Tramadol Toxicity Protocol
1. Mechanism of Action
Opioid Action
Effect: Weak affinity for the μ (mu) opioid receptors.
Manifestations:
- Coma
- Respiratory Depression (RD)
- Miosis
- Hypotension
Non-Opioid Action
Effect: Inhibits reuptake of Norepinephrine (NE) & Serotonin.
Manifestations:
- Tachycardia & Hypertension
- Agitation & Seizures
- Mydriasis
- Serotonin Syndrome
2. Management in Emergency Room (ER)
Goal: Observation and Decontamination.
- Decontamination: Activated charcoal (if within 1-2 hours).
- Investigations: Urine screen (Tramadol, Opiates, BDZ), ABG, Electrolytes, Glucose.
- Observation: Monitor for 6 hours (focus on RR and SpO2).
Outcome: If symptom-free after 6h → Discharge.
Action: Immediate ICU Admission.
1) Investigations Panel
• ABG & Random Blood Sugar
• Electrolytes (Na, K)
• Liver Enzymes (ALT, AST)
• Kidney Function (Urea, Creatinine)
• CPK (Check for Rhabdomyolysis)
• Urine Screen
2) Supportive Care
O2, IV Fluids, Cardiac Monitor, Vital signs monitoring.
3) Specific Management (Decision Tree)
Case A: Seizures Present?
Give Valium 0.1–0.2 mg/kg
Consider Serotonin Syndrome.
Case B: NO Seizures (Respiratory Status)
Scenario 1: RR > 10/min & SpO2 > 90%
→ Continue supportive treatment.
→ Continue supportive treatment.
Scenario 2: RR < 10/min & SpO2 < 90%
→ Give Naloxone (Narcan)
If no improvement: Mechanical Ventilation.
Consider Gastric Lavage with Charcoal.
→ Give Naloxone (Narcan)
If no improvement: Mechanical Ventilation.
Consider Gastric Lavage with Charcoal.
3. Naloxone Administration Protocol
WARNING: Tramadol package insert cautions against Naloxone due to increased SEIZURE RISK. Use with caution.
Dosing Strategy:
- Initial: 0.05 mg → Wait 2–3 mins.
- If no response: Add up to 0.4 mg (1 ampoule) → Wait 2–3 mins.
- Still no response: Gradually increase to 2 mg (5 ampoules).
4. Serotonin Syndrome
Symptoms: Rapid onset altered mental status, rigidity, hyperthermia, tremor, diarrhea, autonomic dysfunction.
Management
- Supportive: Sedation (BDZ), Muscle relaxants, Cooling.
- Severe: Intubation & Mechanical Ventilation.
Specific Antidote (5-HT2a antagonist):
Drug: Cyproheptadine (Triactin 4mg)
Initial: Oral 12 mg
Maintenance: 8 mg every 6 hours
Drug: Cyproheptadine (Triactin 4mg)
Initial: Oral 12 mg
Maintenance: 8 mg every 6 hours
5. Disposition & Important Notes
Discharge Criteria
- Admit to Ward: If improved and symptom-free for 4–6 hours.
- Final Discharge: If free of Signs & Symptoms for 12 hours.
Lactation Note: A lactating tramadol addict should stop lactation to prevent baby toxicity.
