*Updated* Why do we need to establish an IV in a patient with suspected pulmonary edema? If they fit the directive, they more than likely have crackles which would be contraindicated for a fluid bolus.
This question has been raised multiple times and previously answered on ASK MAC. As such, this conflict within the directive was discussed at the provincial level in light of the Comprehensive Medical Directive Review that has been ongoing.
Cases whereby patients with acute cardiogenic pulmonary edema that receive nitro and subsequently becomes hypotensive is a rare event, especially since the introduction of modified 12-lead ECGs to determine if there is RV ischemia occurring (which predisposes to hypotension if nitro given). In cases where iatrogenic (caused by nitro treatment) hypotension occurs, most of these cases will have their hypotension resolve as the nitroglycerin effects wear off. In these cases, an IV fluid bolus CAN be given to correct hypotension as these patients are preload dependent and require this volume to maintain their BP. In these cases, once normotension occurs, stop the IVF bolus and withhold further doses of nitro. If there are any concerns of risk vs benefit of this bolus, this would be an excellent use of a patch to the BHP.
*Addendum: May 26th, 2020* SWORBHP will bring this discrepancy forward to the Provincial MAC to have endorsed language within the companion document that supports the use of IV fluids in these rare circumstances.