St Emlyn’s Lesson Plans
First assessment of suspected poisoning
Assess an uncertain exposure, find current poisons advice and plan observation alongside psychosocial care.
New to Emergency Medicine / Induction / Early-career Emergency Medicine · 45-minute session
For learners
Before: Allow about 18 minutes in total.
When we meet: We will discuss persistent drowsiness after a possible mixed ingestion and an agitated patient whose temperature is rising.
For facilitators
Send: the learner preparation link before teaching.
Bring: Linked public RCEM guidance and, if available, a demonstration of authorised TOXBASE access. Do not display login details. The public guidance supports the discussion if the demonstration is unavailable.
Before the session
If you are attending this session, complete the core preparation below before you come. Allow about 18 minutes in total.
Core preparation
RCEM: Suspected but unidentified poisoning · About 10 minutes
Read the RCEM guideline’s initial-assessment and investigation recommendations. Focus on the information needed when the substance or amount is uncertain.
https://rcem.ac.uk/wp-content/uploads/2025/04/Management_of_Patients_with_Suspected_but_Unidentified_Poisoning_in_the_Emergency_Department_April_2025_.pdf
NICE NG225: Self-harm · About 5 minutes
Read NG225 sections 1.5 and 1.6 on psychosocial assessment and risk tools. Note how assessment can proceed alongside physical treatment.
https://www.nice.org.uk/guidance/ng225/chapter/recommendations
Think about (allow 3 minutes): What information would you want ready before calling the poisons service about an uncertain ingestion?
Picture the scene
A drowsy person is brought to ED with several medication packets and alcohol nearby. The substance, amount and timing are uncertain.
By the end of the session
- Prioritise immediate physiological threats without assuming intoxication explains everything.
- Collect the information needed to use TOXBASE and obtain specialist advice.
- Plan observation, reassessment and psychosocial care without premature clearance.
After the session
- Open TOXBASE using your normal shift device before your next poisoning case.
- Notice whether your handover states the next observation or toxicity decision clearly.
Optional further learning
You do not need to complete this before attending. The listening time is additional to the core preparation above.
Optional listening · 32 min 07 sec
St Emlyn’s Podcast: Ep 272 - Toxicology, Hyperthermia and the Future of Emergency Care (June and July 2025)
Discuss serotonin toxicity and the recognition of emerging synthetic opioid poisoning.
Search for this episode by title in MedPod Learn if you want to record your listening there.
Choose the chapters at 05:09–10:22 (serotonin syndrome) and 27:04 to the end (nitazenes). Bring one recognition or escalation question to check in current TOXBASE/NPIS guidance. The full programme runs for 32 minutes. Use current poisoning guidance for prescribing and antidote decisions.
https://www.stemlynspodcast.org/e/ep-272-toxicology-hyperthermia-and-the-future-of-emergency-care-june-and-july-2025/
Facilitator guide
Send learners the preparation link several days before teaching. Allow about 18 minutes in total.
Before learners arrive
- Verify access to TOXBASE and how to contact NPIS before teaching.
- Check local observation, antidote, agitation and liaison-mental-health pathways.
- No ECG image is needed: case one states that the ECG is abnormal. Ask what further description is needed and where to seek advice; do not infer a particular toxidrome from unspecified findings.
Equipment: Linked public RCEM guidance and, if available, a demonstration of authorised TOXBASE access. Do not display login details. The public guidance supports the discussion if the demonstration is unavailable.
Setup: In trios, one person takes the exposure history, one prepares a poisons-service call and one notes missing information. Revisit those gaps as the case develops; use the stimulant case to compare priorities.
If the preparation has not been completed
Replace immediate assessment and information-finding (13 minutes). Read the linked RCEM initial-assessment recommendations together for eight minutes. For five minutes, use the first case to list the exposure information missing from a poisons-service call. Demonstrate authorised TOXBASE access if available; the public RCEM document is sufficient for the fallback. For the 30-minute version, use the first ten minutes for a six-minute read and four-minute information checklist, replacing the immediate-threats and advice-access activities.
Suggested session plan
- 0–5 min — Immediate assessment. Ask what could kill the patient in the first minutes.
- 5–13 min — Find the right information. Pairs practise explaining the exposure and the question they need TOXBASE or NPIS to answer.
- 13–35 min — Two evolving cases. Reveal persistent drowsiness and then rising temperature; revisit the plan each time.
- 35–40 min — Consolidate. Build a discharge-readiness discussion without a predictive score.
- 40–45 min — Choose a follow-up action. Choose one local access or observation gap to resolve.
Start the discussion
Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.
Cases and discussion
Use these cases, or invite an anonymised case from the group that addresses the same questions.
Drowsiness with an unreliable history
A 21-year-old is drowsy after a possible mixed ingestion. A friend has found a message expressing suicidal intent.
Add this information as the discussion develops:
- The ECG is abnormal and the person remains drowsy several hours later.
- They begin asking to leave.
Ask the group:
- Which immediate threats must you address?
- What exposure information and tests would guide the next decision?
- What would make observation safe, and who must be involved if they wish to leave?
Discussion notes
Points to draw out:
- Assess airway, breathing, circulation, glucose and temperature; look for trauma and other causes of reduced consciousness.
- Establish substances, formulations, timing and possible co-ingestants; use the current RCEM guideline and authorised TOXBASE monographs rather than a memorised fixed panel.
- Persistent symptoms or ECG abnormality require ongoing medical assessment; a short elapsed time does not establish clearance.
- Involve liaison mental health early, assess decision-specific capacity and immediate safety with senior support, and follow the relevant local legal framework.
Common misconceptions:
- Assuming alcohol accounts for all drowsiness.
- Using an improving pulse or one normal blood result to end observation.
For a more experienced group: Rehearse an NPIS call with the actual information available and the precise question still unanswered.
Agitation is a physiological warning
A person has agitation, chest discomfort, sweating and tachycardia after an uncertain stimulant exposure.
Add this information as the discussion develops:
- Temperature rises and communication becomes harder.
Ask the group:
- What makes this medically urgent?
- How will you reduce distress and maintain safety?
- Which treatment decisions need current toxicology guidance?
Discussion notes
Points to draw out:
- Evaluate temperature, circulation, ECG, hydration and complications while obtaining help.
- Use calm communication and the least restrictive safe approach while assessing the cause of distress.
- Sedation, cooling, antidotes and arrhythmia treatment depend on the syndrome and available expertise. Consult current TOXBASE/NPIS guidance for the specific exposure.
Common misconceptions:
- Treating behaviour before recognising physiological deterioration.
- Applying a named toxidrome as proof of one substance.
For a more experienced group: Consider how co-ingestion can obscure a recognisable toxidrome.
Important clinical points
- Do not give activated charcoal to a drowsy person without an appropriate airway and specialist risk assessment.
- Do not use a suicide-risk score to decide treatment or discharge.
- Do not wait for all medical treatment to finish before arranging psychosocial assessment when the patient can participate.
Closing the session
Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.
- What information is missing from a useful poisons-service call?
- What prevents medical clearance today?
- How would you involve mental health colleagues while treatment continues?
Key teaching points:
- Assess and treat immediate threats while considering other causes of the presentation.
- Reassess an uncertain exposure and use current TOXBASE or NPIS advice.
- Involve psychosocial care while medical assessment and treatment continue.
Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.
Adapting the discussion
Uncertainty and local practice
Check drug-specific doses, decontamination and observation intervals in current TOXBASE advice, with NPIS support when needed. These depend on the exposure and clinical course.
If the discussion drifts
What do we know, what remains unknown, and how will that change observation?
For a more experienced group
Add modified-release medication, delayed toxicity or a difficult capacity discussion; require explicit specialist advice.
A 30-minute version
30 minutes: immediate threats 4; advice-access exercise 6; mixed-ingestion case 15; consolidation and reflection 5. Omit the stimulant case.
Evidence and guidance
- RCEM: Suspected but unidentified poisoning — April 2025 guidance; use alongside current TOXBASE advice for the actual exposure.https://rcem.ac.uk/wp-content/uploads/2025/04/Management_of_Patients_with_Suspected_but_Unidentified_Poisoning_in_the_Emergency_Department_April_2025_.pdf
- NPIS: TOXBASE — Explains the current UK poisons information service; individual TOXBASE monographs require authorised access.https://www.npis.org/Toxbase.html
- NICE NG225: Self-harm — Psychosocial assessment, compassionate care and avoiding predictive risk scores.https://www.nice.org.uk/guidance/ng225/chapter/recommendations
Suggested curriculum links
RCEM 2021 curriculum (2025 update): SLO1 Care for physiologically stable adults with acute presentations
Safe assessment, differential diagnosis and disposition.
RCEM 2021 curriculum (2025 update): SLO3 Resuscitate and stabilise adults
Recognition, prioritisation and team escalation.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
First published 2020-06-18 · Natasha Chatham-Zvelebil.