Psych · Emergency psychiatry
Overdose and toxicology for psychiatrists
Also known as Deliberate self-poisoning · Psychotropic overdose · Toxicology for psychiatry · Self-poisoning assessment · Toxidrome approach psychiatry
Exam-exhaustive fellowship hub on overdose and clinical toxicology for psychiatrists — toxidrome approach, relative toxicity of psychotropics (TCA, venlafaxine, SSRIs, antipsychotics, lithium, benzodiazepines), always-screen paracetamol, antidotes (bicarbonate, NAC, naloxone, cyproheptadine), decontamination rules, EXTRIP lithium interface, flumazenil cautions, medical clearance and post-OD suicide risk disposition. FRANZCP-primary, globally tagged.
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Meet the patient
A 34-year-old woman is brought in "found down" at home, GCS 12, surrounded by empty blister packs of amitriptyline, paracetamol and her mother's lithium. Her QRS is 130 ms with a terminal R in aVR, she is tachycardic at 120, and no one can time the ingestion.[16][18]
The ED registrar pages you for "psych clearance." This is the trap the whole topic is built to prevent. There is nothing to interview yet: the airway, the ECG and the paracetamol level must be secured before any conversation about intent. She carries three toxins with three antidotes and three times-to-peak — manage the physiology in parallel, and you will have a patient left to assess.[5][11][16]
You have read the opening of this topic. The complete unit — every section and its primary-source references — is part of the Psychiatry Fellowship fellowship atlas.
References18Show ledgerHide ledger
- [1]Chyka PA, Seger D, Krenzelok EP, Vale JA Position paper: Single-dose activated charcoal. Clin Toxicol (Phila), 2005.PMID 15822758
- [2]Thanacoody R, Caravati EM, Troutman B, et al. Position paper update: Whole bowel irrigation for gastrointestinal decontamination of overdose patients. Clin Toxicol (Phila), 2015.PMID 25511637
- [3]Whyte IM, Dawson AH, Buckley NA Relative toxicity of venlafaxine and selective serotonin reuptake inhibitors in overdose compared to tricyclic antidepressants. QJM, 2003.PMID 12702786
- [4]Isbister GK, Bowe SJ, Dawson A, et al. Relative toxicity of selective serotonin reuptake inhibitors (SSRIs) in overdose. J Toxicol Clin Toxicol, 2004.PMID 15362595
- [5]Liebelt EL Targeted management strategies for cardiovascular toxicity from tricyclic antidepressant overdose: the pivotal role for alkalinization and sodium loading. Pediatr Emerg Care, 1998.PMID 9733258
- [6]Pai K, Buckley NA, Isoardi KZ, et al. Optimising alkalinisation and its effect on QRS narrowing in tricyclic antidepressant poisoning. Br J Clin Pharmacol, 2022.PMID 34312917
- [7]Decker BS, Goldfarb DS, Dargan PI, et al. Extracorporeal Treatment for Lithium Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup. Clin J Am Soc Nephrol, 2015.PMID 25583292
- [8]Baird-Gunning J, Lea-Henry T, Hoegberg LCG, et al. Lithium Poisoning. J Intensive Care Med, 2017.PMID 27516079
- [9]Dunkley EJ, Isbister GK, Sibbritt D, et al. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. QJM, 2003.PMID 12925718
- [10]Boyer EW, Shannon M The serotonin syndrome. N Engl J Med, 2005.PMID 15784664
- [11]Bateman DN, Dart RC, Dear JW, et al. Fifty years of paracetamol (acetaminophen) poisoning: the development of risk assessment and treatment 1973-2023 with particular focus on contributions published from Edinburgh and Denver. Clin Toxicol (Phila), 2023.PMID 38197864
- [12]Smilkstein MJ, Knapp GL, Kulig KW, Rumack BH Efficacy of oral N-acetylcysteine in the treatment of acetaminophen overdose. Analysis of the national multicenter study (1976 to 1985). N Engl J Med, 1988.PMID 3059186
- [13]Williams K, Lang ES, Panchal AR, et al. Evidence-Based Guidelines for EMS Administration of Naloxone. Prehosp Emerg Care, 2019.PMID 30924736
- [14]Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ, 2013.PMID 23372174
- [15]Veiraiah A, Dyas J, Cooper G, et al. Flumazenil use in benzodiazepine overdose in the UK: a retrospective survey of NPIS data. Emerg Med J, 2012.PMID 21785147
- [16]Parris MA, Calello DP Found Down: Approach to the Patient with an Unknown Poisoning. Emerg Med Clin North Am, 2022.PMID 35461619
- [17]Brett J, Wylie CE, Raubenheimer J, Isbister GK, et al. The relative lethal toxicity of pharmaceutical and illicit substances: A 16-year study of the Greater Newcastle Hunter Area, Australia. Br J Clin Pharmacol, 2019.PMID 31173392
- [18]Hüser C, Bethlehem C, Dünser MW, et al. Critical care management of the patient with pharmaceutical poisoning. Intensive Care Med, 2025.PMID 41222651