Extracorporeal treatments for isoniazid poisoning: Systematic review and recommendations from the EXTRIP workgroup

Isoniazid toxicity from self-poisoning or dosing errors remains common in regions of the world where tuberculosis is prevalent. Although the treatment of isoniazid poisoning is centered on supportive care and pyridoxine administration, extracorporeal treatments (ECTRs), such as hemodialysis, have been advocated to enhance elimination of isoniazid. No systematic reviews or evidence-based recommendations currently exist on the benefit of ECTRs for isoniazid poisoning. The Extracorporeal Treatments in Poisoning (EXTRIP) workgroup systematically collected and rated the available evidence on the effect of and indications for ECTRs in cases of isoniazid poisoning. We conducted a systematic review of the literature, screened studies, extracted data on study characteristics, outcomes, and measurement characteristics, summarized findings, and formulated recommendations following published EXTRIP methods. Forty-three studies (two animal studies, 34 patient reports or patient series, and seven pharmacokinetic studies) met inclusion criteria. Toxicokinetic or pharmacokinetic analysis was available for 60 patients, most treated with hemodialysis (n = 38). The workgroup assessed isoniazid as “Moderately Dialyzable” by hemodialysis for patients with normal kidney function (quality of evidence = C) and “Dialyzable” by hemodialysis for patients with impaired kidney function (quality of evidence = A). Clinical data for ECTR in isoniazid poisoning were available for 40 patients. Mortality of the cohort was 12.5%. Historical controls who received modern standard care including appropriately dosed pyridoxine generally had excellent outcomes. No benefit could be extrapolated from ECTR, although there was evidence of added costs and harms related to the double lumen catheter insertion, the extracorporeal procedure itself, and the extracorporeal removal of pyridoxine. The EXTRIP workgroup suggests against performing ECTR in addition to standard care (weak recommendation, very low quality of evidence) in patients with isoniazid poisoning. If standard dose pyridoxine cannot be administered, we suggest performing ECTR only in patients with seizures refractory to GABA_A receptor agonists (weak recommendation, very low quality of evidence).     

A Nationwide Register‐Based Survey of Baclofen Toxicity

To study the use and misuse (poisonings) of baclofen in the time period of 2007–2012 and to evaluate the severity and clinical symptoms of poisonings including ingested baclofen. The National Patient Register (NPR) was searched for admissions due to baclofen poisonings from 2007 to 2012. The search was conducted with ICD‐10 codes for poisoning, self‐harm and suicide, and coupled with the baclofen ATC code. All enquiries about baclofen to the Danish Poison Information Centre (DPIC) in the same period were evaluated. Demographic and clinical data were extracted, and the poisonings were classified according to the Poison Severity Score. The number of baclofen poisonings did not increase from 2007 to 2012. Thirty‐eight admissions with baclofen poisoning were registered at the NPR; however, only one‐third of the reviewed DPIC cases were registered at the NPR with the correct coding. In the group of severely poisoned patients (PSS 3), three patients had only ingested baclofen (mean 2000 mg; SD 500 mg) and eight patients had ingested baclofen together with alcohol or psychotropic drugs (mean 900 mg; SD 641 mg). All patients presented with deep coma and respiratory depression. Additionally, seizures and cardiovascular events (mild hypo‐ or hypertension and bradycardia) occurred. There is a substantial degree of underreporting of baclofen poisonings in Denmark. Symptoms of baclofen poisoning progress very fast, and toxicity was observed even with doses as low as 150 mg. We therefore recommend that observation and treatment of these patients should be carried out in an intermediate‐ or intensive care unit. The most important treatment is the maintenance of a protected airway and respiration.     

An analysis of poison control center reports of ciguatera toxicity in Puerto Rico for one year

Forty-five cases of ciguatera poisoning in Puerto Rico (P.R.) are described. These cases represent all those reported to the P.R. Poison Control Center in 1982. Most of the cases were reported in the spring and summer months. The most common fish ingested was the grouper. The clinical presentation of acute and long term symptoms was similar to that reported in other geographical areas, except the incidence of paresthesias. Paresthesias were reported in 11% of the patients reported to the poison center. A companion telephone survey indicated that persons in P.R. that do not eat fish do so because of fear of ingesting the toxin. Our findings indicate an overall familial contact with the ciguatera toxin in Puerto Rico at 7%. This study is the first to document that ciguatera is a common poisoning reported to the Poison Control Center in Puerto Rico. Our findings also support other authors contentions of geographical variations in clinical symptomatology.     

Levothyroxine Poisoning – Symptoms and Clinical Outcome

Levothyroxine (LT), T4, poisoning is rarely associated with a severe outcome. However, cases with significant complications have been reported. The aim of this study was to identify factors associated with symptoms of poisoning including late‐onset symptoms. All enquiries to the Danish Poison Information Centre (DPIC) concerning LT poisoning between March 2007 and September 2012 were reviewed and the following parameters were recorded: age, dose, time from ingestion, multiple drug intake and symptoms. To evaluate the frequency of late‐onset symptoms, a subgroup of patients without initial symptoms were contacted. A total of 181 patients were registered (112 children). Ingested LT dose ranged from 10 to 9000 mcg (median 275 mcg). A total of 29 of 181 (16%) patients were symptomatic at the time of enquiry, and there was no difference in ingested LT dose between asymptomatic and symptomatic patients, neither in children nor in adults (age 16–92 years) (p < 0.68 and p < 0.47, respectively). In total, 153 of 181 (85%) patients did not have symptoms of poisoning at the time of enquiry; however, in 9 of 21 (43%) patients, we were able to contact, late‐onset symptoms existed. In none of the cases, hospital contact was needed and there were no reports of long‐term sequelae. Acute LT poisoning often follows a benign course. The occurrence of symptoms appears not to be dose dependent. Late‐onset symptoms seem to be common. However, all symptoms resolved spontaneously without need of medical care.     

Baclofen and Alcohol‐Dependent Patients: A Real Risk of Severe Self‐Poisoning

Baclofen is often prescribed in high doses to fight cravings experienced by alcohol‐dependent patients. Such an increase in the availability of baclofen is concerning. This study aimed to determine the change in number and profile of self‐poisoning with baclofen over time, as baclofen has become increasingly popular, in order to describe the severity of self‐poisoning with baclofen and to focus on co‐existing alcohol use disorders, and psychiatric illnesses determine predictors of severity. This was a retrospective study of self‐poisoning with baclofen as reported by the western France Poison Control Center (PCC), which represents a population of more than 12 million people from January 2008 to March 2014. One hundred and eleven cases of self‐poisoning with baclofen were reported to the western France PCC (62 males and 49 females; average age 39 ± 12). Poisoning severities were as follows: ‘null’ (nine cases), ‘minor’ (37 cases), ‘moderate’ (19 cases) and ‘high’ (46 cases, including four deaths). The most frequently reported symptoms were neurological (45%) and cardiovascular (27%). The severity was significantly associated with psychiatric disorders (OR = 2.9; p = 0.03). Baclofen, prescribed in high doses, may lead to severe poisoning, particularly in patients with psychiatric illnesses. Authorities should put forward a new policy for prescribing the drug as a treatment for alcohol dependence.     

粤西地区11家职防与疾控机构突发化学中毒应急资源现状调查分析

目的 研究粤西地区突发化学中毒应急资源及应急业务能力的现状.方法 通过调查表对粤西地区市县级的职防与疾控机构共11家机构进行调查和资料收集,进行整理和统计分析.结果 11家职防与疾控机构中,有7家机构(7/11)建立了工作场所监测系统;11家机构平均仅拥有15种装备,其中3种个体防护装备,10种现场采样与保存装备.以及2种快速鉴定装备.结论 广东省粤西地区防与疾控机构在应急队伍建设、个体防护用品配置、实验室装备、应急物资储备、信息网络、预案体系等诸多方面与应急上作需要存在较大的差距,丞待改进.     

粤西地区11家职防与疾控机构突发化学中毒应急资源现状调查分析

目的 研究粤西地区突发化学中毒应急资源及应急业务能力的现状.方法 通过调查表对粤西地区市县级的职防与疾控机构共11家机构进行调查和资料收集,进行整理和统计分析.结果 11家职防与疾控机构中,有7家机构(7/11)建立了工作场所监测系统;11家机构平均仅拥有15种装备,其中3种个体防护装备,10种现场采样与保存装备.以及2种快速鉴定装备.结论 广东省粤西地区防与疾控机构在应急队伍建设、个体防护用品配置、实验室装备、应急物资储备、信息网络、预案体系等诸多方面与应急上作需要存在较大的差距,丞待改进.     

粤西地区11家职防与疾控机构突发化学中毒应急资源现状调查分析

目的 研究粤西地区突发化学中毒应急资源及应急业务能力的现状.方法 通过调查表对粤西地区市县级的职防与疾控机构共11家机构进行调查和资料收集,进行整理和统计分析.结果 11家职防与疾控机构中,有7家机构(7/11)建立了工作场所监测系统;11家机构平均仅拥有15种装备,其中3种个体防护装备,10种现场采样与保存装备.以及2种快速鉴定装备.结论 广东省粤西地区防与疾控机构在应急队伍建设、个体防护用品配置、实验室装备、应急物资储备、信息网络、预案体系等诸多方面与应急上作需要存在较大的差距,丞待改进.     

The clinical picture of olanzapine poisoning with special reference to fluctuating mental status

BACKGROUND: Olanzapine is an atypical antipsychotic drug that is increasingly used in intentional drug overdoses. Although acute olanzapine overdose is predominantly associated with anticholinergic symptoms and central nervous system depression, miosis and unpredictable fluctuations between somnolence/coma and agitation/ aggression have been suggested as typical signs of olanzapine intoxication in single case reports. AIMS: To confirm the suggestion that fluctuating central nervous system changes and miosis are characteristic signs of olanzapine intoxication. To estimate the dose-response relationship as a guide for the provision of optimal management of olanzapine intoxicated patients. METHODS: Retrospective analysis of all well-documented cases of olanzapine intoxication reported to the Swiss Toxicological Information Centre between January 1997 and October 2001. Inclusion criteria for detailed analysis were patient age > or = 16 yr, acute olanzapine monointoxication, ingested dose > 20 mg, and a causal relationship between olanzapine overdose and clinical effects. The Poisoning Severity Score of the European Association of Poison Centres and Clinical Toxicologists (EAPCCT) assessed the intoxication severity. RESULTS: Out of a total of 131 cases of olanzapine overdose, 26 cases fulfilled the inclusion criteria. The ingested olanzapine doses ranged from 30 to 840 mg. The most frequent findings were somnolence (77%), agitation (42%), and miosis (31%). The Poisoning Severity Score was "minor" in 14 (54%), "moderate" in 11 (42%), and "severe" in 1 (4%) patients. Nine patients (35% of all patients) with moderate olanzapine poisoning (120-840 mg) showed unpredictable fluctuations between somnolence and agitation. Five of these patients also demonstrated marked miosis. All patients recovered within 48h. One patient with severe poisoning (560 mg) had coma and convulsions. Moderate (and severe) symptoms occurred only at ingested doses above 120 mg. There was a statistically significant association between increasing ingested olanzapine doses and poisoning severity. CONCLUSIONS: Although olanzapine is tolerated relatively well in acute overdose, unpredictable and transient fluctuations between central nervous system depression and agitation, frequently associated with miosis, appear to be characteristic findings in moderate to high olanzapine overdoses. They are transient in nature and require careful clinical monitoring but rarely require specific therapeutic interventions.     

Inhalation Toxicology of Ricin Preparations: Animal Models,Prophylactic and Therapeutic Approaches to Protection

Ricin is a toxin and seed protein produced by the castor oil plant, Ricinus communis. The toxin is a dimeric protein consisting of an enzymic A chain and a B chain with lectin properties aiding the uptake of the whole molecule into cells. Ricin has been considered a possible military threat for several decades and is now also of some concern as a terrorist agent. The inhalation route is of primary concern in these situations, although previous attacks with ricin have used other approaches. Medical countermeasures against ricin are urgently required and the strategy adopted has been first to understand the nature of the problem, in this case the inhalation toxicology of ricin, followed by the preparation of vaccine antigens. Toxoided ricin and modified recombinant A chain components have been examined in terms of efficacy as potential vaccine candidates in protection of animal models against inhaled ricin, primarily in laboratories both in the United Kingdom and in the United States. One recombinant A chain vaccine has been taken through to clinical trials in the United States and should become commercially available in the next few years. Toxoided ricin has also been used as an antigen to prepare antitoxin antibodies for therapeutic treatment following poisoning. In this review, a synopsis of the inhalation toxicology of ricin and approaches to medical prophylaxis and therapy of poisoning is given, based on work conducted at our laboratory and at other research institutes.     

Inhalation toxicology of ricin preparations: animal models, prophylactic and therapeutic approaches to protection

Ricin is a toxin and seed protein produced by the castor oil plant, Ricinus communis. The toxin is a dimeric protein consisting of an enzymic A chain and a B chain with lectin properties aiding the uptake of the whole molecule into cells. Ricin has been considered a possible military threat for several decades and is now also of some concern as a terrorist agent. The inhalation route is of primary concern in these situations, although previous attacks with ricin have used other approaches. Medical countermeasures against ricin are urgently required and the strategy adopted has been first to understand the nature of the problem, in this case the inhalation toxicology of ricin, followed by the preparation of vaccine antigens. Toxoided ricin and modified recombinant A chain components have been examined in terms of efficacy as potential vaccine candidates in protection of animal models against inhaled ricin, primarily in laboratories both in the United Kingdom and in the United States. One recombinant A chain vaccine has been taken through to clinical trials in the United States and should become commercially available in the next few years. Toxoided ricin has also been used as an antigen to prepare antitoxin antibodies for therapeutic treatment following poisoning. In this review, a synopsis of the inhalation toxicology of ricin and approaches to medical prophylaxis and therapy of poisoning is given, based on work conducted at our laboratory and at other research institutes.     

N‐acetylcysteine in Acute Organophosphorus Pesticide Poisoning: A Randomized,Clinical Trial

Organophosphorus poisoning is a major global health problem with hundreds of thousands of deaths each year. Research interest in N‐acetylcysteine has grown among increasing evidence of the role of oxidative stress in organophosphorus poisoning. We aimed to assess the safety and efficacy of N‐acetylcysteine as an adjuvant treatment in patients with acute organophosphorus poisoning. This was a randomized, controlled, parallel‐group trial on 30 patients suffering from acute organophosphorus poisoning, who were admitted to the Poison Control Center of Tanta University Emergency Hospital, Tanta, Egypt, between April and September 2014. Interventions included oral N‐acetylcysteine (600 mg three times daily for 3 days) as an added treatment to the conventional measures versus only the conventional treatment. Outcome measures included mortality, total dose of atropine administered, duration of hospitalization and the need for ICU admission and/or mechanical ventilation. A total of 46 patients were screened and 30 were randomized. No significant difference was found between both groups regarding demographic characteristics and the nature or severity of baseline clinical manifestations. No major adverse effects to N‐acetylcysteine therapy were reported. Malondialdehyde significantly decreased and reduced glutathione significantly increased only in the NAC‐treated patients. The patients on NAC therapy required less atropine doses than those who received only the conventional treatment; however, the length of hospital stay showed no significant difference between both groups. The study concluded that the use of N‐acetylcysteine as an added treatment was apparently safe, and it reduced atropine requirements in patients with acute organophosphorus pesticide poisoning.     

Clinical toxicology of beta‐blocker overdose in adults

Beta‐blocker overdose is potentially harmful due to the strong blood pressure‐lowering and heart rate‐lowering effects. However, conflicting data exist as to their differential toxicity, single‐substance exposures and the effect of co‐exposure with additional antihypertensive medication. For this, a 10‐year retrospective, explorative analysis of the Mainz Poison Center/Germany database with regard to circumstances of beta‐blocker exposure, doses, symptoms and treatment was carried out. Analyses were restricted to adult patients with single‐substance exposures and co‐exposures with one additional antihypertensive substance. Written follow‐up information was obtained in half the cases. A total of 2967 cases were analysed, of which 697 were single‐substance exposures. Metoprolol was most frequently reported followed by bisoprolol, atenolol, propranolol and sotalol. Metoprolol showed a linear dose‐symptom relationship, whereas propranolol and sotalol seemed to have a threshold dose beyond which symptoms aggravated. Symptoms did not differ substantially, except for more seizures being reported with propranolol, and more CNS depression/vomiting with sotalol. Activated charcoal was used in 38%, gastric lavage in 11%, temporary pacemaker in 3%, glucagon in 1%, intubation for respiratory insufficiency and cardiopulmonary resuscitation in 1% and 0.5%. All patients recovered. In 174 co‐exposure cases, the distribution of poisoning severity and rate of worsening of symptoms was comparable with single‐substance exposures except one patient deceased after bisoprolol and verapamil co‐exposure. In adults with beta‐blocker overdose, no significant differences in poisoning severity among beta‐blockers were detected, and no fatalities were observed with single‐substance exposures. Co‐exposures with other antihypertensives, sedatives or alcohol should be carefully attended to as fatalities might occur.     

Overdoses with Aripiprazole: Signs,Symptoms and Outcome in 239 Exposures Reported to the Danish Poison Information Centre

The aim of this study was to characterize the clinical signs and symptoms of exposures to aripiprazole overdoses. We retrospectively identified all aripiprazole exposures reported to the Danish Poison Information Centre (DPIC) from June 2007 to May 2015. Information concerning demographics, ingested dose and symptoms was extracted from the DPIC database and medical records. Information on death and admission to hospital was obtained from Danish national registers. We analysed 239 cases, 86 concerning single‐drug exposures to aripiprazole, and 153 cases where aripiprazole had been taken with at least one other substance (mixed‐drug). The median ingested aripiprazole dose was 105 mg (IQR: 50‐1680 mg) in the single‐drug exposure group and 120 mg (IQR: 60‐225 mg) in the mixed‐drug exposure group . The most commonly reported symptom was light sedation, reported in 63% of the single‐drug group and 50% of the mixed‐drug exposure group. There were no malignant arrhythmias or ECG abnormalities after single‐drug exposures. No deaths were recorded in relation to the intake. We found a long‐term mortality rate of 13 deaths per 1000 person‐years (95% CI: 7; 23 per 1000 person‐years), which is significantly higher than in an age‐ and gender‐matched background population. In conclusion, we found that aripiprazole overdoses had few and mild symptoms predominantly related to the sedative properties. We detected a benign cardiovascular safety profile and no new safety concerns. Our findings may support an increased threshold of 300 mg for hospital admission after a single‐drug exposure with aripiprazole and symptoms not worse than light sedation.     

Impact of the voluntary withdrawal of over‐the‐counter cough and cold medications on pediatric ingestions reported to poison centers

Purpose

To assess the impact of a voluntary withdrawal of over‐the‐counter cough and cold medications (OTC CCMs) labeled for children under age 2 years on pediatric ingestions reported to the American Association of Poison Control Centers.

Methods

Trend analysis of OTC CCMs ingestions in children under the age 6 years resulting from therapeutic errors or unintentional poisonings for 27 months before (pre‐) and 15 months after (post‐) the October 2007 voluntary withdrawal was conducted. The rates and outcome severity were examined.

Results

The mean annual rate of therapeutic errors involving OTC CCMs post‐withdrawal, in children less than 2‐years of age, 45.2/100 000 (95%CI 30.7–66.6) was 54% of the rate pre‐withdrawal, 83.8/100 000 (95%CI 67.6–104.0). The decrease was statistically significant p < 0.02. In this age group, there was no difference in the frequency of severe outcomes resulting from therapeutic errors post‐withdrawal. There was no significant difference in unintentional poisoning rates post‐withdrawal 82.1/100 000 (66.0–102.2) vs. pre‐withdrawal 98.3/100 000 (84.4–114.3) (p < 0.21) in children less than 2‐years of age. There were no significant reductions in rates of therapeutic errors and unintentional poisonings in children ages 2–5 years, who were not targeted by the withdrawal.

Conclusions

A significant decrease in annual rates of therapeutic errors in children under 2‐years reported to Poison Centers followed the voluntary withdrawal of OTC CCMs for children under age 2‐years. Concerns that withdrawal of pediatric medications would paradoxically increase poisonings from parents giving products intended for older age groups to young children are not supported. Copyright © 2010 John Wiley & Sons, Ltd.     

Severe seafood poisoning in French Polynesia: a retrospective analysis of 129 medical files

We present a retrospective study of 129 medical files concerning seafood poisonings (SFPs) registered at the central hospital of Tahiti (French Polynesia) between 1999 and 2005. Even if during that period most of the described cases (96%) concerned the ichtyosarcotoxism ciguatera, it is interesting to note that we also registered three other SFPs: tetrodotoxism, carchatoxism and lyngbyatoxism due to the consumption of tetraodon/diodon species, sharks or sea turtles, respectively. In ciguatera, cardiovascular symptoms were the primary criteria of severity with bradycardia and hypotension observed at 75% and 43%, respectively. Neurological manifestations (such as cerebellar syndrome, language troubles, diplopia or polyradiculoneuritis), trouble and/or loss of consciousness and dyspnoea were secondary criteria of severity. Body temperature was reported under 36.5 degrees C in 48 of 80 documented files. This observation, which has not previously been described in humans, may be related to possible central effects of the ingested toxin. The last remark concerns two extremely severe cases of ciguatera fish poisoning in which physicians had suspected an inflammatory neuropathy called the Guillain-Barré syndrome (GBS). Even if it is premature to conclude any correlation between the intoxication and the appearance of GBS, it is interesting to note that in both pathologies, morphological disturbances of nerve fibres have been reported.     

Comparative Drug Dose and Drug Combinations in Patients that Present to Hospital Due to Self‐Poisoning

Self‐poisoning is a common reason for acute presentation to hospital. Commonly involved drugs have been reported, but few data exist concerning the different combinations of agents or comparative doses ingested. The present study sought to better characterise the typical patterns of drug overdose that may present via the emergency department. Consecutive adults ≥16 years of age that presented to York Hospital owing to self‐poisoning were studied for 2010–2011 inclusive. The primary outcome measure was reported dose, expressed as a multiple of the defined daily dose (DDD) to allow comparison between different agents. There were 1024 patients, including 622 women (60.7%), and median age was 32 years (range, 16 to 92 years). Overdose in men was associated with a higher overall quantity of drugs: arithmetic mean of 20 DDD multiples (95% CI, 15–26) versus 13 (11–15), p = 0.001. Overdose involved a single agent only in 538 patients (52.5%). The mean paracetamol dose was 4.0 (95% CI, 3.7–4.3) DDD multiples; the doses of antidepressants (19.4, 17.0–21.7, p < 0.0001) and benzodiazepines (18.0, 12.8–23.2, p < 0.0001) were comparatively higher. The types of agents involved in self‐poisoning and common combinations of agents are characterised. Psychotropic medications were ingested in comparatively larger quantities than analgesic agents and had worse clinical outcome. Further work is required to understand the factors that determine the quantity of drug ingested in patients at risk of drug overdose so as to minimise the risk of significant toxicity.     

Pattern and determinants of poisoning in a teaching hospital in Riyadh,Saudi Arabia

Background

The Drug and Poison Information Center (DPIC) at King Khalid University Hospital, Riyadh, Saudi Arabia, was founded in 1983. Since then it has responded adequately to queries from medical and non-medical callers from all over the Kingdom. Queries ranged from simple material identification to poisoning cases.

Objectives

To assess the pattern and circumstances of poisoning in the Kingdom of Saudi Arabia through reviewing data from DPIC in King Khalid University hospitals.

Methods

This is a retrospective study of referred cases and calls received by DPIC. All records and documentation forms during the study period were investigated.

Results

This study included 1161 cases. There were 7.9% infants, 52.9% under 5 years old, 7.2% between 6–12 years old and 32.0% more than 12 years old. Number of males with toxic exposure was almost equal to that of females. More than 92% of cases were toxic exposure through oral route. Causes of poisoning include drugs among 76.7% of cases followed by household chemicals (6.8%). Suicidal intention was reported among 25.6% of cases. Using multivariate regression analysis, significant predictors of suicidal attempts are more than 12 years old, patients who were exposed to more than one toxin and patient who came to the hospital within 1–3 h since poisoning.

Recommendations

Establishing and operating DPIC centers throughout the kingdom, in addition to implementing of legislations to ban over the counter selling of medications and to sell potentially dangerous chemicals in childproof containers.     

Tramadol intoxication: a review of 114 cases

Tramadol as a centrally acting analgesic is extensively used in the management of moderate to severe pain. It slightly affects opioid receptors and inhibits the reuptake of norepinephrin and serotonin in the CNS. There are reports about toxicity and abuse of tramadol. The objective of the present study was to evaluate epidemiology of intentional tramadol intoxications. All poisoning cases that admitted to Loghman-Hakim Hospital Poison Center from April to May 2007 were studied. A total of 114 cases (82 men and 32 women) of intentional tramadol intoxications with the median age of 23.66 +/- 6.87 years (range 16-54 years) were identified. Other illicit drugs were found to be used in combination with tramadol in some of the cases, which among them benzodiazepines were the most common. Tramadol overdose has been one of the most frequent causes of drug poisoning in the country in the recent years, especially in male young adults with history of substance abuse and mental disorders. Nausea, vomiting, Central Nervous System (CNS) depression, tachycardia, and seizure are the most common findings in this kind of poisoning. Cardiopulmonary arrest was found as the cause of death in cases who had ingested more than 5000 mg tramadol.