Tramadol Dosage Guide

## Presentation Tramadol overdose presents differently from typical opioid overdoses, and this difference can be life-threatening if emergency responders treat it as a straightforward opioid OD. **Seizures are the primary and most dangerous manifestation of tramadol overdose.** Generalized tonic-clonic seizures can occur as the first sign of overdose, sometimes before significant respiratory depression develops. This is the opposite of what happens with morphine or heroin overdoses, where respiratory depression is the leading threat. Additional overdose symptoms include: - Serotonin syndrome (hyperthermia, clonus, agitation, diaphoresis) - Respiratory depression (present but typically less severe than with full mu-agonists) - Altered mental status progressing to coma - Tachycardia or cardiovascular instability - Nausea and vomiting with aspiration risk ## Emergency Response - **Call 911 immediately** — tramadol overdose can deteriorate rapidly due to seizures - **Naloxone (Narcan) is partially effective** — it reverses only the opioid component of tramadol toxicity. Naloxone will NOT prevent or treat tramadol-induced seizures and will not reverse serotonin syndrome. Administer naloxone if respiratory depression is present, but do not rely on it as a complete antidote - **Benzodiazepines** are the first-line treatment for tramadol-induced seizures in the emergency setting - Place the person in the recovery position if unconscious - Monitor for hyperthermia — active cooling may be necessary if serotonin syndrome is present - Do not induce vomiting — seizure risk makes this dangerous ## Lethal Dose Fatal tramadol overdoses have been reported at doses as low as 2-5 grams, though the lethal dose varies enormously based on CYP2D6 phenotype, co-ingestants, and tolerance. Ultra-rapid metabolizers are at significantly greater risk. Deaths from tramadol alone, while less common than deaths from stronger opioids, are well-documented and are almost always associated with seizures or serotonin syndrome rather than isolated respiratory depression.