St Emlyn’s Lesson Plans
Initial assessment of suspected poisoning
Approach an uncertain ingestion with supportive care, targeted information and physical and psychosocial safety in parallel.
Medical Students · 45-minute session
For learners
Before: Allow about 12 minutes in total.
When we meet: We will work through mixed ingestion and stimulant-associated illness, gathering information for poisons advice while planning physical and psychosocial care.
For facilitators
Send: the learner preparation link before teaching.
Bring: Fictional packets and a blank substance/time/amount table; no real medication.
Before the session
If you are attending this session, complete the core preparation below before you come. Allow about 12 minutes in total.
Core preparation
RCEM unidentified poisoning guidance 2025 · About 7 minutes
Read the summary on printed page 2, “General approach to the poisoned patient” on page 10, and the investigation discussion on pages 13–14. Focus on stabilisation, useful history and tests, and access to specific poisons advice; the detailed toxidrome and antidote tables are optional.
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 3 minutes
Read the ED assessment and psychosocial referral recommendations (1.7.12–1.7.14) and the opening recommendations under “Risk assessment tools and scales”. Focus on care alongside physical treatment and the limits of a risk score.
https://www.nice.org.uk/guidance/ng225/chapter/Recommendations
Think about (allow 2 minutes): What would you assess first in a drowsy patient when the substances, dose and timing are uncertain?
Picture the scene
A drowsy person arrives after a possible mixed ingestion with alcohol. Empty medication packets accompany them; the dose and timing are uncertain.
By the end of the session
- Recognise and escalate physiological danger before identifying every substance.
- Gather information that makes TOXBASE or NPIS advice useful.
- Explain why improving observations do not alone establish medical or psychosocial readiness for discharge.
After the session
- Find the department’s TOXBASE access route and practise opening it with a supervisor before an urgent case.
Facilitator guide
Send learners the preparation link several days before teaching. Allow about 12 minutes in total.
Before learners arrive
- Check access to TOXBASE and the NPIS contact route so you can show learners how to seek current advice.
- Locate liaison psychiatry, escalation and safe observation arrangements.
Equipment: Fictional packets and a blank substance/time/amount table; no real medication.
Setup: Pairs build a structured handover, then receive the next observation. Keep discussion of self-harm respectful and allow learners to pass on personal examples.
If the preparation has not been completed
Replace the five-minute “Establish the essentials” slot. Use case 1 on screen and six board headings: substance, formulation, amount, time, co-ingestion and current condition. Spend two minutes sorting known and missing information, two choosing the first assessment priorities, and one identifying where the responsible clinician obtains TOXBASE or NPIS advice. Packets or other props are optional.
Suggested session plan
- 0–5 min — Explore. Ask what must happen before knowing the toxin.
- 5–10 min — Establish the essentials. Build the information needed for a useful poisons enquiry.
- 10–32 min — Discuss & Apply. Spend 14 minutes on uncertain ingestion and 8 on hyperthermia and escalation.
- 32–40 min — Consolidate. Ask pairs to give a concise poisons-enquiry handover and explain why persistent drowsiness prevents simple reassurance.
- 40–45 min — Reflect & Transfer. Arrange for learners to check the department’s TOXBASE access route with a supervisor before their next clinical shift.
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.
Mixed ingestion and persistent drowsiness
A 21-year-old was found with empty medication packets after communicating suicidal intent. They respond to voice and have slurred speech. Alcohol was present, but nobody knows what was taken.
Add this information as the discussion develops:
- Reveal slowed breathing; a colleague attributes this to alcohol.
- After initial treatment, vital signs improve but drowsiness persists and the patient remains distressed.
Ask the group:
- What must be assessed before the complete drug history?
- What information changes the period of observation or treatment?
- Who should be involved before considering discharge?
Discussion notes
Points to draw out:
- Assess airway, ventilation, circulation, consciousness, temperature and glucose; seek urgent help for physiological compromise. Consider trauma and medical causes alongside poisoning.
- Use the current TOXBASE entry or NPIS advice with formulation, dose, timing and evolving observations; modified-release and uncertain ingestions may need a different plan.
- RCEM advises paracetamol testing in all possible deliberate self-harm ingestions and consideration in unknown poisoning. Other assays and investigations are selected by clinical features and expert advice.
- Offer liaison assessment early alongside physical care. Persistent drowsiness and a reassuring snapshot of tests are not proof that delayed toxicity is excluded.
Common misconceptions:
- Calling someone ‘medically cleared’ after an arbitrary few hours.
- Assuming ethanol explains all reduced consciousness.
- Giving charcoal routinely to a drowsy person without an appropriate airway assessment and toxicology indication.
For a more experienced group: Explain why mental-health assessment can start before all toxicology observation has finished, while participation and capacity are assessed individually.
Chest pain, agitation and a high temperature
A 32-year-old is agitated and sweaty after a party, with chest discomfort, tachycardia, marked hypertension and a rising temperature.
Add this information as the discussion develops:
- They disclose stimulant use; the ECG shows ischaemic changes.
- They become harder to engage and their temperature rises further.
Ask the group:
- Which dangers need immediate senior attention?
- How can the team keep assessment calm and safe?
- Why should a single remembered antidote list not drive care?
Discussion notes
Points to draw out:
- Treat this as a medical emergency: seek senior/critical-care help, monitor and assess hyperthermia, cardiac complications and other causes.
- Use de-escalation and an appropriate monitored environment. Sedation, cooling and cardiovascular management require the responsible team and current toxin-specific guidance.
- Use a descriptive presentation rather than an ‘excited delirium’ label. Consider mixed ingestions and do not conflate serotonin toxicity with neuroleptic malignant syndrome.
Common misconceptions:
- Dismissing chest pain because a stimulant precipitated it.
- Restraint without attention to physiology or medical deterioration.
- Applying a categorical drug prohibition without current expert advice.
For a more experienced group: Ask which features might support different toxidromes while avoiding premature certainty.
Important clinical points
- Do not use a suicide risk score or low/medium/high label to decide discharge.
- A normal initial ECG or blood test does not exclude delayed toxicity.
- Toxin-specific drug doses and observation periods must come from current TOXBASE/NPIS and the responsible clinician.
Closing the session
Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.
- Give a concise poisons-enquiry handover.
- Explain why persistent drowsiness changes the plan despite improved vital signs.
- Describe how liaison input and physical treatment can overlap.
Key teaching points:
- Assess and support airway, breathing and circulation while gathering the ingestion history.
- Accurate substance, formulation and timing information makes poisons advice more useful.
- Arrange physical and psychosocial care alongside each other.
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
Unknown substances, delayed absorption and changing stories are common; record uncertainty and plan reassessment instead of inventing a precise ingestion.
If the discussion drifts
What can harm this person in the next few minutes, and what information would change our plan?
For a more experienced group
Consider capacity as decision- and time-specific; ask the supervising clinician to explain local legal arrangements if the person wants to leave.
A 30-minute version
30 minutes: opening 3, history grid 5, first case 14, consolidation 5, reflection 3. Omit detailed toxidrome comparison.
Evidence and guidance
- RCEM unidentified poisoning 2025 — Initial assessment and targeted testing.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 — Early psychosocial assessment; risk scales must not determine discharge.https://www.nice.org.uk/guidance/ng225/chapter/Recommendations
- TOXBASE — Professional-access treatment resource; its monographs were not inspected here.https://www.toxbase.org/
Suggested curriculum links
GMC Outcomes for graduates / MLA 2026: Poisoning; self-harm and acute deterioration
Recognition, safe information gathering, supervised care and compassionate communication.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
First published 2020-09-22 · Natasha Chatham-Zvelebil.