionnaire, 96% of whom had imaged suicidal patients. Radiographers were confident in justifying and optimising these radiographic examinations, however, less confident in communicating with and caring for these patients. Radiographers reported insufficient patient history on imaging referrals and challenges in communicating with suicidal patients, which many attributed to lack of training. Radiographers expressed interest in further education related to caring for patients who've attempted suicide, which they felt should include an introduction to psychiatry, strategies for communicating with suicidal patients and building resilience.

CONCLUSION

Radiographers' experiences of imaging suicidal patients have been reported along with several challenges which could be addressed through further education.

IMPLICATIONS FOR PRACTICE

Further education in caring for suicidal patients should be offered to radiographers which aligns with their educational needs. Referring clinicians should be reminded of the importance of informing radiographers of patients' suicide attempt when referring them for diagnostic imaging.

Factors Affecting Inpatients' Mortality through Intentional Self-Harm at In-Hospitals in South Korea

This study aimed to identify the patient characteristics, comorbidities, risk factors, and means of the self-harm of patients who attempt self-harm in and outside of a hospital, and to determine the characteristics of death by suicide among survival and death patient groups in South Korea. This study used data from the Korean National Hospital Discharge In-depth Injury Survey conducted from 2007 to 2019. In total, 7192 outpatient participants and 43 inpatient participants performed self-harm. Frequency analysis, chi-square tests, Fisher's exact test, and logistic regression analysis were performed using STATA, version 15.0 (StataCorp), and statistical significance was set at 5%. Thirty-one inpatients who performed self-harm survived, and 12 died. Among male inpatients, the older they were, the higher the rates of self-harm and mortality rates due to falls and poisoning if they had comorbidities and financial problems. In addition, the rate of self-harm attempts within a short period after hospitalization was high. Our evidence of the characteristics of patients who performed self-harm in the hospital and the influencing factors of self-harm can be used as primary data for predicting patients at a high risk of self-harm and for creating preventative policies to reduce the risk of self-harm among inpatients in South Korea.

Approach to Displaced Intra-Articular Calcaneus Fractures After Attempted Suicide Among Patients With Psychiatric Disorders: Nonsurgical or Surgical?

Displaced intra-articular calcaneus fracture is one of the injurious events in psychiatric patients after high-jump suicide attempts. These patients are reported to have poorer compliance and worse postoperative outcomes compared to those with no psychiatric condition.  We aimed to compare nonsurgical and surgical treatment with respect to functional and radiological outcomes and complications in this patient. We evaluated medical records of 42 psychiatric patients who had displaced intra-articular calcaneal fractures after high-jump suicide attempt. 20 (54%) of these were treated nonsurgically and further 17 patients (46%) received surgical intervention. We compared to nonsurgical and surgical approaches statistically. The mean follow-up period were 30.4 ± 8.02 months and 31.8 ± 7.5 months in the nonsurgical and surgical groups, respectively. Böhler's angle was significantly higher in the surgical group (30.4 ± 6.4) than that in the nonsurgical group (16.1 ± 3.7) (p = .001). AOFAS scores and supination levels were significantly higher in the surgical group than that in the nonsurgical group (p ≤ .05). During the follow-up period, one patient from the surgical group re-attempted high-jump suicide and died, and another one caused the subtalar joint to re-collapse after full weightbearing on the first postoperative day. Surgical treatment of displaced intra-articular calcaneal fractures following a high-jump suicide attempt in psychiatric patients may not cause increased complication rates. However, behavioral manifestations of the psychiatric disorder might be associated with several complications. Should any surgical intervention be decided, minimal invasive approach would be the appropriate choice.

Bilateral and Symmetrical Lesions in the Basal Ganglia Associated With Metabolic Acidosis in a Patient With a History of Alcohol Addiction: A Case Report

Metabolic acidosis is defined as a pathologic process that, when unopposed, increases the concentration of hydrogen ions in the body and reduces the concentration of HCO3. Methanol poisoning is an important cause of metabolic acidosis. Methanol and ethylene glycol poisonings cause scores of fatal intoxications annually, and even relatively small ingestions of these alcohols can produce significant toxicity. Neuroimaging findings are very suggestive and help in the diagnosis even before the measurement of serum methanol (when available at the health service). Rapid recognition and early treatment, including alcohol dehydrogenase inhibition, are crucial. In this sense, some studies question that many intoxications by different chemical agents (in addition to methanol and ethylene glycol) generate a conglomeration of neuroimaging findings that summarily reflect the presence of metabolic acidosis. Therefore, in this article, we discuss the imaging findings of metabolic acidosis, methanol poisoning, and their main differential diagnoses in neuroimaging, directing earlier diagnostic reasoning in order to initiate the most appropriate treatment promptly.

Unusual attempted suicide or covered attempted homicide? A neck stabbing case report and review of literature

A medico-legal consult is frequently required in a clinical context in order to assess the eventual compatibility of specific wounds with a self- or hetero-infliction. Accordingly, the case of a 52-year-old man with a single, penetrating stab wound of the neck, reported as self-inflicted, is here presented. The forensic aspects, taken into account in order to determine the self- or hetero-infliction nature of the wound, are further discussed and compared to cases described in the literature.

Injury after non-judicial hanging

Hanging is an important and increasingly common method of suicide in developed countries. Little is known about the true human pathophysiological changes and injury patterns associated with hanging and near hanging. Cervical spine injury is commonly reported; however, there is a paucity of large data sets concerning this injury. This review article focuses on the incidence of cervical spine and associated neck injuries and their role in morbidity and mortality following non-judicial hanging. A total of 26 heterogeneous studies were identified examining injury after hanging or near hanging. In total, there were 2795 patients; 1530 (54.7%) with true hanging and 1265 (45.3%) with near hanging. Cervical spine injury was reported in a total of 58 (2.08%) patients. Injuries to the airway and vessels of the neck seem rare. This is somewhat lower than the current accepted incidence for cervical spine injury after hanging or blunt force trauma. The overall incidence of cervical spine injury after hanging is low. Spinal immobilisation should probably be instituted depending on the mechanism of the hanging. However, a patient presenting with signs of life to an emergency department is unlikely to have a severe cervical spine injury.