Can We Rename Epi Already?

People often say to me, “Graham, you are a crazy person,” and I say “Yes, I know that.” It is in this vein (yes, pun intended), I’d like to ask someone smarter than me (that’s you, readers): Why the hell do we still call Epinephrine “One to one thousand” and “one to ten thousand?”

The thought’s come up on several occasions over the past few months: working a few shifts with bad allergic reactions, a recent EMCrit podcast, an EMRAP episode, a recent Annals article, and a near-miss with a colleague where he wanted IM and the nurse almost gave IV.

Epinephrine seems to be the only drug that’s written as a ratio, as opposed to a concentration or percentage, and I’m scratching my head to figure out why. Maybe it’s because there’s less confusion over someone verbally saying “one-thousand” versus “ten-thousand,” compared to “zero point one percent” and “zero point zero one percent?” But come on, is this really the best we’ve come up with? “One” versus “ten” is our safety measure with a drug like epi, that’s pretty much only used when people are already super sick or super dead, and by definition people are not reacting calmly? One study shows when dosed as ratios, people give way more epi and take way longer to give it.

Here’s what we’ve got right now:

Ratio Concentration Percent
1:1,000 1mg/mL 0.1%
1:10,000 0.1mg/mL 0.01%

I propose something else entirely: let’s give it a word, and label it that way. Color, too. (Maybe dark red vs pink or something to show one is more dilute.) Some ideas:

  • High vs. Low Concentration
  • Concentrated vs. Dilute
  • Skin vs. Intravenous
  • Strong vs. Weak
  • Muscle vs. Cardiac

There’s a limited number of people who give epinephrine: us (ahem, our nurses), the intensivists (and that’s usually in drip form), paramedics, and other nurses during codes. Why not set a new standard and fix this once and for all?

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