Benzodiazepines

Benzo dosing and pharmacology has always been confusing to me. Here are some tidbits and pearls that stick with me:

Our very own fabulous Dr. Reuben Strayer’s IV to IM conversion of commonly utilized benzodiazepines. As he notes as well, conversions are more of an art than a science.

PO conversion: 1 mg lorazepam = 10 mg diazepam = 25mg chlordiazepoxide (librium)

Short acting: midazolam, alprazolam/xanax

Medium acting: lorazepam, clonazepam/klonopin

Long acting: diazepam, librium  

IM midazolam, not IM lorazepam. Lorazepam’s intramuscular absorption is erratic/slower and it is longer acting than versed.  

Lorazepam is not a code white medication.  

10mg IM midazolam -> this patient goes to resus at least initially. This is an increasingly common dose for someone to receive by pre-hospital.  

Be wary of ETOH + benzos, these are extremely high risk patients.

The treatment of severe ETOH withdrawl/DT's requires probably an uncomfortable amount of benzos.

Prescription Drug Prices

Prescription drug prices are highly variable and out of control in the United States. Often times, we will find ourselves telling a patient they should see their PMD and take all their medications, or we’ll be prescribing a medication for a newly diagnosed chronic condition. Whether or not our patients follow our advice is dependent on dozens of socioeconomic factors, but one of those is the price of prescription medications.

I was curious about the prices our patients face for some of the common medications we often send them home with or expect them sometimes for the rest of their lives. Of course, insurance is a whole other issue, but these are just some of the upfront costs that particularly our most vulnerable and socioeconomically destitute patients may face:

*prices listed are the lowest price at a pharmacy within 5 miles of the hospital

Albuterol HFA inhaler, $22.14

Amlodipine 5mg, 30 tabs, $5.20

Amoxicillin 400mg/5mL, 100mL bottle, $9.45

Atorvastatin 10, 30 tabs, $6.27

Azithromycin 250, Z pack with 6 tablets, $9.49

Cephalexin 500mg, 30 tabs, $10.86

Ciprofloxacin 500mg, 20 tabs, $17.42

Clopidogrel 75mg, 30 tabs, $6.60

Doxycycline 100mg, 30 tabs, $19.46

Divalproex 500mg, 30 tabs, $14.41

Furosemide 40mg, 30 tabs, $5.10

Gabapentin 300mg, 30 tabs, $6.07

HCTZ 12.5, 30 tabs, $5.58

Ibuprofen 400mg, 30 tabs, $6.65

Levothyroxine 50mcg, 30 tabs, $10.72

Lisinopril 20mg, 30 tabs, $4.99

Metformin 500mg 30 tabs, $4.99

Nitrofurantoin 100mg, 14 tabs, $18.64

Omeprazole 20mg, 30 tabs, $7.47

Prednisone 10mg, 21 tabs, $14.29

Tamsulosin 0.4mg, 30 tabs, $7.77

Drug prices are extremely hard to track down. For instance, the NYS DOH website for searching drug prices hasn’t updated their list of prices for our MMC Pharmacy since 2013.

Our wonderful ED pharmacist Ankit Gohel also pointed out to me that you can look up the average wholesale price of any medication on uptodate in the ‘price’ section.

The Epocrates app will also list average retail prices.

Hope this can be some food for thought.

Source: www.communitycaresrx.com

https://apps.health.ny.gov/pdpw/SearchDrugs/Home.action

https://www.goodrx.com/

Sengstaken-Blakemore for Massive Variceal Bleed

At the request of some of the residents and in light of the case this morning, here’s a review on the Blakemore device for massive variceal bleeding. It can also be used for gastric lavage of acute toxic ingestions for which there is no antidote.

Procedure:

This very well done video on EM:RAP probably describes the procedure better than text:

https://www.youtube.com/watch?v=NHelCd5Jtp4

-Almost all patients will require endotracheal intubation to avoid aspiration.

-All patients require appropriate sedation as you’re passing a giant tube and keeping it there.

-Place in left lateral decubitus if possible to decrease gastric emptying/regurgitation.

-Check the balloons for leaks before starting

-Pass tube and inflate gastric balloon, it can hold 250 cc’s of air! Get an x-ray to confirm it is in the right place.

-For variceal bleeds, the esophageal balloon should be inflated to about 30mm of mercury pressure. The purpose of the additional OG tube/salem sump in the video is to check for continued bleeding. If there is continued bleeding, the esophageal ballon can be inflated up to 45mm of pressure.

-Through the stomach tube, aspirate all air, water, and blood as subsequent sampling will be an index of the effectiveness of hemorrhage control

-Finally, secure the Blakemore using the method described in the video with kerlex and an IV pole. In our cabinet, we also have a football helmet, see attached image. The concept is the same, to provide enough tension so the Blakemore stays in place.

-Irrigate and aspirate the tube every 30 minutes with 50cc’s of warm water to monitor for worsening bleeding.