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Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 143-145

Attempted suicide by poisoning: A growing challenge in adolescence


1 Department of Pediatrics, LHMC and Associated Hospitals, New Delhi, India
2 Department of Forensic Medicine and Toxicology, LHMC and Associated Hospitals, New Delhi, India

Date of Submission04-Mar-2021
Date of Decision28-Apr-2021
Date of Acceptance30-Apr-2021
Date of Web Publication31-May-2021

Correspondence Address:
Dr. Ankita Goel Sharma
Room No. 339, Third Floor, New Building, Kalawati Saran Children Hospital, Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipcares.ipcares_78_21

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How to cite this article:
Sharma AG, Ray S, Singh S. Attempted suicide by poisoning: A growing challenge in adolescence. Indian Pediatr Case Rep 2021;1:143-5

How to cite this URL:
Sharma AG, Ray S, Singh S. Attempted suicide by poisoning: A growing challenge in adolescence. Indian Pediatr Case Rep [serial online] 2021 [cited 2021 Sep 21];1:143-5. Available from: http://www.ipcares.org/text.asp?2021/1/2/143/317369



Suicidal behavior is one of the leading causes of injury and death, globally. Suicide, defined as the act of intentionally causing one's own death, accounts for the second most common cause of death amongst adolescents aged 15–19 years[1]. Attempted suicide or parasuicide is any form of nonfata, serious, deliberate, self-harm, with or without suicidal attempt. The exact estimate of parasuicide in adolescents is unknown, but the World Health Organization estimates it to be 40–100 times higher than the number of reported suicides, annually[2]. In the United States, completed suicide is thrice as common in adolescent boys than girls, while attempted suicide is twice as high in teenage girls, compared to boys. In India, a country with the largest adolescent population worldwide, suicides and suicidal attempts present a grave issue with a 15-year-old individual in India having a 1.3% cumulative risk of dying before the age of 80 years by suicide.[3] Suicidal attempts are 25 times greater than suicide, with self-poisoning the most common mode of parasuicide[4]. Poisoning (usually with pesticides or drug overdose) is an act of impulsiveness commonly seen in adolescent girls, in India and globally.

Poisoning, whether accidental or suicidal, is one of the most common situations encountered in a pediatric emergency department. As practicing pediatricians, we should be competent enough to suspect, identify, and manage such cases efficiently to save the patient's life, as well as fulfill our basic medicolegal responsibilities and duties. This can be done by timely and appropriate management that encompasses sensitively collecting and documenting legal evidence, ensuring medical and psychiatric intervention, and notifying the competent authorities. This article aims to sensitize our readers to these critical aspects of attempted suicidal poisoning by describing a true but anonymized case.


  Case Report Top


A 15-year-old girl was brought to the emergency department of our hospital by her family, with an alleged history of ingestion of 2 caps (around 10 mL) of floor cleaner 2 h earlier, followed by loss of consciousness within 15 min. There was no history of any vomiting, loose motions, abnormal odor, seizures, visual disturbances, bleeding from any site, or respiratory difficulties. On reviewing the history for a precipitating event, it was revealed that she had been scolded by her mother immediately before ingestion. The nature of the floor cleaner was probably phenyl, though it was kept in an unlabeled bottle, since it was apparently milky white in color and diluted with water.

On examination, she was found to be normothermic, with normal heart rate, respiratory rate, and blood pressure for her age. General physical examination revealed no frothing or burns in or around the oral cavity. There was no abnormal odor coming from her mouth or clothes. Multiple healed cut marks were noted on her left wrist. The patient regained consciousness almost as soon as the examination started, which was approximately an hour post ingestion. She complained of a mild headache and pain and burning sensations in her throat. The resident on duty registered an MLC and informed the police constable posted in the hospital police station. Her pupils were of normal size and reaction. The level of consciousness, higher mental functions, and neurological examination were normal. The rest of the systemic examination was unremarkable.

After obtaining informed consent from the child and her mother, external decontamination was done and the contaminated clothes were kept in a large bag for toxicological sampling. Gastric lavage was not done since the amount ingested was small and there had been a delay of about 2 h before reaching the health facility. Samples for toxicological examination including blood and urine were collected and sealed. Supportive management was provided in the form of intravenous fluids and antacids. Baseline investigations were normal.

On probing further, it was learned that she had tried to cut her wrist 10 months earlier following a scolding by her brother, but no medical intervention had been sought. There was no history of drug/substance abuse, psychiatric illnesses, or similar suicidal attempts in the family or circle of friends and acquaintances. She was a student of class 10 in a government-run school and average in studies. Her father was a painter and her mother a homemaker. She had a 20-year-old elder brother (who worked with their father) and an 18-year-old elder sister, who was married. The family belonged to the lower socioeconomic Class A referral was sent for a psychiatry evaluation. She was reported to have normal affect and mood with no active suicidal ideation. The current incident was deemed as an impulsive act with low lethality. A final diagnosis of parasuicide (by probable phenyl poisoning) was made. The patient and her family underwent counseling and she was discharged after drawing up a plan for follow-up with the outdoor psychiatry services.

Let's ask the experts

How common is suicide and parasuicide in Indian adolescents? In 2019, 7% of the total number of suicides were individuals <18 years of age. Poisoning (26%) was the second most common modality, in which 17.3% consumed insecticides[5].

What are the causes of suicidal ideation in Indian adolescents? The main causes of suicides in this age group include family problems, failure in examinations, love affairs, and illnesses[5]. Although nonsuicidal self-injury does not include an intent to die (as in this case), it is a strong risk factor for suicidal attempts. Social and environmental risk factors are exacerbated by an immediate trigger like agitation, intoxication, or an acute stressful event in most circumstances.

How does one manage a case of suspected poisoning? The approach is given in [Table 1].
Table 1: Medical duties in case of suspected poisoning

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What are the legal duties of a doctor in case of poisoning? This entails the following proper medicolegal documentation and preservation of samples[6]:

  1. Inform the nearest police officer/magistrate in all cases of poisoning, whether accidental, suicidal, or homicidal
  2. If the patient is critically sick, inform the magistrate to record the dying declaration, or record the dying declaration in person in the presence of an independent witness. This has to be recorded irrespective of the age. The admissibility is decided later by the court, on the basis of assessment of maturity of understanding of the individual or his/her mental competence to be a witness
  3. Prepare a medicolegal report with details of history and examination findings and nature of poison, if known. Preserve relevant samples (given below) and hand over to the investigating officer in a sealed condition for forensic analysis
  4. In case of death with suspected poisoning or a patient brought dead, do not issue a death certificate but send for a medicolegal postmortem after informing the police.


What samples need to be preserved in case of a suspected poisoning? In cases of suspected poisoning, the following samples need to be collected:

  1. Blood sample: 10 mL each in 2 containers, one with preservative (EDTA or sodium fluoride) and one without preservative
  2. Urine sample: Preferably two samples of 20 mL should be collected, one immediately on arrival, and the second after ½ an hour
  3. Gastric lavage fluid: This should be preserved with pure NaCl (4 g/100 mL)
  4. Vomitus/feces/any other fluid available
  5. Clothes stained with vomitus/spilled poison
  6. Suspected material recovered from possession of the victim/accused and from circumstantial environmental materials such as food and drink.
  7. Properly seal, label, sign and hand over all the samples to the investigating officer.


Is it Phenyl or phenol poisoning – a diagnostic dilemma and implications? Household floor cleaners are frequently used for attempted suicide due to ease of availability. They can be broadly categorized into white phenyl (predominantly pine oil with a very small percentage of phenolic by-products) and black phenyl (an emulsified blend of coal tar acids in an anionic soap base). The former has relatively low toxicity with small doses and only causes skin irritation, mild respiratory discomfort, and occasionally central nervous system (CNS) depression. In contrast, phenol is highly toxic/corrosive with a fatal dose as low as 50 mg. It causes nausea, vomiting, diarrhea, chemical burns, CNS manifestations, hemolytic anemia, methemoglobinemia, pulmonary edema, and hypotension. Thus, it is critical to determine the nature of the floor cleaner, as the prognosis and outcome differs markedly.


  Legislature Top


In India, attempted suicide was an offense punishable under Section 309 of the Indian Penal Code (IPC) which stated “Whoever attempts to commit suicide and does any act towards the commission of such offence, shall be punished with simple imprisonment for a term which may extend to 1 year or with fine, or with both.” However, this was decriminalized by the Mental Health Act in 2018, which states “Notwithstanding anything contained in section 309 of the IPC, any person who attempts to commit suicide shall be presumed, unless proved otherwise, to have severe stress and shall not be tried and punished under the said code.”

Doctors are legally bound to inform all cases of poisoning to the competent authority after initiating life-saving measures and stabilizing the patient. If not done, the doctor may be held liable under section 176 IPC (omission to give notice or information to a public servant by a person legally bound to give). If the doctor intentionally fails to collect, preserve, and seal the evidence related to the case of poisoning, he is liable to be punished under section 201 IPC. The doctor may need to take a dying declaration in impending death if a district magistrate is unavailable. Through this case, we have tried to highlight the standard protocols for management of an adolescent with attempted suicide by poisoning. These cases are on a rise in recent years due to various changes in societal and family dynamics and increasing expectations. Doctors should be aware of the medical, psychosocial, and legal aspects of such cases to help improve their competency in management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Shain B; COMMITTEE ON ADOLESCENCE. Suicide and suicide attempts in adolescents. Pediatrics 2016;138:e20161420.  Back to cited text no. 1
    
2.
Michel K, Ballinari P, Bille-Brahe U, et al. Methods used for parasuicide: Results of the WHO/EURO Multicentre Study on Parasuicide. Soc Psychiatry Psychiatr Epidemiol 2000;35:156-63.  Back to cited text no. 2
    
3.
Patel V, Ramasundarahettige C, Vijayakumar L, et al. Suicide mortality in India: A nationally representative survey. Lancet 2012;379:2343-51.  Back to cited text no. 3
    
4.
Radhika G, Radhakrishnan S, Rajamanickam R. Prevalence and predictors of suicidal behaviour among adolescents in India: A systematic review and meta analyses. JCR 2020;7:8754-70.  Back to cited text no. 4
    
5.
National Crime Report Bureau 2019 Report- Suicide in India. Available from: https://ncrb.gov.in/sites/default/files/Chapter-2-suicides_2019.pdf. [Last accessed on 2021Apr 27].  Back to cited text no. 5
    
6.
Millo T, Jaiswal AK, Bharadwaj DN. Medicolegal duties of doctor in poisoning cases. JFCT 2017;3:107-13.  Back to cited text no. 6
    



 
 
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