Ultracet is a combination pain relief medication consisting of tramadol hydrochloride and acetaminophen (Tylenol). Tramadol is a centrally acting opioid agonist that is prescribed to patients experiencing moderate to severe pain. Acetaminophen is a mild over-the-counter pain reliever that reduces fever and is proven to enhance the pain-relieving effects of Tramadol.
Tramadol is an addictive substance that has a high overdose potential, especially when mixed with acetaminophen. Due to the high risk of complications, the minimum effective dose of Ultracet should be administered. Ultracet should only be taken in short duration. Ultracet is not indicated for the treatment of chronic pain. The primary risk factor of prolonged Ultracet treatment is liver toxicity.
Ultracet should not be taken concurrently with other central nervous system depressants. These include other opioids, tranquilizers, anticonvulsants, benzodiazepines, non-benzodiazepine sedative/hypnotics, muscle relaxants, and alcohol. The concomitant consumption of these medications can lead to potentially life-threatening respiratory depression.
Ultracet should not be mixed with serotonergic drugs such as those recommended to treat depression. The combined use of Ultracet with selective serotonin reuptake inhibitors (SSRIs) and tricyclics can lead to a dangerous condition of serotonin overload called serotonin syndrome. Serotonin syndrome can lead to irreversible psychosis and death if left untreated.
The acute effects of tramadol typically present life-threatening complications long before those of acetaminophen. Acetaminophen overdose is typically drawn out over the course of several days of painful illness before death occurs. The initial symptoms of acetaminophen overdose include nausea, vomiting, pain in the area of the liver and excessive sweating. If left untreated, the process of dying can take anywhere between a few days to several weeks.
The effects of an Ultracet overdose can take effect within hours. Ultracet is a powerful central nervous system depressant, so it makes sense that the clear sign of an overdose from this medication is severe respiratory depression. Roughly speaking, Ultracet is as potent as codeine and is approximately one-tenth as powerful as morphine.
Ultracet acts directly on the brainstem. The brainstem controls the autonomic urge to breathe by triggering respiration when carbon dioxide levels in the blood become elevated. High doses of Ultracet suppress this mechanism, potentially leading to carbon dioxide toxicity and hypoxia (oxygen deprivation).
Pinpoint pupils and severely decreased levels of consciousness are the other two primary signs of opioid overdose. Together, they make what is called the “opioid overdose triad.” Pupils become maximally constricted and unresponsive even to light. As the patient deteriorates due to oxygen deprivation, the pupils will eventually become fully dilated.
Severely decreased level of consciousness is defined as extreme lethargy that quickly progresses to stupor and coma. Other adverse effects of Ultracet overdose can include a weak pulse, peeling skin rash, seizures, hallucinations, agitation, rapid heart rate, diarrhea, fainting, poor coordination, nausea, and vomiting.
Ultracet comes in oral tablets containing 37.5 mg of tramadol and 325 mg of acetaminophen. 325 mg is the maximum single dosage of acetaminophen allowed by the Federal Drug Administration (FDA). Ultracet should not be taken for more than five days in a row. The initial dose of Ultracet should not exceed two tablets every four to six hours as needed for pain relief. Patients should not take more than eight tablets of Ultracet per day.
The amount of Ultracet necessary to overdose will vary between patients. Factors that influence the likelihood of overdose include the patient’s age, weight, overall physical health, genetic tendencies, kidney and liver function, and opioid tolerance. Patients with impaired kidney function should not exceed two tablets every 12 hours. Individuals with impaired liver function may also require reduced doses due to the increased likelihood of liver complications.
In the event of an Ultracet overdose, the priorities will be to support the patient’s breathing with either assisted or controlled ventilation. If the patient is unconscious they may require the placement of an endotracheal tube to ensure that the airway does not become obstructed. A bag-valve mask may be used to assist ventilation if the patient remains conscious.
Other supportive measures, including oxygen therapy and vasopressors, may be necessary to manage pulmonary edema and cardiovascular depression.
Naloxone will need to be administered if clinically significant respiratory depression is present. Naloxone is a rapid-onset opioid antagonist that can fully negate the effects of tramadol within seconds when administered intravenously.
To address acetaminophen toxicity, N-acetylcysteine (NAC) should be administered as early as possible. Activated charcoal should be administered within the first few hours to decontaminate the digestive tract.
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