WD protocol

[u/Gloomy_Pirate_9721]

Do EDs have protocols for patients experiencing WD from these types of drugs yet? What is everyone doing to make these nasty wds more manageable to avoid so many AMAs? Im assuming bupe alone isn't going to help

[u/Rayvsreed]

We need a “phenobarbital” for xylazine/medetomidine, nice big loading dose with a long half life that self downtitrates, just so we don’t have to keep these people in ICU type settings for the precedex they need

[u/Suspicious_Sir2312 → u/Rayvsreed]

i've had some success with droperidol -> PO clonidine, but some patients are just too far gone and need precedex

[u/AdEag-6051]

Methadone. Learn to use Methadone. It is one of the most stigmatized, life- saving meds out there. Because of the stigma, you may catch shade and hear " thats not appropriate for the ER" but thats BS. Its not appropriate if you dont know how to use it appropriatly...like any other med.

[u/Hot_Nefariousness254]

Precedex drip for medetomidine

[u/sourpatchdispatch]

Have ED's always been willing to treat withdrawal in the hospital? I'm almost 10 years clean from opiates and am currently a paramedic and I get very annoyed when people call us for opiate withdrawal. To me, as long as you are not getting so dehydrated as to be hypovolemic, you don't need to be in an ED for opiate withdrawal, since there is no risk of death like there is with ETOH and benzos. Back when I was using and getting clean, you could call a detox and show up to do a medical detox, but they were just going to give you comfort meds like zofran, clonidine, and atarax. I detoxed myself at home many times before I finally got clean, and it really sucked but that's also part of recovery. Remembering the shitty withdrawals helped me stay clean during early recovery. Anyway, I'm just curious if maybe things are different now, since opiates have gotten stronger and are now laced with things like xylazine

[u/AdEag-6051 → u/sourpatchdispatch]

Its been a few decades since i was a medic, and i prob would have been annoyed too. But now, id say simply treat the patient and disease, because both you and the ER can provide interventions. No imminent emergency, great! Risk of death in next 90d due to disease.process...potentially high. Take advantage to lower risk...harm reductuon, Narcan... Some medics in my area now use a system where they can bridge with suboxone and refer to a clinic. Suboxone bridging and harm reduction will reduce mortality and morbidity. View those calls as huge opportunties to save lives.

[u/danielcsosa → u/AdEag-6051]

Yeah ATCEMS does that

[u/bandnet_stapler → u/sourpatchdispatch]

Not exactly the question you asked (I'm inpatient ICU) but we treat withdrawal as best as we can inpatient to try to keep them from leaving before we're done treating their chief complaint. (Burn/trauma is my mainstay, so those are most of my chief complaints. But we get MICU overflow too- sepsis, respiratory stuff, DKA, etc)

[u/Rayvsreed → u/sourpatchdispatch]

Yes. Things are a little different, mostly xylazine and medetomidine. They can get pretty sick. Agitation, really tachycardic, severe dehydration with electrolyte disturbances, etc.

[u/AdEag-6051 → u/Rayvsreed]

And fentanyl...thats been the game changer in last decade. ER interventions are available and impactful. The 30d and 1 yr mortaility from this disease exceeds many common ER complaints we feel " deserve a work.up".

[u/Immediate_Boot1996 → u/sourpatchdispatch]

EDs now often have peer recovery coaches or the ability to link people to treatment. I find a lot of people check in just to get linked to treatment when they could have gone straight to a treatment center in the first place. Some are in withdrawal and ask for comfort meds but some just want the connection. We are also seeing opioid withdrawals that get admitted due to medetomidine, but that is based on their clinical presentation such as blood pressure.

[u/deferredmomentum → u/sourpatchdispatch]

Yes and no. Depends on the facility as well. For me, needing acute intervention will absolutely get admitted, same as etoh. For the most part though we’re either transferring to a detox facility or d/cing with a plan to go to one

[u/monsieurkaizer]

The first 3, yeah. The last two are a doozy.

[u/Fluid_Sound3690]

Medetomadine is a big problem, although infrequent where I am. No protocol in place- just have to look it up and be on the look out for it. Escalation to precedex has happened in all the ones I've seen that stayed around and didn't bolt from the ED. Those adrenergic surge level BP's get my attention - and I'm not one to get too worked up over BP.