Refractory shock and asystole related to tramadol overdose

Abstract

Introduction. Tramadol use is largely considered safe. However, several lethal cases of tramadol intoxication were reported, suggesting an underestimated toxicity. We report for a tramadol overdose case in combination with other central nervous system depressants, leading to refractory shock requiring extracorporeal life support. Case report. A 33-year-old man was admitted in our intensive care unit for drug intoxication with coma, seizures, and hypotension without signs of heart failure. A few hours later, he developed a ventricular tachycardia, followed by a brief cardiac arrest in asystole with refractory shock requiring an extracorporeal life support, vasopressors, and hemofiltration. With this aggressive support, his overall status gradually improved. Repeated echocardiography showed an improvement in the cardiac function. The patient was weaned off extracorporeal life support on day eight and discharged on day 12. On admission, a urine analysis, using gas chromatography-mass spectrometry, showed high peaks of tramadol and desmethyltramadol with the presence of hydroxyzine, gabapentine, and clonazepam. The tramadol blood concentration measured by the high-performance liquid chromatography method-diode array detector was 23.9 mg/L, much higher than many previously reported fatal overdoses. No other drugs with potential cardiac toxicity, such as beta-blockers, calcium antagonists, antiarrythmic, antidepressants, meprobamate, or other xenobiotics were detected. Conclusion. This case illustrates that tramadol overdose may cause refractory shock and asystole when taken in combination with CNS depressants, and reminds all physicians to be vigilant with regard to the potential toxic effects of tramadol.

Respiratory Apnea in Patients with Acute Poisoning by Tramadol (Two Years Study)

“…The mean ingestion dose in males and females were reported 2413 and 1706 mg, respectively, which went well with our study's results [5]. During two-yr study, only one patient (0.29%) out of completely poisoned patients died eventually which was less than some other studies [18][19][20].…”

Severe acute lactic acidosis and hypoglycemia due to isolate tramadol poisoning

“…21 The patient, however, took a massive overdose of tramadol, alongside with hydroxyzine, gabapentin, and clonazepam. He had a long-lasting seizure, hypotension, hypothermia, and a prolonged QTc at the ECG, thus showing several clinical characteristics that clearly distinguished he from the case here described.…”

Electrocardiographic changes in patients with tramadol-induced idiosyncratic seizures

“…Nausea/vomiting and respiratory depression have also been reported 5, 7, 8. Of cardiac issues, hypotension, especially affecting systolic blood pressure (SBP) and sinus tachycardia have been listed as tramadol toxicity complications 5, 7, 8, 12, 13, 14…”