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Clinical Atlas Prestige · Evidence-first

Psych VivasEmergency psychiatry

Psych Vivas · Emergency psychiatry

Overdose and toxicology — structured clinical viva

Fellowship viva on relative toxicity of venlafaxine vs SSRIs, always-screen paracetamol, seizure management, observation, and post-OD risk assessment.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the psychiatry registrar. ED asks you to review a 27-year-old after a large venlafaxine and possible paracetamol overdose. She had two brief seizures. HR 118, BP 100/62, GCS 13. ECG QTc borderline prolonged, QRS 98 ms. A junior doctor says 'SSRIs are safe in OD so she can go to the psych ward now.' Defend relative toxicity, immediate medical priorities, antidote decisions, observation needs, and aftercare.

Interpretation

Reveal interpretation

Reject premature transfer. Venlafaxine is not risk-equivalent to many SSRIs in overdose; relative toxicity data place it closer to higher-risk agents for seizures and serious outcomes. She already seized — she needs medical observation, monitoring, and toxin work-up, not an immediate psych-ward bed.[1][2][5]

Immediate priorities. ABCDE, continuous monitoring, glucose, ECG serial review, benzodiazepines for recurrent seizures, timed paracetamol level and NAC if indicated, basic labs, early toxicology advice. Airway vigilance if GCS falls.[3][4]

Disposition thinking. Observe through expected peak effects; escalate to ICU if status epilepticus, airway compromise, or progressive cardiotoxicity. Only after medical clearance: structured suicide risk assessment, means restriction (dispose stock, safer future prescribing), and least-restrictive safe psychiatric plan.[4]

Escalating viva probes

ProbeModel point
Whyte/Buckley finding?Venlafaxine and TCAs higher relative toxicity than many SSRIs
Always-screen toxin?Paracetamol in deliberate self-poisoning
Charcoal for lithium?No — not bound
Flumazenil in mixed OD?Not routine — seizure risk
TCA QRS treatment?Sodium bicarbonate

Key points

Relative toxicity

Venlafaxine is not “just another SSRI” in overdose rankings.

Medical first

Seizures and toxin work-up precede psych-ward transfer.

Paracetamol

Timed level ± NAC — never assume denial is complete.
[1] [3] [4]

References

  1. [1]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
  2. [2]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
  3. [3]Bateman DN, Dear JW, Thanacoody HK, Thomas SHL 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
  4. [4]Parris MA, Ragan FA, Lin A Found Down: Approach to the Patient with an Unknown Poisoning. Emerg Med Clin North Am, 2022.PMID 35461619
  5. [5]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