Naloxone non-responder and tramadol variant

Naloxone non-response: exclude hypoglycaemia; consider clonidine (Seger: naloxone awoke 40 of 51 somnolent paediatric patients; 10 mg boluses caused no adverse events in 20 bradycardic children), pontine haemorrhage (will not reverse), co-ingestants, or a high-potency synthetic needing more than a single reversal — reassess pupils for asymmetry and image if atypical.^[5]

Tramadol: Ryan (71 overdoses): 8 seizures, 0 Hunter serotonin toxicity — seizures and respiratory depression dominate, and tramadol alone is unlikely to cause serotonin toxicity. Treat seizures with benzodiazepines; naloxone only if there is opioid-mediated respiratory depression. Chronic high-dose tramadol can meet Hunter criteria (van Gemert case).^[6][2]