12-phase flow (10)

1. 1FRAME
   Clonidine withdrawal crisis = abrupt cessation of central α2-agonist → rebound NE release surge from removal of presynaptic α2-mediated inhibition → severe HTN + tachy + diaphoresis + tremor + agitation 18-72 h after last dose. Pharmacology pivot: RESUME CLONIDINE (oral 0.1-0.3 mg load + transdermal Catapres-TTS-3 patch 0.3 mg/24h max for sustained); IV labetalol bridge (mixed α/β SAFE here because resumed α2-agonist restores central inhibition — different from pure cocaine pharmacology); phentolamine IV for severe. AVOID isolated β-blocker (unopposed alpha — same principle as cocaine + pheo). Route to parent engine for shared HTN-emergency arc; this dossier owns the rebound-specific pharmacology + perioperative + adherence prevention.
   inputs: sbp, dbp, heart_rate, clonidine_or_alpha2_agonist_med_history, cessation_timing_and_reason
   advance: clonidine withdrawal etiology confirmed by history (med + cessation timing 18-72 h)
2. 2ENTRY
   Recognize rebound toxidrome (HTN + tachy + diaphoresis + tremor + agitation + headache + insomnia 18-72 h post cessation); ECG within 10 min if chest pain; resume clonidine PO or transdermal immediately
   inputs: age, sbp, tremor_and_agitation_assessment
   advance: IV access + cardiac monitor + clonidine PO loading dose given OR transdermal patch placed
3. 3CONTEXT
   Clonidine medication details (dose, frequency, duration, oral vs transdermal); cessation timing (last dose, reason — NPO/refill/transdermal failure/deliberate); concurrent β-blocker (raises rebound risk); other antihypertensives (drug list reconciliation); comorbidities (CKD affects clonidine dose; OR scheduled?); medication adherence history; patient education history (was taper instructed?)
   inputs: age
   advance: comprehensive med rec + cessation reason identified + concurrent β-blocker noted
4. 4RED_FLAGS
   ICH (severe rebound HTN can cause ICH in elderly); aortic dissection (severe HTN risk factor); MI (NE surge demand ischemia in elderly with CAD); concurrent β-blocker exposure (worsens rebound by leaving alpha-vasoconstriction unopposed); recurrent withdrawal events (suggests systemic adherence failure — needs multidisciplinary intervention); post-op missed dose during NPO scheduled surgery (preventable — needs perioperative protocol); transdermal patch failure (detached/removed/expired)
   inputs: sbp, temperature, neurologic_exam
   actions: htn_emergency
   advance: RED flags screened + life-threats addressed + ICH/dissection/MI ruled in/out
5. 5INITIAL_WORKUP
   ECG (QTc, ischemia, demand strain); troponin (q3-6h × 2 if chest pain or elderly with CAD); CBC + BMP + Mg; CT head non-con (exclude ICH given severe headache + HTN); CTA chest if dissection concern (back pain, BP differential); CXR (pulmonary edema if acute LV strain); medication-list reconciliation (look for concurrent β-blocker that worsens rebound)
   inputs: ecg_12_lead, troponin, creatinine, neurologic_exam
   actions: panel.cardiac, panel.renal
   advance: workup documented + ICH/dissection/MI ruled in/out + medication reconciliation done
6. 6BRANCHING_WORKUP
   If ICH → AHA/ASA 2022 ICH pathway + IV nicardipine target SBP 130-140 + resume clonidine; if dissection → CTA + emergency CT surgery + parent aortic-dissection HTN engine; if MI → cardiology + ACS pathway (IV labetalol acceptable here unlike cocaine because resumed α2-agonist restores central inhibition); if perioperative scheduled OR pending → resume clonidine via transdermal patch peri-op (Garbus Anesthesiology 1979)
   advance: syndrome-specific pathway activated if needed
7. 7TREATMENT
   STEP 1 — RESUME CLONIDINE: oral 0.1-0.3 mg PO loading dose, then 0.1-0.2 mg PO q6-8h titrate (or restart at home dose); for sustained release, place transdermal Catapres-TTS-3 patch (0.3 mg/24h × 7 d, MAX 0.3 mg/24h to avoid overshoot) — onset 2-3 d (depot effect — bridge with PO during wait). STEP 2 — IV labetalol 10-20 mg IV q10 min titrate to SBP <160 (mixed α/β SAFE here because resumed α2-agonist restores central inhibition; different from pure cocaine pharmacology where labetalol controversial). STEP 3 — Phentolamine 1-5 mg IV q5-15 min if severe rebound or labetalol insufficient (alpha-blockade). STEP 4 — Nitroglycerin IV (5-200 mcg/min titrate) as alternative or adjunct. STEP 5 — Benzodiazepine for symptomatic relief of tremor + agitation + insomnia (lorazepam 0.5-1 mg IV q4-6h). AVOID isolated β-blocker without α-blockade restoration (same unopposed-alpha principle as cocaine + pheo). Counseling: future taper over 7-14 d if discontinuing clonidine.
   inputs: sbp, dbp, heart_rate
   advance: clonidine resumed (PO + transdermal) + BP at target SBP <160 + symptoms improving
8. 8DISPOSITION
   ICU / step-down for q15 min BP + telemetry minimum 12-24 h; observe for transdermal patch onset (2-3 d depot effect); ensure outpatient supply secured before d/c; patient education on adherence + missed-dose protocol + warning sign card
   advance: monitored bed assigned + 24-h observation plan + outpatient clonidine supply confirmed
9. 9MONITORING
   Continuous ECG + telemetry; q15-30 min BP; serial troponin q3-6h × 2 if elderly or CAD; serial neuro exam q2h × 12 h; tremor + agitation assessment; UOP
   inputs: sbp, heart_rate
   actions: panel.cardiac
   advance: BP at target + no organ damage + symptoms resolved + clonidine onset confirmed (PO active or transdermal at steady state)
10. 10FOLLOWUP
    CRITICAL ADHERENCE COUNSELING + medication-card warning ("Do not stop clonidine abruptly — taper over 7-14 d if discontinuing"); MEDICALERT BRACELET if recurrent events; if patient continues clonidine — establish reliable refill system + advance-supply (90-day fill); if patient discontinuing clonidine — gradual taper over 7-14 d (e.g., 0.3 mg → 0.2 mg × 3 d → 0.1 mg × 3 d → 0.05 mg × 3 d → off); PERIOPERATIVE PROTOCOL — continue clonidine perioperatively OR convert to transdermal Catapres-TTS-3 patch 24-48 h pre-op (Garbus Anesthesiology 1979); transition to alternative HTN regimen with appropriate titration if discontinuing (e.g., introduce ACEi/ARB + CCB before clonidine taper); psychiatric/substance use evaluation if recurrent events suggest deeper issue; PCP + cardiology follow-up within 1-2 weeks
    advance: taper plan documented OR continuation supply secured + medication-card issued + perioperative protocol noted + 1-2 wk follow-up booked