Table 3 [ ]. Accidental ingestion of tramadol is well tolerated by children [ 50 , 71 , ]. Side effects of tramadol seem to be more common but milder in children.
Vomiting is especially common in them [ ]. Riedel and Stockhausen reported that tramadol could cross the blood brain barrier BBB in children and suppress the brain [ ].
Rectal administration of tramadol resulted in severe CNS depression in a 5-week-old infant which was explained to be due to the decreased kinetic elimination and increased permeability of the BBB [ 51 ].
Mazor et al. Short-term use of tramadol in lactating mother is not dangerous [ ] and the risk of neonatal dependency is low. Tramadol can cause SS without the effect of any other medication while in the adults the risk is increased if a SSRI is also taken [ 40 ]. In an 8-month-old infant with SS, the cause of hospital presentation was epistaxis.
Sinus tachycardia, hyperthermia, hypertension, agitation, drowsiness, and hyper-reflexia of the lower extremities occurred within the first 24 hours after ingestion of mg of tramadol. Neurologic and cardiovascular effects recovered in two days. The infant was discharged after five days in good condition [ ]. Treatment should focus on conservative approaches including maintenance of airway, breathing, and circulation, oxygen therapy, fluid resuscitation, and diazepam administration to control agitation and seizure [ 6 , 14 , 36 ].
Patients should be monitored for increased CPK and possible acute renal failure that may happen within the next two days [ 6 , 14 ]. Hemodialysis should be considered in cases with acute renal failure and severe creatinine increase [ 14 ]. They may need intubation and ICU admission. Gastrointestinal decontamination should be performed in the patients who have referred within the first two hours post-ingestion and have no contraindications [ 8 , 49 , 50 ].
In severe toxicities due to ingestion of large amounts of sustained-release drug, multiple dose activated charcoal should be considered if no contraindication exists [ 6 , ]. In cases with resistant shock or asystole, extracorporeal methods may be needed [ 6 , 35 ]. Treatment of liver failure is conservative, as well, and urgent liver transplantation is not feasible in many cases [ 18 ].
In severe cases who have not even seized, experimental therapy with diazepam can be performed which can be of help in mild undiagnosed SS [ 6 , 44 ]. Treatment of SS in also conservative and includes withdrawal of the culpable drug and external cooling. In a clinical study on patients, naloxone administration could induce seizure in tramadol-intoxicated patients [ 75 ].
Therefore, naloxone should not routinely be administered to treat decreased level of consciousness in tramadol toxicity unless respiratory depression has developed [ 21 , 45 ]. Seizures due to tramadol do not respond to naloxone but improve with administration of benzodiazepines. Naloxone can be considered for treatment of post-seizure complaints [ ]. Shadnia et al suggested that because of the low risk of multiple seizures in tramadol toxicity, anticonvulsant treatment should not be routinely given even in those with initial seizures [ 52 ].
Stoops et al evaluated naltrexone and showed that it could reverse the opioid-induced effects such as miosis; but, increased the serotonergic and adrenergic effects such as mydriasis [ 56 ].
Intravenous lipid emulsion ILE can reduce mortality due to acute toxicity of tramadol in rabbits, but increasing the ILE dose may cause reverse effects. In a study on 30 rabbis, ILE reduced tramadol-induced tachycardia when administered within 30 minutes of poisoning and showed positive effects on normalizing mean arterial pressure and diastolic blood pressure but it did not have major effect on systolic blood pressure.
Intralipid also prevented tramadol-related seizures in low doses and reduced the frequency of increased CPK with higher doses [ ]. Although tramadol has less side effects, addicting capacity, and respiratory depression power in comparison with other opioids, many cases of dependency, abuse, intentional overdose, or poisoning have been reported following its use [ 20 , 27 , 48 , 56 , 70 , , , ].
Tramadol withdrawal lasts longer compared with other opioids [ ]. Where ultrarapid metabolizers are high in number, people are expected to have a higher risk of dependency to tramadol [ ].
Tramadol is as potent as heroin to cause euphoria [ 2 , 55 , ]. Withdrawal occurs after rapid abrupt discontinuation of tramadol with clinical manifestations including abdominal cramps, anxiety, skeletal pain, depression, diarrhea, goose flesh, insomnia, lacrimation, nausea, restlessness, rhinorrhea, and sweating. The manifestations may sometimes be atypical and include hallucination, paranoia, panic attack, confusion, and atypical sensational experiences such as paresthesia, itching, tingling, delusion, depersonalization, derealization, and tinnitus [ 22 , 55 ].
Tramadol dependency happens faster in those who abuse it with other analgesics or ethanol [ 55 ]. Clinical therapeutic doses of tramadol may affect psychomotor and physiologic capacities of the patients who recreationally abuse it [ ]. Tramadol abuse in pregnancy may cause preterm labor and withdrawal manifestations in the newborn baby depending on the age of pregnancy, time elapsed since the beginning of tramadol use, dose of tramadol, CYP D2 polymorphism, development of the liver conjugation, and renal function of both mother and baby.
Attempts have been performed to treat this syndrome in neonates using clonidine alone or in combination with the thin opioid tinctures, chloral hydrate, benzodiazepines, and methadone [ 55 ]. In a study on patients with chronic non-cancer pain, it was shown that the frequency of abuse and dependency on tramadol and NSAIDs were the same and significantly less than hydrocodone [ ]. It is less dangerous to the organs in comparison with selective and nonselective NSAIDs and very powerful in the treatment of chronic pains [ ].
Tramadol can also be used in moderate to severe toothaches alone or in combination with acetaminophen or codeine [ , ]. In opioid-addicted patients, tramadol can be used for the treatment of withdrawal pain [ 68 ].
Tramadol in combination with paracetamol has a fair efficacy, immunity, and acceptance rate by the patients without development of dependency syndrome [ , , ]. Complications can be decreased by adding tramadol to the controlled medications [ ]. Monitoring of the liver function especially when the maximum daily doses are given is mandatory. Also, because of drug-drug interactions and differences in the individual metabolism and the chance of dependency, tramadol administration should be controlled by the treating physician.
If the patient is an opioid-addict, tramadol should not be administered unless absolutely indicated [ , ]. Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3. Help us write another book on this subject and reach those readers. Login to your personal dashboard for more detailed statistics on your publications.
Edited by Ana Cristina Andreazza. Edited by Theophile Theophanides. We are IntechOpen, the world's leading publisher of Open Access books. Built by scientists, for scientists. Our readership spans scientists, professors, researchers, librarians, and students, as well as business professionals. Downloaded: Introduction Poisoning is one of the leading causes of mortality and morbidity in many countries.
Table 1. Studies on tramadol-induced seizures. Carcinogenic effects In long-term studies on rats and mice, no tramadol-attributed carcinogenic changes were detected. Biochemical findings of tramadol Bleeding time BT , clotting time CT , prothrombin time, partial thromboplastin time, and body temperature were not affected by tramadol [ 17 ].
Table 2. Studies on patients with tramadol poisoning. Serotonin syndrome Serotonin syndrome SS is a potentially fatal syndrome due to increased synthesis, decreased metabolism, increased release, and reuptake inhibition of serotonin or direct agonism at the serotonin receptors [ 5 , 53 ].
Three key clinical features of this syndrome include: Neuromuscular hyperactivity tremor, clonus, myoclonus, hyper-reflexia, stiffness, impaired coordination. Drug interactions Opioids metabolized by CYP including tramadol may induce many drug-drug interactions [ ]. Tramadol-related mortalities Fatalities have been reported after tramadol overdose or its co-ingestion with other medications.
Miscellaneous side effects Mannocchi and assistants reported a case of death due to tramadol and propofol due to advanced severe dyspnea [ ].
Table 3. Studies on deaths related to tramadol poisoning. Toxicity in children Accidental ingestion of tramadol is well tolerated by children [ 50 , 71 , ]. Treatment Treatment should focus on conservative approaches including maintenance of airway, breathing, and circulation, oxygen therapy, fluid resuscitation, and diazepam administration to control agitation and seizure [ 6 , 14 , 36 ].
Dependency and withdrawal Although tramadol has less side effects, addicting capacity, and respiratory depression power in comparison with other opioids, many cases of dependency, abuse, intentional overdose, or poisoning have been reported following its use [ 20 , 27 , 48 , 56 , 70 , , , ]. More Print chapter. How to cite and reference Link to this chapter Copy to clipboard.
Available from:. Over 21, IntechOpen readers like this topic Help us write another book on this subject and reach those readers Suggest a book topic Books open for submissions. More statistics for editors and authors Login to your personal dashboard for more detailed statistics on your publications. Access personal reporting. By Bruno Nunes. More About Us. Publication year. Number of patients. Cause of ingestion. Co-administration or comorbidity. Raigeret al. Prescribed by physician. History of seizure.
Petramfar et al. Prescribed by physician in History of epilepsy in Mehrpour M []. Dosage or concentration. Afshari and Ghooshkhanehee [ 14 ]. Context: Tramadol is a commonly used centrally acting analgesic associated with seizures and suspected to cause serotonin toxicity in overdose.
Objective: This study sought to investigate the effects of tramadol overdose, and included evaluation for serotonin toxicity based on the Hunter Serotonin Toxicity Criteria where the seven clinical features of spontaneous clonus, inducible clonus, ocular clonus, agitation, diaphoresis, tremor and hyperreflexia are examined for in all patients taking serotonergic medications; seizures and central nervous system depression.
Demographic details, information on ingestion dose and co-ingestants , clinical effects, complications seizures, serotonin toxicity and cardiovascular effects and intensive care unit ICU admission were extracted from a clinical database. Results: There were 71 cases of tramadol overdose median age: 41 years, range: years; and median ingested dose: mg, interquartile range [IQR]: mg.
They should also not try to induce vomiting. They should also try to prevent the person who overdosed from moving around, which may accelerate the speed at which the Tramadol enters the blood stream. Unless emergency crews suggest, do not give the person who has overdosed anything to eat or drink. A Tramadol overdose may be treated with a drug to counteract the effects. Other Tramadol treatments may include induced vomiting, pumping of the stomach and close monitoring of the breathing and heart rates.
If you think you or a loved one is overdosing on tramadol, take them to the emergency room where they can get their stomach pumped or possibly a different medication to neutralize the effects.
Tramadol is a highly dependent drug. Often, tramadol addictions happen accidentally by patients unknowingly abusing their prescribed medication. When used for a prolonged amount of time, the body builds up a certain amount of tolerance. The user has to continually take more per dosage in order to receive the same initial effect. This is a dangerous concept because eventually, the body will not be able to handle the amount of the drug administered.
This is when an overdose may occur. Tramadol is in a group of drugs called opiate agonists. It is used to treat moderate to severe pain by changing the way the body senses pain.
Tramadol can either be taken as a normal tablet or an extended-release long-acting tablet to be taken through the mouth. The regular tablet can be taken with or without food every four to six hours, or as needed. The extended-release tablet should only be taken once a day around the same time every day. When using extended-release the patient either needs to always take it with food or always take it without food. The extended-release tablets should only be taken whole.
It is dangerous to split, chew, crush, snort or inject the dissolved form of the tablet.
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