Bedside calculators

The scores that change your order.

A focused toolbox of the clinical scores most relevant to inpatient medication order entry. Each one is live, deterministic, and shows you exactly what to do with the result — not just the number.

Creatinine clearance (Cockcroft-Gault)

Estimates renal function for renally-cleared drug dosing. Uses actual body weight unless obese (use IBW or ABW).

Age (years)

Sex

Weight (kg)

Serum creatinine (mg/dL)

CrCl

—

Affects orders

Renal-dose vancomycin, DOACs (apixaban, rivaroxaban, dabigatran), enoxaparin, gabapentin, opioids (esp. morphine, tramadol), and many antibiotics whenever CrCl < 60.

Ideal & adjusted body weight

Devine formula. Used for aminoglycosides, neuromuscular blockade, opioid PCA basal, vancomycin (ABW if obese).

Sex

Height (in)

Actual weight (kg)

for ABW only

IBW

—

ABW

—

Affects orders

Use IBW for aminoglycoside loading and neuromuscular blockers. Use ABW for vancomycin and enoxaparin when actual > 1.2× IBW.

BMI

Body mass index — context for dosing decisions and VTE-prophylaxis selection.

Weight (kg)

Height (cm)

BMI

—

Affects orders

VTE prophylaxis: enoxaparin 40 mg SC daily if BMI < 40; consider 40 mg BID or 0.5 mg/kg if BMI ≥ 40.

Corrected calcium

Albumin-corrected calcium. Required when albumin is abnormal — otherwise the total Ca underestimates ionized Ca.

Total Ca (mg/dL)

Albumin (g/dL)

Corrected Ca

—

Affects orders

If symptomatic hypocalcemia: IV calcium gluconate 1–2 g (each amp = 1 g) over 10 min, then infusion. If hypercalcemia > 14 or symptomatic: IV NS 200–300 mL/hr + calcitonin / bisphosphonate.

Anion gap

Na − (Cl + HCO₃). Optional albumin correction. Elevated AG = MUDPILES workup.

HCO₃

Alb (opt)

Anion gap

—

Albumin-corrected

—

Affects orders

High AG → start IV fluids (LR or NS), consider source-specific Rx (insulin + dextrose for DKA, fomepizole for toxic alcohol, dialysis for severe / refractory).

Morphine milligram equivalents (MME / day)

CDC opioid-prescribing conversion. Use when titrating, switching opioids, or co-prescribing benzodiazepines.

Opioid

Dose each (mg)

Doses / day

Morphine PO · factor 1 — Baseline for the MME scale (factor 1.0).

MME / day

—

Affects orders

≥ 50 MME/day → document risk + offer naloxone. ≥ 90 MME/day → avoid in opioid-naïve; require risk-mitigation plan. Avoid co-prescribing benzodiazepines at any MME.

Steroid conversion (glucocorticoid equivalence)

Convert a systemic corticosteroid dose to an equipotent dose of another. Anti-inflammatory equivalence only — does not adjust for mineralocorticoid effect or duration.

From drug

Dose (mg)

Prednisone · Intermediate (18–36 h) · mineralo: Minor · PO — Pro-drug — activated to prednisolone by the liver. Give prednisolone in hepatic failure.

Affects orders

Taper before stopping if the patient has been on > 20 mg prednisone-equivalent per day for > 2–3 weeks (HPA-axis suppression). Stress-dose for major surgery, sepsis, or trauma in chronic steroid users: hydrocortisone 100 mg IV load then 50 mg IV q6h. Give PPI + calcium/vit D + DVT prophylaxis for prolonged high-dose courses.

Steroid taper planner

Enter the current dose + exposure duration. Get a day-by-day pred-equivalent taper with the same dose in your chosen drug and a printable pocket-card for the patient.

Current drug

Current dose (mg)

Exposure duration

Moderate (1–3 mo) — Standard weekly taper — most inpatient discharges after 1–3 mo pred-equivalent exposure.

Affects orders

Never taper too fast in chronic users. HPA-axis suppression persists up to 6–12 months after stopping. Watch for adrenal-insufficiency symptoms: fatigue, N/V, orthostasis, hypoglycemia. Stress-dose hydrocortisone (100 mg IV load then 50 mg IV q6h) for surgery, sepsis, or trauma during and up to 12 months after any taper. Consider AM cortisol below 5 mg prednisone-equivalent — if < 5 μg/dL, continue physiologic replacement and endocrine consult.

RxFlow Review · Steroid taper plan

Educational — verify against institutional protocol + patient factors before signing.

Starting drug: Prednisone

Starting dose: NaN mg ( mg prednisone-eq)

Exposure: Moderate (1–3 mo)

Interval: reduce every 7 days

Starting day	Prednisone-eq	Prednisone dose	Note

Warning signs — call the office immediately: unexplained fatigue with N/V, dizziness on standing, low blood sugar, or fever with feeling faint. During surgery, serious illness, or trauma within 12 months of stopping steroids, ask your clinician about stress-dose hydrocortisone.

COWS — Opioid withdrawal (5-item ×11)

Objective 11-item exam. Score ≥ 8 = withdrawal signs sufficient for buprenorphine induction without precipitating withdrawal.

Resting pulse (bpm)

Sweating (past 30 min)

Restlessness

Pupil size

Bone / joint aches

Runny nose / tearing

GI upset (past 30 min)

Tremor (outstretched hands)

Yawning

Anxiety / irritability

Gooseflesh skin

None / minimal

0/ 48

Affects orders

≥ 8: safe window for buprenorphine 4 mg SL induction (repeat q1–2 h up to 16 mg/day). ≥ 25: consider IV rehydration, clonidine 0.1–0.3 mg PO Q6H PRN for autonomic symptoms, ondansetron for nausea, loperamide for diarrhea, hydroxyzine for anxiety.

CIWA-Ar — Alcohol withdrawal (10-item)

Assess q1h during active withdrawal. Score drives symptom-triggered benzodiazepine dosing.

Nausea / vomiting (0–7)

Tremor (arms out, fingers apart) (0–7)

Paroxysmal sweats (0–7)

Anxiety (0–7)

Agitation (0–7)

Tactile disturbances (0–7)

Auditory disturbances (0–7)

Visual disturbances (0–7)

Headache / fullness in head (0–7)

Orientation / clouding of sensorium (0–4)

Mild — observation

0/ 67

No benzodiazepine; reassess q1h

Affects orders

Before/with first benzo: thiamine 100 mg IV, folate 1 mg PO/IV, multivitamin, replete Mg / K / PO4. Score ≥ 15 or history of DTs / seizures → consider phenobarbital-loading strategy in ICU.

Treatment

Opioid overdose reversal

The goal is adequate ventilation — spontaneous respirations ≥ 12/min with SpO₂ ≥ 92 % — not full alertness. Fully waking an opioid-dependent patient precipitates severe withdrawal and agitation.

Route	Initial dose	Onset	Notes
Intranasal (Narcan)	4 mg / spray, 1 spray each nostril	2–5 min	Preferred lay-rescuer + EMS route. Repeat q2–3 min PRN.
Intramuscular	0.4 mg IM	2–5 min	Auto-injector 2 mg for community use.
Intravenous (titrated)	0.04–0.4 mg IVP → repeat q2 min	1–2 min	Titrate to adequate respiration; low starting dose in chronic users.
Continuous infusion	2/3 of effective bolus / hr in NS	—	For long-acting opioid (methadone, ER morphine, fentanyl analog).

Precipitated withdrawal

Anticipate agitation, N/V, diaphoresis, HTN, tachycardia when reversing opioid-dependent patients.
Use lowest effective dose; if unclear, start 0.04 mg IV push and titrate.
Prepare for restraint / airway; do NOT bolus 2 mg IV in an obtunded chronic user.

Order set essentials

Airway / ventilation support (BVM ± advanced airway if unstable).
Naloxone as above; document mg + route + response.
Post-reversal monitoring ≥ 4–6 h; longer (12–24 h) for methadone, fentanyl analog, or infusion.
Rule-out co-ingestion (BZD, alcohol, stimulants); check finger-stick glucose.
Offer buprenorphine or methadone MOUD referral — use the COWS calculator to time buprenorphine safely.
Discharge with take-home naloxone + written harm-reduction plan.

Treatment

Alcohol withdrawal

Symptom-triggered benzodiazepines (driven by CIWA-Ar) shorten LOS and reduce total dose compared with fixed-schedule regimens. Fixed-schedule and phenobarbital-loading are reasonable alternatives when frequent CIWA scoring is impractical (e.g. ICU or extubated patients).

CIWA-Ar	Symptom-triggered dose	Notes
< 8	No benzodiazepine	Continue q1h monitoring for 6 h then de-escalate.
8–14	Lorazepam 1 mg PO/IV q1h PRN	Diazepam 10 mg PO/IV or chlordiazepoxide 25–50 mg PO in preserved LFTs.
15–19	Lorazepam 2 mg IV q1h PRN	Consider step-down / continuous monitoring.
≥ 20	Lorazepam 2–4 mg IV q30–60 min · ICU	Impending DTs. Consider phenobarbital load or continuous IV.

Give before / with the first benzo

Thiamine 100 mg IV/IM daily × 3 d — BEFORE any dextrose (prevent Wernicke).
Folate 1 mg PO/IV daily, multivitamin.
Replete Mg, K, PO4 aggressively — deficits drive seizure + arrhythmia.
D5NS or D5½NS at maintenance; NPO if agitated / seizure risk.

Adjuncts (never monotherapy)

Phenobarbital — loading dose 10 mg/kg IV over 30 min (ICU) for refractory withdrawal or benzo failure.
Dexmedetomidine / clonidine — autonomic control adjunct; does NOT treat withdrawal.
Haloperidol 2.5–5 mg IV — hallucinations refractory to adequate benzos; watch QTc.
Beta-blockers only after benzos to control HR/BP; they mask CIWA autonomic scoring.

Escalate to ICU

Withdrawal seizure or delirium tremens (DTs).
CIWA ≥ 20 despite adequate q1h benzos.
Autonomic instability requiring vasopressors or airway support.
Concurrent hepatic failure, sepsis, GI bleed, or arrhythmia.