Cardiogenic shock due to acute tramadol intoxication Elodie Perdreau • Xavier Iriart • Jean-Baptiste Mouton • Zakaria Jalal • Jean-Benoı ˆt Thambo Ó Springer Science+Business Media New York 2014 Abstract Tramadol is a common analgesic, widely pre- scribed because of its efficiency and safety. We report the case of a 7-year-old child admitted in cardiac intensive care unit for cardiogenic shock due to tramadol intoxication. Without any past history, the child was admitted at emer- gency room for generalised convulsion, followed by respiratory distress. Cardiogenic shock was suspected after clinical examination and chest X-ray and confirmed by transthoracic echocardiography showing low left ventric- ular ejection fraction ( \ 30 %) with pulmonary hyperten- sion. No evidence of cardiac infarction or myocarditis was found. Tramadol intoxication was suspected because of empty tramadol tablets found near the child and later confirmed by toxicologic analysis showing high blood concentration of tramadol ( [ 1 mg/L) and O-desmethyl- tramadol ( [ 1.5 mg/L). Hemodynamic support by inotropic drug infusion and diuretics was necessary. Left ventricular function normalised after 2 days of treatment allowing drug infusion weaning. Cardiac magnetic resonance imaging performed 3 days after admission confirmed nor- mal left ventricular ejection fraction and volumes without evidence of late gadolinium enhancement. Cardiogenic shock due to tramadol intoxication is rare but exists. Negative inotropic effect of high doses of tramadol has been suspected. Quick recovery is possible. Keywords Heart Á Cardiac support Á Analgesics Á Cardiovascular toxicity Introduction Tramadol is a centrally acting analgesic commonly used in the treatment of moderate-to-severe pain, in the post- operative period and in chronic pain syndrome [1, 2]. It has a low affinity to l-opioid receptors and inhibits the reup- take of serotonin and norepinephrine neurotransmitters [1, 2]. The desmethyltramadol is its active metabolite. Because of its limited potential abuse, it has been prescribed extensively [3]. Several lethal cases related to tramadol intoxication alone or in association with benzodiazepine have been previously described [4, 5]. We report the case of a 7-year-old child admitted at cardiac intensive care unit for cardiogenic shock due to tramadol intoxication. Case report Without past history, a 7-year-old child was admitted to emergency room for generalised seizure and respiratory distress requiring intubation. The initial clinical examina- tion found signs of acute pulmonary oedema with pink, frothy sputum and crackles on pulmonary auscultation associated with hepatomegalia, low blood pressure (sys- tolic pressure 71 mmHg, diastolic pressure 36 mmHg, mean pressure 50 mmHg), tachycardia (140 bpm) and oxygen dependence to maintain good saturation. Temper- ature was normal. The chest X-ray supported the diagnosis of cardiogenic shock showing diffuse bilateral alveolar opacities radiated from hila to sides with thickening of the minor fissure, which was consistent with the presence of acute pulmonary oedema. The electrocardiogram was in sinus rhythm, without signs of ischaemia. The initial echocardiography (Fig. 1) showed severely impaired left E. Perdreau (&) Á X. Iriart Á J.-B. Mouton Á Z. Jalal Á J.-B. Thambo Service de Cardiologie Conge ´nitale et Pe ´diatrique, Ho ˆpital du Haut-Le ´ve ˆque, CHU Bordeaux, Avenue de Magellan, 33604 Pessac, France e-mail: elop85@yahoo.fr 123 Cardiovasc Toxicol DOI 10.1007/s12012-014-9262-2