IV Contrast and Lorazepam Shortages

Iodinated contrast shortage changes emergency imaging, but it does not erase diagnostic rigor: some abdominal CT indications remain accurate without contrast, while PE, mesenteric ischemia, and any angiographic question do not. Lorazepam shortage matters less clinically than many assume because seizures, alcohol withdrawal, and agitation all have workable alternatives.

IV Contrast Shortage Imaging

• Noncontrast abdominal CT utility: Noncontrast CT remains highly useful for appendicitis, bowel obstruction, diverticulitis, and necrotizing fasciitis, with one appendicitis study suggesting adequate performance in patients with BMI above 23.
• Contrast essential indications: Contrast-enhanced CT remains the standard for mesenteric ischemia and any angiographic question; a noncontrast scan should not be used as a substitute when vascular pathology is the target.
• Pulmonary embolism workup: PE evaluation should start with Wells, PERC, and d-dimer in lower-risk patients because noncontrast chest CT has poor sensitivity, and high-risk patients still need CT pulmonary angiography.
• AAA and spinal infection: Suspected AAA is better served by bedside ultrasound plus early vascular surgery involvement, while spinal epidural abscess should push you toward MRI rather than a compromised CT pathway.
• Medicolegal documentation language: Shortage-era charting should explicitly note the global iodinated contrast shortage, ACR-guided alternative imaging, and that the changed diagnostic pathway was discussed with the patient. The bedside macro is worth hearing in the episode.

Lorazepam Shortage Workarounds

• Seizure treatment substitutes: For active seizures, midazolam and diazepam are reasonable substitutes because benzodiazepine efficacy is not unique to lorazepam in this setting.
• Alcohol withdrawal choice: Lorazepam is not the preferred benzodiazepine for alcohol withdrawal, and phenobarbital is another strong option when usual pathways are disrupted.
• IV onset differences: By IV route, diazepam has the fastest onset at roughly 0 to 1 minute, ahead of lorazepam at 2 to 3 minutes and midazolam at 2 to 5 minutes.
• IM onset tradeoffs: By IM route, midazolam is the practical fastest option at about 15 minutes, while diazepam is unreliable because intramuscular absorption is variable.
• Single-dose duration nuance: Diazepam's single-dose clinical effect can fade in about 20 minutes despite its long half-life, a pharmacokinetic mismatch with practical implications we get into in the episode.
• Agitation alternatives: For acute agitation, ketamine, olanzapine, and haloperidol are viable non-lorazepam options when benzodiazepine supply is constrained.

References:

1. ACR. Statement from the ACR Committee on Drugs and Contrast Media. Published May 06, 2022. Link.
2. ASHP. Considerations for Imaging Contrast Shortage Management and Conservation. Published May 13, 2022. Link.