Case Report: Acute Polysubstance Overdose in a 27-Year-Old Male with a History of Depression

Case at a Glance

A 27-year-old male with a BMI of 42.3 and a known history of major depressive disorder, substance use disorder, and prior suicide attempts presented to the emergency department following an intentional overdose on tramadol, clonazepam, alprazolam, and ethanol.

Patient's Story

The patient is a 27-year-old male with a significant psychiatric history including severe depression and substance addiction. He has made two documented suicide attempts in the past. He was discovered by his partner at their residence, unresponsive on the bathroom floor. Evidence at the scene suggested a large, intentional ingestion of multiple substances.

Initial Assessment

The patient was found approximately two hours after the presumed time of ingestion. His partner discovered empty containers for tramadol (estimated 3000 mg), clonazepam (80 mg), and alprazolam (60 mg), along with an empty bottle of wine. On initial discovery, the patient was described as having slow, shallow breathing and a weak, thready pulse. There was no evidence of emesis. Emergency Medical Services were immediately contacted for transport to the hospital.

The Diagnostic Journey

Upon arrival of paramedics, the patient was found with a profoundly decreased level of consciousness, significant respiratory depression, and bradycardia. In the Emergency Department, he remained unresponsive to verbal or painful stimuli. Given the combination of an opioid (tramadol) and high doses of benzodiazepines, the primary concerns were severe central nervous system (CNS) and respiratory depression, as well as the risk of seizures from the tramadol. A toxicology screen was ordered to confirm the ingested substances. An electrocardiogram (ECG) was performed to assess for cardiac abnormalities, such as QTc prolongation, which can be associated with tramadol toxicity.

Final Diagnosis

1. Intentional Polysubstance Overdose (Tramadol, Clonazepam, Alprazolam, Ethanol)
2. Acute Respiratory Failure secondary to CNS Depression
3. Altered Mental Status
4. Major Depressive Disorder, Severe, Recurrent
5. Substance Use Disorder

Treatment Plan

The patient required immediate airway management and was intubated and placed on mechanical ventilation to manage his acute respiratory failure. He was admitted to the Intensive Care Unit (ICU) for continuous cardiorespiratory monitoring and supportive care. While naloxone is the reversal agent for opioids, and flumazenil for benzodiazepines, the use of flumazenil was contraindicated due to the high risk of precipitating seizures in the context of a mixed overdose, particularly with a seizure-inducing agent like tramadol. Treatment was focused on supportive measures, allowing the substances to be metabolized while protecting his airway and vital functions. Once medically stable and weaned from mechanical ventilation, a comprehensive psychiatric consultation was initiated.

Outcome and Follow-up

After several days in the ICU, the patient's respiratory status improved, and he was successfully extubated. He regained consciousness and was deemed medically stable for transfer. He was then admitted to an inpatient psychiatric facility for intensive treatment of his underlying depression, management of his suicide risk, and to begin a structured substance abuse rehabilitation program. The long-term plan includes ongoing psychotherapy, medication management for his mood disorder, and participation in addiction support groups upon discharge.