Hesitate no Longer: Identifying Suicide Attempts with Self-Inflicted Cuts in the ED
50-year-old male ambulates to triage with a self-made tourniquet on his right forearm with blood present. The amount of bleeding cannot be determined, and the decision is made to activate a trauma.
The primary survey is negative, except for a 5cm straight laceration with clean edges into the subcutaneous fat with minimal active bleeding on the right anterior forearm, and two superficial parallel abrasions over the patient’s right jugular area.
The patient states he was moving a heavy piece of wood furniture and fell. When re-questioned, the patient states glass fell on him while moving furniture.
As the medical student irrigates the right forearm, multiple superficial wounds are seen parallel to the primary wound that were not noted previously.
The medical student reports that there is concern for a suicide attempt, as the wound pattern is suggestive of hesitation marks. Among the medical team, there is debate as to whether this wound pattern reflects self-inflicted injury.
Clinical Question: Is there a well-defined injury pattern of suicide attempts with self-inflicted cuts that can be identified in patients?
Forensic Pathology has identified common patterns that can help differentiate nonaccidental vs. accidental injuries.
There are over 400,000 annual ED visits for suicide attempts, with 21% attributed to cutting/piercing. (1,2) Completed suicide by cutting/piercing represents 2-3% of the 45,000 annual completed suicides in the US. (3,4) The patient who cuts or stabs himself in a suicide attempt is more likely to present to the ED than the Medical Examiner’s office.
Terms to describe wounds in clinical medicine are often used incorrectly. Revisiting the case, this patient did not have abrasions or lacerations present.
Abrasion: A scraping force that removes the superficial layer of skin. (5)
Laceration: An impacting that force results in abraded/irregular tissue edges, with skin splitting/tissue bridges outside of the directly impacted area. (5)
Cut/Incised Wound: Terms are synonymous. Sharp instrument applied with a force that causes an injury with length is greater than depth. By definition there is no tissue bridging or irregular edges. (5)
Summary of Evidence:
Hesitation marks are defined as superficial cuts found when a patient attempts to cut the skin. Wounds are generally confined to the epidermis, however may involve deeper dermal layers. The “hesitation” results from a the pain associated with cutting, and the patient’s lack of familiarity with the amount of force required to cut through the skin. (3) Hesitation marks are more superficial compared to the primary wound. (6)
The presence of hesitation marks is a hallmark of suicide attempts by cutting. Incidence of hesitation marks may be as high as 74% in all suicide cases involving cutting, with similar incidence between genders. (7)
The presence of hesitation marks confirms suicide attempt; however, the absence of hesitation marks should not rule this out. (3)
The most common locations of hesitation marks (in descending order) are the anterior surface of the upper extremities distal to the antecubital fossa, the neck, and left anterior chest. (7)
Hesitation marks are generally grouped adjacent to the location of the primary wound. They overwhelmingly run parallel to each other, and to the primary wound. The regular pattern of hesitation marks help to differentiate between suicidal and non-suicidal wounds. (3,7)
In general, hesitation marks will be seen on the opposite side of the body from the dominant hand. However, hesitation marks may be present on either side or bilaterally. (3,7)
Early 40s is the average age of completed suicide by cutting with and without the presence of hesitation marks.
The Case, Revisited:
50-year-old left-handed male is seen in the ED with a 5cm horizontal cut through the subcutaneous fat to the right anterior forearm with multiple superficial parallel cuts to the epidermis grouped closely to the primary wound. Two 3cm superficial parallel cuts to the epidermis of the right jugular area are also appreciated. The patient’s injury pattern is highly suggestive of a suicide attempt.
Become familiar with the recognizable injury pattern of suicide attempt by cutting. If you are able to identify hesitation marks, you will be able to identify a suicide attempt reliably.
Learn to recognize the difference between cuts and lacerations, which are caused by different mechanisms and therefore have different features.
Use correct terminology to describe and diagnose injuries, to communicate correctly the nature and causation of the injuries
Recognize that forensic pathologists are often available for clinical forensic consultations. All you need to do is ask,
A special thanks to Jonathan L. Arden, MD for help and guidance with this project. Autopsy photo depicting bilateral hesitation marks courtesy of Dr. Arden.
1.Doshi A, Boudreaux E, Wang N, Pelletier A, & Camargo C. National Study of US Emergency Department Visits for Attempted Suicide and Self-Inflicted Injury, 1997-2001. Annals of Emergency Medicine. 2005; 46(4), 369–375.
2.Ting S, Sullivan A, Boudreaux E, Miller I, Camargo C. Trends in US emergency department visits for attempted suicide and self-inflicted injury, 1993–2008. General Hospital Psychiatry. 2012; 34(5), 557–565.
3.Karakasi M, Nastoulis E, Kapetanakis S, Vasilikos E , Kyropoulos G, Pavlidis P. Hesitation Wounds and Sharp Force Injuries in Forensic Pathology and Psychiatry: Multidisciplinary Review of the Literature and Study of Two Cases. Journal of Forensic Sciences. 2016; 61(6): 1515–1523.
4. Hedegaard H, Curtin SC, Warner M. Suicide rates in the United States continue to increase. NCHS Data Brief, no 309. Hyattsville, MD: National Center for Health Statistics. 2018.
5.Spitz WU, Fisher RS. Spitz and Fisher's Medicolegal Investigation of Death: Guidelines for the Application of Pathology to Crime Investigation. 6th edition. Springfield, Il: Charles C. Thomas; 2006. 478, 532-575
6. Arden JL. 2018, Oct 6. Oral Communication.
7.Racette S, Kremer C, Desjarlais A, Sauvageau A. Suicidal and homicidal sharp force injury: a 5-year retrospective comparative study of hesitation marks and defense wounds. Forensic Science, Medicine, and Pathology. 2008; 4(4), 221–227.