ALBUTEROL SULFATE (Proventil, Ventolin )

Transcription

1 Actions: ALBUTEROL SULFATE (Proventil, Ventolin ) Ë Broncodilator Ë Dilates broncioles Ë Reduces airway resistance Ë Broncospasm caused by: Acute astma Near drowning COPD Drug overdose Broncitis Pulmonary edema Toxic gas inalation Ë Crus syndrome Suspected yperkalemia Crus force > 4 ours Contraindications: Ë Maximum prescribed inalation dose taken by patient Ë Inaler not prescribed for patient Adverse Effects: Cardiovascular Neurological tacycardia tremors ypertension nervousness eadace Respiratory dizziness coug weezing Gastrointestinal nausea EMT-Basic providers are not autorized to carry broncodilators, but may assist patient wit teir own pysician prescribed albuterol inaler. 1 spray inaled by using eiter te metered dose inaler wit or witout a spacer device. May repeat 1 spray in 3-5 minutes one time. < 12 years Not recommended for preospital use > 12 years Same as adult Witin 5 minutes 4-6 ours Te albuterol inaler is for EMERGENCY SUPPORTIVE THERAPY ONLY and is not a substitute for immediate medical care. An ALS unit must be enroute or te patient must be transported immediately to te nearest emergency department if ALS response is not available. 2-1

2 ALBUTEROL SULFATE (Proventil, Ventolin ) (Continued) Hypoxic patients may experience dysrytmias. Monitor pulse periodically for irregularity. Administer supplemental O 2 before and after treatment to decrease ypoxemia. Directions for Using Metered Dose Inaler Witout a Spacer Device 1. Sake container vigorously several times. 2. Instruct patient to exale deeply. 3. Instruct patient to place lips around moutpiece. 4. Instruct patient to take a slow, deep breat and depress te medication canister wile patient inales. 5. Instruct patient to remove moutpiece and old breat for as long as possible. 6. Instruct patient to exale slowly troug pursed lips. 7. Replace patient O 2 and reevaluate breat sounds. 8. Repeat procedure one time if needed. Directions for Using Metered Dose Inaler Wit a Spacer Device 1. Sake container vigorously several times. 2. Remove cap from spacer. 3. Attac spacer to inaler. 4. Instruct patient to exale deeply. 5. Instruct patient to place lips around moutpiece. 6. Depress te medication canister to fill te spacer camber. 7. Instruct patient to take several slow, deep breats to inale medication in spacer. (Tere may be a wistling sound if te patient inales too rapidly.) 8. Instruct patient to remove moutpiece and old breat for as long as possible. 9. Instruct patient to exale slowly troug pursed lips. 10. Replace patient O 2 and reevaluate breat sounds. 11. Repeat procedure one time if needed. (1/00) Included in Los Angeles County "Expanded" Scope of Practice 2-2

3 CHARCOAL (ACTIVATED) (Acta-Car, Actidose, Carcoaid, Insta-Car, Liqui-Car ) Actions: Ë Cemical absorbent Ë Absorbs ingested drugs and cemicals Ë Suspected drug overdose or ingestion of poisons Contraindications: Ë Altered level of consciousness or risk of decreased consciousness in te field Ë Absent gag reflex Adverse effects: Gastrointestinal Respiratory vomiting aspiration Use preparations witout Sorbitol 25-50g PO as tolerated 0-2 years Not recommended for preospital use. > 2 years Same as adult. Immediate 24 ours DO NOT ADMINISTER IF THERE IS A POTENTIAL FOR ALTERED LEVEL OF CONSCIOUSNESS. Tere is a risk of vomiting and aspiration if a decrease in consciousness occurs. Patient must be able to drink witout assistance. DO NOT ADMINISTER CHARCOAL WITH SORBITOL TO PATIENTS LESS THAN 2 YEARS OLD. Sorbitol acts as a potent catartic and may cause fluid and electrolyte disturbances. Sake bottle vigorously prior to administration to ensure tat carcoal is torougly suspended. Carcoal is most effective if administered witin 30 minutes of overdose or poison ingestion. Carcoal does not absorb cyanide, etanol, metanol, ferrous sulfate, caustic alkali or mineral acids. (1/00) Not included in Los Angeles County Scope of Practice 2-3

4 CHEMOTHERAPEUTIC AGENT Actions: Ë Cytotoxic agent Ë Eradicates or controls rapidly reproducing cells suc as cancer cells Ë Cancer treatment Adverse effects: Ë Not significant during interfacility transport Infusion pump is required. Rate must be adjusted by ospital/ome ealt personnel. Same as adult Determined by specific medication 48 ours - 7 days Pregnant or nursing moters sould defer patient care to partner. Exposure to cemoterapeutic agents places te primary care provider at risk for developing cancer, genetic damage, and may cause birt defects. Healt care professionals must wear protective cloting wen caring for patient. Immediate first aid treatment is required for exposure. Direct contact wit some cemoterapeutic agents may cause irritation, burning and tissue destruction. Spills must be immediately cleaned up. All units must ave a spill kit readily available since IV leakage and spills can occur. IV tubing sould ave luerlock connections and a plastic-backed absorbent liner sould be placed under te IV tubing. All soiled linens, dressings and absorbent padding must be disposed of separately and not placed in regular waste containers. Cemoterapeutic agents are excreted in body fluids. Notes: Protective Cloting Latex gloves at least.007 inc tick Gown; lint-free, low permeability fabric, closed front, long sleeves and tigt-fitting cuffs 2-4

5 CHEMOTHERAPEUTIC AGENT (Continued) Spill Kit 2 pairs of disposable gloves: inner -- latex, powder free, at least.007 inc tick outer -- utility strengt Gown: lint-free, low permeability fabric, closed front, long sleeves and tigt-fitting cuffs Soe covers Splas goggles Respirator (special mask) Absorbent, plastic-backed seets Disposable toweling 2 prelabeled plastic azardous disposal bags Plastic scoop for broken glass Puncture-resistant container for glass fragments First Aid Skin -- was immediately wit soap and water. Eyes-- flus wit normal saline solution for 5 minutes (1/00) ***All exposures must be reported and evaluated by a pysician*** Included in Los Angeles County Expanded Scope of Practice 2-5

6 Actions: DEXTROSE PREPARATIONS (ORAL) DEXTROSE CARBONATE SOLUTION and GLUCOSE PASTE / GLUCOSE GEL Ë Hyperglycemic agent (carboydrate) Ë Immediate source of glucose wic is needed for cellular metabolism Ë Conscious diabetic patient wo as signs/symptoms of ypoglycemia Contraindications: Ë Unresponsive patients Ë Patients wo are unable to swallow or ave a diminised gag reflex Ë Patients complaining of nausea Adverse Effects: Gastrointestinal Respiratory vomiting Solution Paste/Gel Solution Paste/Gel g (10g/oz) PO, sipped slowly. aspiration obstructed airway 1 tube of paste/gel swallowed or 1 inc placed between ceek and gum. 1g/kg PO, sipped slowly Not recommended for preospital use Witin 20 minutes Depends on te degree and cause of ypoglycemia Precautions Administer solution only to patients wo can old te bottle and drink witout assistance or administer paste/gel if te patient as te ability to swallow. Tere is a risk of airway obstruction, vomiting, and aspiration if te patient is unable to swallow or as a diminised gag reflex. Te entire amount does not need to be administered if te patient's condition improves. Signs/Symptoms of ypoglycemia: rapid onset, cool, moist skin, unger, bizarre/combative beavior, anxiety, restlessness, weakness, appearance of intoxication or stroke suc as slurred speec and staggering gait, and seizures. (1/00) Included in Los Angeles County "Expanded" Scope of Practice 2-6

7 DEXTROSE 5% IN WATER (D 5 W) SOLUTION Actions: Ë Isotonic/ypotonic solution (5g dextrose/100ml water) Ë Provides some sugar for cellular metabolism Ë Supplies body water Ë Intravenous access for drug administration Adverse Effects: Ë Increases free water and may cause intracellular edema May transport wit infusion adjusted to a TKO rate by ospital personnel. Must transport wit a volume-control set and rate adjusted to a TKO rate by ospital personnel. Immediate minutes Monitor infusion rate frequently; if signs of fluid overload, turn off IV drip. Infusion may result in fluid overload. Ceck IV site frequently and if infiltration is noted, turn off IV drip. IV may infiltrate during transport. Signs of fluid overload: distended neck veins (JVD), rapid respirations, sallow tidal volume, fine auscultatory crackles, dyspnea, and periperal edema. Signs of infiltration: swelling and pain around IV site. (1/00) 2-7

8 EPINEPHRINE HYDROCHLORIDE (Adrenalin ) EPIPEN AUTO-INJECTOR Actions: Ë Sympatomimetic agent (catecolamine) Ë Dilates broncioles Ë Constricts blood vessels Ë Anapylaxis (severe allergic reaction) Contraindications: Ë Not significant in above indication Adverse effects: Cardiovascular Neurological tacycardia seizures ypertension cerebral emorrage cest pain eadace ventricular fibrillation tremors dizziness Gastrointestinal anxiety nausea/vomiting EMT-Basic providers are not autorized to carry te EpiPen Auto-Injector, but may assist patients wit teir own pysician prescribed device. EpiPen Auto-Injector (0.3mg) IM in te upper-outer tig. No repeat. EpiPen Jr. Auto-Injector (0.15mg) IM in te upper-outer tig. No repeat minutes 20 minutes Te EpiPen is for EMERGENCY SUPPORTIVE THERAPY ONLY and is not a substitute for immediate medical care. An ALS unit must be enroute or te patient must be transported immediately to te nearest emergency department if ALS response is not available. DO NOT INJECT INTO BUTTOCKS, HANDS, FEET, OR ADMINISTER INTRAVENOUSLY. Injection into buttocks, ands or feet may result in loss of blood flow to te affected area and result in delayed absorption and tissue necrosis. Intravenous injection may result in an acute myocardial infarction or cerebral emorrage. 2-8

9 EPINEPHRINE HYDROCHLORIDE (Adrenalin ) EPIPEN AUTO-INJECTOR (Continued) Only administer if solution is clear and not expired. A solution tat is discolored, contains particles, or if outdated may be cemically altered and may lose its potency or result in muscle damage. Te EpiPen contains 2ml (2mg) of epineprine. Te Auto-Injector delivers 0.3ml (0.3mg); approximately 1.7ml remains in te pen after activation. Anapylaxis may be caused by insect stings or bites, foods, drugs, oter allergens, exercise, or may be spontaneous. Signs/symptoms of anapylaxis: flused skin, nervousness, syncope, tacycardia, tready or unobtainable pulse, ypotension, convulsions, vomiting, diarrea, abdominal cramps, urinary incontinence, weezing, stridor, difficulty breating, itcing, ras, ives, and generalized edema. Directions for Using EpiPen Auto-Injector 1. Pull off gray safety cap. 2. Cleanse injection site wit alcool swab.** 3. Place black tip on te upper-outer tig, at rigt angle to te leg. 4. Press EpiPen ard into tig until Auto-Injector activates and old in place for several seconds. 5. Remove EpiPen and place in needle container. 6. Massage te injection site for 10 seconds wit alcool swab. ** Patient's may ave been instructed tat tey can use EpiPen troug cloting. Tis is not recommended for basic life support providers. (1/00) Included in Los Angeles County "Expanded" Scope of Practice. 2-9

10 FOLIC ACID (Vitamin B 9 ) INFUSION Action: Indication: Ë Nutritional supplement (water soluble vitamin) Ë Aids in te development of red and wite blood cells and formation of platelets Ë Suspected malnutrition, especially in te presence of cronic alcool abuse, poor diet, and impaired food absorption Adverse Effects: Ë Not significant during interfacility transport May transport a maximum IV solution concentration of 1mg/1000ml IV solution. Infusion must be adjusted to a TKO rate by ospital personnel. Concentration same as adult. Infusion must be on a volume-control set and adjusted to a TKO rate by ospital personnel. Ceck IV site frequently and if infiltration is noted, turn off IV drip. IV may infiltrate during transport. Folic acid may be administered in conjunction wit multi-vitamin infusion. (1/00) Included in Los Angeles County "Expanded" Scope of Practice 2-10

11 INSULIN via PATIENT-CONTROLLED PUMP Action: Indication: Ë Hypoglycemic agent Ë Decreases blood sugar Ë Insulin dependent diabetes Adverse Effects: Ë Hypoglycemia EMT-Basic providers may not activate or adjust infusion pump. May transport patients wit eiter an internal or external administration pump. Medication infusion is programmed for te individual patient and may only be activated by patient or caregiver. Same as adult Evaluate level of consciousness and beavior frequently. Patients may experience ypoglycemia; If mild signs/symptoms develop, administer oral yperglycemic agent. Signs/symptoms of ypoglycemia: nervousness, trembling, irritability, combative beavior, weakness, incoordination, confusion, weak and rapid pulse, cold and clammy skin, drowsiness, seizures, and altered level of consciousness. (1/00) Included in Los Angeles County "Expanded" Scope of Practice 2-11

12 LACTATED RINGER'S SOLUTION Action: Ë Isotonic solution (crystalloid) Ë Replaces fluid and electrolytes lost from te intravascular and intracellular spaces Ë Initial fluid replacement for ypovolemia and deydration Ë IV access for drug administration Adverse effects: Pediatrics: Ë Circulatory fluid volume overload May transport wit infusion adjusted to a TKO rate by ospital personnel. Must transport wit a volume-control set and rate must be adjusted to a TKO rate by ospital personnel. Immediate < 1 our Monitor infusion rate frequently. Infusion may result in fluid overload. Ceck IV site frequently and if infiltration is noted, turn off IV drip. IV may infiltrate during transport. Signs of fluid overload: distended neck veins (JVD), rapid respirations, sallow tidal volume, fine auscultatory crackles, dyspnea, and periperal edema. Signs of infiltration: swelling and pain around IV site. (1/00) 2-12

13 Actions: MEPERIDINE HYDROCHLORIDE (DEMEROL ) via PATIENT-CONTROLLED ANALGESIC PUMP Ë Narcotic analgesic Ë Alters pain perception and produces euporia Ë Moderate to severe pain Adverse effects: Cardiovascular Neurological tacycardia sedation bradycardia dizziness ypotension eadace ypertension confusion tremors Respiratory seizures depression allucinations arrest Gastrointestinal nausea/vomiting EMT-Basic providers may not activate or adjust infusion pump. May transport wit locked settings. Medication infusion is programmed for individual patient and may only be activated by patient or caregiver. Same as adult 2-5 minutes Individual per patient program Monitor pulse quality and blood pressure. Infusion may cause ypotension. If ypotension persists, place patient in sock position. Monitor respiratory status frequently and ventilate wit bag-valve mask device if necessary. Infusion may cause respiratory depression or arrest. Tere are different Patient-Controlled Analgesic pumps. Transferring personnel must provide te EMT-B provider wit emergency sut off instructions regarding te specific pump used. (1/00) Included in Los Angeles County "Expanded" Scope of Practice 2-13

14 Actions: MORPHINE SULFATE via PATIENT-CONTROLLED ANALGESIC PUMP Ë Narcotic analgesic Ë Alters pain perception and produces euporia Ë Moderate to severe pain Adverse effects: Cardiovascular Neurological tacycardia sedation bradycardia dizziness ypotension eadace ypertension confusion tremors Respiratory seizures depression allucinations arrest Gastrointestinal nausea/vomiting EMT-Basic providers may not activate or adjust infusion pump. May transport wit locked settings. Medication infusion is programmed for individual patient and may only be activated by patient or caregiver. Same as adult 2-5 minutes Individual per patient program Monitor pulse quality and blood pressure. Infusion may cause ypotension. If ypotension persists, place patient in sock position. Monitor respiratory status frequently and ventilate wit bag-valve mask device if necessary. Infusion may cause respiratory depression or arrest. Tere are different types of Patient-Control Analgesic pumps. Transferring personnel must provide te EMT-B provider wit emergency sut off instructions regarding te specific pump used. (1/00) Included in Los Angeles County "Expanded" Scope of Practice 2-14

15 MULTI-VITAMIN INFUSION Action: Indication: Ë Nutritional supplement Ë Vitamins are organic compounds needed for growt, resistance to infection, and normal metabolism Ë Suspected malnutrition Adverse Effects: Pediatrics: Ë Not significant during interfacility transport May transport a maximum concentration of 1 vial/1000ml IV solution. Infusion must be adjusted to a TKO rate by ospital personnel/ome ealt personnel. Concentration same as adult. Infusion must be on a volume-control set and adjusted to a TKO rate by ospital/ome ealt personnel. Ceck IV site frequently; if infiltration is noted, turn off IV drip. IV may infiltrate during transport. Multi-vitamins for infusion contain bot water and fat soluble vitamins. Wen added to an IV infusion, it gives a yellow color to te fluid. (1/00) Included in Los Angeles County "Expanded" Scope of Practice 2-15

16 NITROGLYCERIN TABLETS or LINGUAL AEROSOL (Nitrolingual Spray) Actions: Ë Vasodilator Ë Dilates blood vessels Ë Dilates coronary arteries Ë Decreases te workload of te eart Ë Cest pain Contraindications: Ë Blood pressure below 100 systolic Ë Patient as taken tree doses prior to te arrival of EMT-B providers Ë Sildenafil citrate (Viagra ) taken witin 24 ours Adverse effects: Cardiovascular Neurological ypotension trobbing eadace bradycardia dizziness/faintness reflex tacycardia confusion rebound ypertension blurred vision Tablet Spray Gastrointestinal nausea/vomiting dry mout General flused skin sublingual burning EMT-Basic providers are not autorized to carry nitroglycerin tablets or aerosol, but may assist patients wit teir own pysician prescribed medication. 1 tablet (1/150gr or 0.4mg) SL 1 spray (0.4mg) SL or TM (transmucosal) Not recommended for preospital use 1-3 minutes minutes Nitroglycerin administration is for EMERGENCY SUPPORTIVE THERAPY ONLY and is not a substitute for immediate medical care. An ALS unit must be enroute or te patient must be transported immediately to te nearest emergency department if ALS response is not available. DO NOT ADMINISTER IF BLOOD PRESSURE IS BELOW 100 SYSTOLIC. May cause ypotension due to vasodilation. Always take blood pressure before and 5 minutes after administration of Nitroglycerin. 2-16

17 NITROGLYCERIN TABLETS OR LINGUAL AEROSOL (Nitrolingual Spray) (Continued) DO NOT SHAKE CONTAINER. One spray delivers 0.4mg of nitroglycerin. If te container is saken it will alter te dose delivered. INSTRUCT PATIENT NOT TO INHALE SPRAY. Inaling spray affects absorption rate. Directions for Administering Nitroglycerin Tablets 1. DO NOT ADMINISTER IF B/P IS BELOW 100 SYSTOLIC. Take blood pressure before administration. 2. Place tablet under tongue and instruct patient not to swallow, but to allow tablet to dissolve under tongue. 3. Retake blood pressure and pulse after 5 minutes. If ypotension develops, place patient in sock position. Directions for Administering Nitroglycerin Aerosol 1. DO NOT ADMINISTER IF B/P IS BELOW 100 SYSTOLIC. Take blood pressure before administration. 2. Instruct patient not to inale spray and do not sake container. 3. Administer spray on or under te tongue. 4. Retake blood pressure and pulse after 5 minutes. If ypotension develops, place patient in sock position. (1/00) Included in Los Angeles County "Expanded" Scope of Practice 2-17

18 OXYGEN Actions: Ë Gaseous element (21% of room air) Ë Essential element for normal metabolic function (aerobic metabolism) Ë Assists in te breakdown of glucose into a useable energy form Ë Hypoxemia Ë Increased oxygen demand Ë Cest pain of myocardial origin Ë Respiratory insufficiency Ë Cardiopulmonary arrest Contraindications: Ë Not significant in above indications Adverse effects: Ë Not significant in above indications Oxygen percentage may vary sligtly depending on tecnique and equipment. Delivery Device Flow Rate Delivered Nasal Cannula 2-6 L/min 23-44% Face Mask 8-15 L/min 40-60% Face Mask wit O 2 Reservoir 6-10 L/min 60-95% Bag-Valve-Mask wit O 2 Reservoir L/min 40-90% ET -- Bag-Valve Device wit O 2 Reservoir L/min 100% ET -- T-tube L/min 60-70% ETC (combitube) -- Bag-Valve Device wit O 2 Reservoir L/min 40-90% Same as adult except te ETC (combitube) is contraindicated in pediatric patients less tan 4 feet tall. 2-18

19 OXYGEN (Continued) 1-2 minutes Up to 30 minutes Observe te patient closely for canges in respiratory and mental status. Be prepared to assist ventilations if necessary. In some CO 2 retaining COPD patients, administration of oxygen may decrease teir respiratory drive. DO NOT ADMINISTER MORE THAN 6 L/MIN VIA NASAL CANNULA. Oxygen is not umidified and may dry out or irritate mucus membranes. DO NOT USE HIGH FLOW OXYGEN-POWERED-BREATHING-DEVICES IN PEDIATRIC PATIENTS LESS THAN 12 YEARS OF AGE OR IN CONJUNCTION WITH AN ET TUBE. Tese devices may result in gastric distention or pneumotorax due to ig pressures. Oxygen sould never be witeld from a patient in respiratory distress. Hig flow oxygen-powered-breating-devices are manually triggered, or demand valves wic ave a flow rate of 100 liters/minute. (1/00) 2-19

20 POTASSIUM CHLORIDE (KCl) INFUSION Actions:. Ë Electrolyte Ë Regulates nerve conduction and muscle contraction Ë Potassium deficiency Adverse effects: Cardiovascular Neurological dysrytmias parestesia arrest muscular paralysis confusion Respiratory depression General arrest yperkalemia venous trombosis Gastrointestinal nausea/vomiting abdominal pain Infusion pump is required. Rate must be adjusted by ospital personnel. May transport a maximum IV solution concentration of 20mEq/1000ml IV solution. Same as adult. Infusion must be on a volume-control set and adjusted to a TKO rate by ospital personnel. Monitor pulse periodically for irregularity; if cange in regularity occurs, turn of IV drip. KCl may cause dysrytmias. Ceck IV site frequently for infiltration; if present, turn off IV drip. IV may infiltrate during transport, and cause tissue necrosis. If concentration is greater tan 20mEq/1000ml of IV solution, patient must be transported by ALS unit and patient placed on an ECG monitor. (1/00) Included in Los Angeles County "Expanded" Scope of Practice 2-20

21 SODIUM CHLORIDE 0.9% (Normal Saline) SOLUTION Actions: Ë Isotonic solution Ë Replaces fluid and sodium lost from te intravascular and intracellular spaces Ë Initial fluid replacement for ypovolemia, deydration, and crus syndrome Ë Intravenous access for drug administration Adverse effects: Ë Circulatory fluid volume overload May transport wit infusion adjusted to a TKO rate by ospital personnel. Must transport wit a volume-control set and te rate adjusted to a TKO rate by ospital personnel or field paramedic in a multiple casualty situation. Immediate < 1 our Infusion may result in fluid overload. Monitor infusion rate frequently; if signs/symptoms of fluid overload, turn off IV drip IV may infiltrate during transport. Ceck IV site frequently; if infiltration noted, turn off IV drip. Signs of fluid overload: distended neck veins (JVD), rapid respirations, sallow tidal volume, fine auscultatory crackles, dyspnea, and periperal edema. Signs of infiltration: swelling and pain around IV site. (1/00) 2-21

22 THIAMINE (Vitamin B 1 ) INFUSION Action: Indication: Ë Nutritional supplement (water soluble vitamin) Ë Aids in metabolizing carboydrates, fats and amino acids and detoxifying alcool Ë Suspected malnutrition, especially in te presence of cronic alcool abuse Adverse Effects: Ë Not significant during interfacility transport May transport a maximum IV solution concentration of 100mg/1000ml IV solution. Infusion must be adjusted to a TKO rate by ospital/ome ealt personnel. Concentration same as adult. Infusion must be on a volume-control set and rate adjusted to a TKO rate by ospital/ome ealt personnel. Ceck IV site frequently; if infiltration noted, turn off IV drip. Tere is a potential for IV to infiltrate during transport. Tiamine may be administered in conjunction wit multi-vitamin infusion. (1/00) Included in Los Angeles County "Expanded" Scope of Practice 2-22

23 TOTAL PARENTERAL NUTRITION (TPN) Actions:. Ë Caloric agent Ë Provides total nutritional needs to sustain life Ë Patients unable to take food orally or absorb adequate nutrition troug te gastrointestinal tract Adverse effects: Ë Not significant during interfacility transport Must transport wit an infusion pump. Te infusion is adjusted for te individual patient and te rate may only be adjusted by ospital or ome ealt personnel. Same as adult Prevent separation of IV tubing. A break in te system may result in an air embolism wic may be fatal. Prevent disruption of infusion and insure tat an adequate amount of TPN solution is available trougout transport. Interruption of TPN infusions may result in ypoglycemia. (1/00) Included in Los Angeles County "Expanded" Scope of Practice 2-23