Questions: Management of Xylazine toxicity, overdose, dependence and withdrawal: a systematic review

A 29-year-old man with a history of opioid use disorder and recent fentanyl misuse presents after being found unconscious at the subway. According to EMS, he was cyanotic with shallow respirations, 4 breaths/min, and a pulse of 38 bpm. Naloxone 4 mg intranasal was administered twice with only partial improvement in respiratory rate, but the patient remained lethargic, with bradycardia and persistent hypotension. In the emergency, EKG shows sinus bradycardia.

What is the next best step in management?

What is the primary mechanism of action of xylazine?

What is the primary concern when xylazine is combined with opioids such as fentanyl as presented in the case in question 1?

Which of the following clinical signs and symptoms is most commonly seen in xylazine toxicity such as the patient in the case presented in question 1?

A 32-year-old woman presents to the ER with xylazine toxicity and a heart rate of 45 bpm. In the management of bradycardia associated with xylazine toxicity, which pharmacologic agent has been shown in the literature to be effective?

Which of the following interventions should be prioritized for a patient with suspected xylazine intoxication?