How to take a parasuicide history in a patient with a Glasgow Coma Scale (GCS) score of 15?

Taking a Parasuicide History in a Patient with GCS 15

In a patient with GCS 15 following a suicide attempt, conduct a systematic assessment focusing on the method used, timing, intent, current mental state, and immediate medical risks, while simultaneously evaluating for occult injuries and toxic exposures that may cause delayed deterioration.

Initial Clinical Assessment

Neurological Status Documentation

• Document the complete GCS score (eye opening, verbal response, motor response) rather than just the sum score, as component scores provide more granular information about the patient's neurological status 1, 2.
• A GCS of 15 indicates the patient is fully alert and oriented, which is prognostically favorable but does not exclude serious underlying pathology 3.
• Perform serial GCS assessments every 15-30 minutes initially, as deterioration can occur rapidly even from an initial GCS of 15, particularly with toxic ingestions or occult head trauma 4, 3.

Method-Specific Risk Stratification

• Identify the specific method of suicide attempt immediately, as this determines both medical management and mortality risk 5.
• Poisoning (particularly organophosphates, aluminum phosphide, or other household toxins) carries high mortality even with preserved consciousness 5.
• Inquire about tablet overdose, hanging attempts, or self-harm that may have caused head trauma requiring imaging 5.
• Ask specifically about alcohol co-ingestion, as this is common in male suicide attempts and may mask evolving neurological deterioration 5.

Structured History Components

Circumstances of the Attempt

• Timing: Exact time of ingestion/attempt (critical for toxicology management and observation period determination).
• Location: Where found, by whom, and how long until medical attention.
• Substances involved: Specific names, quantities, and formulations of any ingested substances.
• Method lethality: Assess whether the method chosen has high case-fatality (e.g., aluminum phosphide poisoning has very high mortality) 5.

Intent Assessment

• Planned versus impulsive: Was this premeditated or a sudden decision?
• Expectation of rescue: Did the patient take measures to avoid discovery or ensure discovery?
• Regret or ongoing intent: Current suicidal ideation must be explicitly assessed.
• Previous attempts: History of prior suicide attempts significantly increases risk.

Precipitating Factors

• Familial disharmony and domestic violence are the most common precipitants, particularly in married women 5.
• Romantic relationship problems, unemployment, and academic failure are common in males 5.
• Recent major life stressors or losses.
• Psychiatric history including depression, psychosis, or substance use disorders.

Social Context

• Marital status (marriage appears less protective for women than men in some populations) 5.
• Living situation and social support.
• Access to means for future attempts.
• Occupational and educational background 5.

Critical Medical Evaluation Alongside History

Warning Signs Requiring Immediate Intervention

• Any decline in GCS score (even from 15 to 14) dramatically increases risk and may indicate evolving pathology 4.
• New onset confusion, vomiting, or focal neurological deficits indicate potential deterioration 3.
• Patients with initial GCS 15 who deteriorate have approximately 3-6% risk of requiring neurosurgical intervention 6.

Toxic Exposure Assessment

• For poisoning cases with GCS 15: The preserved consciousness does NOT exclude lethal ingestion, particularly with delayed-toxicity agents 5.
• Obtain exact substance names, amounts, and time of ingestion.
• Consider co-ingestions (multiple substances are common).

Occult Trauma Evaluation

• Even with GCS 15, assess for head trauma if there was a fall, hanging attempt, or assault 6.
• Indications for head CT even with GCS 15 include: headache, vomiting, age >60 years, focal neurological deficit, signs of skull fracture, or dangerous mechanism of injury 6.
• Loss of consciousness or amnesia are NOT required to justify imaging if other risk factors are present 6.

Common Pitfalls to Avoid

Clinical Pitfalls

• Do not assume GCS 15 equals "medically stable": Delayed deterioration occurs in toxic ingestions and evolving intracranial pathology 3, 5.
• Do not discharge based solely on GCS 15: The method of attempt and substances involved determine observation period, not neurological status alone 5.
• Do not underestimate household poisons: Aluminum phosphide and organophosphates have very high mortality despite initial normal presentation 5.

Psychiatric Assessment Pitfalls

• Do not accept superficial reassurance or claims that "it was a mistake" without thorough assessment of ongoing intent.
• Do not overlook intoxication at presentation, which may mask both medical deterioration and true suicidal intent 5.
• Alcohol use is more common in male suicide attempts and may facilitate the attempt 5.

Disposition Planning

Observation Requirements

• Minimum 24-48 hours observation for most toxic ingestions, even with GCS 15 3.
• Serial neurological examinations to detect deterioration 3.
• Psychiatric evaluation cannot proceed until medical clearance is complete and patient is sober.

Documentation Essentials

• Complete GCS with components, not just sum score 1, 2.
• Exact substances, quantities, and timing.
• Current suicidal ideation and plan.
• Social supports and safety planning.
• Clear follow-up arrangements with mental health services.