All about triage
Unless the patient is in immediate need of resuscitation a veterinary technician will have ample time to conduct a systematic initial assessment. A full physical exam should take under five minutes and should focus on respiration, alertness, and perfusion. If done appropriately, the cardiovascular, respiratory, and central nervous systems will all be assessed.
Respiratory
Any change in an animal’s breathing is an emergency. Owners often mistake laboured breathing as “panting” and shallow breathing as “sniffing.” When performing a physical exam it is important to step back and simply look at how the patient is breathing. Observation is one of the most important tools in determining whether the patient is having difficulty breathing. If there is any question regarding the degree of respiratory dysfunction, the patient should be given supplementary oxygen until treatment and diagnostics can begin.
Mucous membrane colour is an important tool in determining respiratory function. Though not completely accurate (because lighting, anemia, or icterus hides the appearance of cyanotic membranes) any apparent cyanosis needs to be addressed immediately.
A pulse oximetry machine should be used to measure the oxygen saturation of hemoglobin, which is a very insensitive measure of oxygenation. A healthy animal should have a range from 98-100% on room air.
Alertness
Upon initial presentation the level of consciousness (LOC) should be assessed.
Alert: Normal behaviour and is responsive
Depressed: Awake but subdued. Uninterested in environment
Delirious: Awake but altered perception. Responds inappropriately to stimulus
Stuporous: Remains in sleep state. Only aroused by strong stimulus
Comatose: Deep unconsciousness. Unable to rouse despite stimulus
An animal may be conscious but have abnormal mentation, such as slow or inappropriate response to stimuli. Any patient that has a declining LOC is an emergency, and the prognosis worsens. Since a normal healthy animal is usually anxious at a veterinary clinic, any animal that appears depressed or unusually subdued should be a concern, and may indicate an emergency.
Perfusion
The most common conditions that can cause a change in cardiovascular status are hypovolemia, anemia, sepsis, and cardiac dysfunction. Mucous membrane colour may be altered from a normal healthy pink to a muddy, grey or pale colour. Any change in mucous membrane colour is a life-threatening emergency. Capillary refill time should always be under two seconds; during cardiovascular collapse you may see an increase to three seconds or greater.
Heart rate may be either increased or decreased, and pulse strength may be either bounding or weak. Both the heart rate and pulse rate may be irregular or nonsynchronous. One of the key indicators in the early stage of shock is an elevated heart rate. There are numerous types of heart arrhythmias and until the patient receives a full cardiac workup all arrhythmias should be considered life-threatening. If, during the physical exam a heart arrhythmia is ausculated, the patient should have an electrocardiogram performed.
Unique triages
Reproductive emergencies
When a reproductive emergency arrives at the clinic involving an animal giving birth, ideally all new puppies/kittens are brought to the clinic as well, so that they can be given right back to the mother to nurse when she is finished delivering. Upon arrival the neonates that have already been born should be removed from the mother and kept in a warm, clean area. This way the focus can be on the mother.
A dystocia occurs:
- If no signs of labour are present within 24 hours of a decrease in rectal temperature or a decrease in progesterone levels.
- If no fetus is produced after 30-60 minutes of hard labour.
- With crying, biting, or injury to the vulva area.
- With abnormal vaginal discharge (hemorrhage, odorous, mucopurulent).
- When resting for more than four hours between fetuses without contractions.
- With the presence of a fetus or fetal membranes in the vulva for greater than 15 minutes.
- With weak or absent contractions for more than 2 hours.
- With signs of illness in the female (major exhaustion, fever, tremors, multiple vomiting).
Even if the owner knows how many puppies/kittens the mother is having, a lateral radiograph, taken immediately after the patient has been checked into the hospital, should still be taken to confirm how many more are expected. The radiograph will also show if there is a baby stuck in the birth canal. Sedation should be avoided since this will only hinder the birthing process and may affect the unborn puppies/kittens.
Ocular emergencies
There are four true ocular emergencies: acute blindness, acute red or cloudy eye, acute painful eye, and anything penetrating the eye. As a rule of thumb, if an owner calls with concerns regarding their pet’s eye it is best to have them come in to assess whether it is truly an emergency.
Upon arrival at the clinic, the pet should be triaged normally; however, depending on the nature of the eye problem the pet may need immediate treatment. If the pet has to wait to be seen it should be placed in an Elizabethan collar to avoid further injury.
Neurological emergencies
Neurological emergencies require rapid assessment and quick treatment for optimal results. The three most common neurological emergencies are acute spinal cord injury, acute brain injury, and tick paralysis. Other neurological emergencies include all types of seizures.
If a neurological injury is suspected the owner should be advised to minimize the pet’s motion and get to the clinic as soon as possible. After a full physical exam a brief neurological exam should be conducted. This should start with the pet’s LOC. Any change in LOC is an emergency that needs immediate attention. You should pay particular attention to the pet’s eyes and whether the pupils are the same size, have normal reaction to light, and lack nystagmus or anisocoria.
Also check with hemostats for conscious proprioception deficits and deep pain. The pet should immediately withdraw its foot even with the slightest pressure. If the pet is delayed in responding or does not pull back at all, there is a neurological deficit.
While acute brain injury cases may be easy to label as an “emergency”, acute spinal cord injuries may not. A good triage technician will fully assess the pet upon its arrival at the hospital; as a rule, any animal that shows any neurological deficit should have immediate treatment.
Neonates
Ideally the sick neonate should be brought in separately to minimize the risk of disease transmission and stress to the rest of the litter.
Anyone transporting a neonate should be instructed to keep it warm during transport through the use of hot water bottles and warm blankets. Upon entering the hospital the neonate should be immediately placed in a warm environment with a temperature between 98-100°F.
Hypoglycemia is particularly common in toy breed neonates due to their increased demand for glucose due to their low fat reserves. They also have poor liver and muscle glycogen reserves. Because hypoglycemia is so common in neonates, any neonate that presents into a veterinary clinic with signs of illness should immediately have a blood glucose test performed.
Conclusion
Triage is one of the most important jobs of an emergency room technician. The ability to triage quickly and appropriately will give your patient the best chance of survival.
This article is based on Ms. Breton’s presentation at the North American Veterinary Community Conference in Orlando, FL.CVT
