Increased rate of seizures and respiratory complications due to tramadol poisoning have been observed, even with first time of tramadol intake. So, the present work was used to investigate the clinical manifestations and laboratory investigations of acute tramadol toxicity and the correlation between toxic tramadol manifestations and blood tramadol level and laboratory parameters. A study was performed on 100 patients (80 males and 20 females) acutely intoxicated with tramadol, admitted to toxicology unit of Al-Azhar University Hospital (New Damietta) in the period from January to December 2017. Informed consent, urine sample was collected and 10 mL of blood was separated and used for extraction of tramadol residues by using a high-performance liquid chromatography (HPLC) and other blood samples were stored at-8°C for routine investigations. Then a detailed clinical examination was done to all patients. Generally, the frequency of seizures was (46 %) with acute tramadol poisoning. There was no correlation between blood tramadol level and toxic manifestations of tramadol poisoning. So, the frequency of seizures and toxic manifestations are not dosed dependent. Cannabis was the most common co-ingested drugs and adult males were more commonly affected by tramadol poisoning. It is recommended that the drug abuse problem must be treated at the level of community problems in order to minimize medical emergencies related to acute tramadol overdose occurring mostly by addiction and further studies should be proposed to extend our knowledge about relationships between sex and seizures among tramadol intoxicated patients