ER triage: the vet tech's role
HALIFAX, NS – In emergency medicine, it is rare that a patient presentation follows a standard SOAP format: Subjective, Objective, Assessment, and Plan. ER physicians and techs do not have time to write down a history, or give detailed dictations about a physical before instituting treatment. So their thinking must be a little different, explained David Liss, RVT, VTS (ECC), speaking at the Atlantic Provinces Veterinary Conference. He said the immediate concerns are identifying patients that need care immediately, and then rapidly instituting life saving measures that are proven to reduce morbidity and mortality.
Triage
Mr. Liss said that knowing what is coming in is half the battle. Telephone triage tips include recommending a visit to the veterinary hospital, providing limited information about possible disease processes, providing accurate directions to the hospital, advising of possible wait times, and cautioning them to be careful if their pet is in pain.
Once the animal arrives and a brief history is taken, it should be determined whether the case is critical or not. Triaging is a rough categorizing of patients, identifying which patients should be seen immediately, within hours, within days, or those patients that have expired.
Triage levels
| Critical | Causing death within minutes | Respiratory emergencies Cardiac emergencies Life-threatening hemmorhage |
| Emergent | Causing death within hours | Shock Hemorrhage Severe sepsis Urethral obstructions Compromised trauma patients (w/o intractable vomiting) |
| Urgent | Causing death within days | Untreated infections Dehydration |
| Non-urgent | No risk of immediate death | Self-contained clean wounds Dermatological problems |
| Dead | Self-explanatory |
Primary survey: TPR + ABC’s + Mentation + BP
Total physical response provides a rectal temperature, heart or pulse rate, respiration rate and effort, and often MM/CRT parameters. Mr. Liss said that adding mentation as a parameter “gets us to think that patients in shock may not be receiving adequate cerebral perfusion and be obtunded.” He added that blood pressure is mandatory on every critical patient.
Airway assessment checks for dyspnea that may be caused by upper or lower airway obstruction or pleural effusion. The rate and character of an animal’s breathing should be checked, and auscultated for wheezes/crackles. Circulation assessment involves pulse quality, assessment of both femoral and distal pulses, and auscultation for any murmurs.
Assessment of an animal’s mentation will provide information on whether they are alert, responsive to verbal and painful stimulation, or unconscious. He noted that if the patient has a derangement in one of these parameters, they might be in shock. Signs of shock include tachycardia, bradycardia, hypothermia, hypotension, hypertension, obtundation, and tachypnea.
After all of this information has been assessed and processed the veterinary technician proceeds to diagnostics and treatments to evaluate minimum database, fluid therapy, and analgesics.
The minimum database is a collection of tests aimed at figuring out whether the patient is going to crash quickly. The database often includes blood glucose, BUN, venous blood gas, electrolytes, lactate, and PCV/TS.
Fluid therapy
The goal of fluid therapy is to increase effective circulating volume to maximize organ perfusion. Fluid options include crystalloids (e.g. lactated Ringer’s solution, Plasma-Lyte, 0.9% NaCL, or buffered solutions), colloids (e.g. Hetastarch, Dextran), and hypertonic solutions (e.g. 7.5% NaCL).
If a patient has a perfusion deficit (e.g. tachycardia, weak pulses, hypotension, or normotension with tachycardia), they will need a bolus. If a patient receives a fluid bolus, and they are not responding well, all parameters should be re-checked.
Nursing observations and interventions in critical patients
| Nursing observations | Nursing interventions (with DVM order as needed) | |
| 1. Fluid balance* | Mucous membrane colour, feel, CRT, skin tent, sunken eyes? | Administer fluids, increase rate, decrease rate, change fluid therapy plan as needed |
| 2. Oncotic pull* | Skin texture, edema, chemosis | Nutrition, colloid support, massage if edema present |
| 3. Glucose* | Weakness, lethargy, hypo/hyperglycemia | Administer insulin, dextrose support, monitor blood glucose levels |
| 4. Electrolytes* | Collapse, weakness, hypoventilation, ECG changes, hypo/hyper Na, K, Cl, Mg, PO4, Ca | Administer antidotes or supplement as needed, monitor patient reaction, ECG |
| 5. Oxygenation and ventilation* | Ventilation, RR, character, orthopnea, cyanosis | Administer oxygen, supplement ventilation |
| 6. Mentation* | BAR, QAR, depressed, obtunded, stuporous, responds to verbal/painful stimuli, coma | Treat underlying disease process, administer diuretics if increased ICP suspected |
| 7. Blood pressure* | Hypo, hypertension, tachycardia (prompt to perform a BP) | Fluids, vasopressors, recheck BP at regular intervals |
| 8. HR, rhythm, contractility* | HR, pulse quality, MM, CRT, mentation, temperature | Various medicaments, recheck BP, perfusion parameters |
| 9. Albumin* | Hypo/hyperalbuminemia | None specific |
| 10. Coagulation* | Tendency to bleed, Primary/secondary coagulation deficit-bleeding from catheter sites, ecchymoses/petechiae, gingival bleeding, harsh lung sounds, joint pain | Use smaller gauge catheters, avoid large vessels, only "good sticks" |
| 11. RBC/Hgb concentration* | MM, CRT, HR, RR, pulse quality | Monitor transfusions and patient reaction |
| 12. Renal function* | UOP, BUN, Creatinine, USG, signs of fluid overload | Monitor renal values, UOP measurements regularly |
| 13. Immune status, Abx dosage, WBC count | Careful maintenance of invasive devices, nosocomial infection prevention (gloves, washing hands), properly administering medications), Institute effective protocols to minimize colonization, protecting rectal thermometers, swabbing ports before injection, using a many one-time-use items as possible. | |
| 14. GI motility/mucosal integrity* | Vomiting, diarrhea, anorexia, hematemesis, melena, hematochezia, tenesmus | Administer medicaments as prescribed, observe for aspiration, keep patient clean/dry |
| 15. Drug dosages/metabolism | Pediatric, geriatric pets, patients with liver/kidney dysfunction, various medications change metabolism (CYP450 inhibitors) | Use drug charts to assess compatibility |
| 16. Nutrition* | Poor BCS, muscle wasting, history of anorexia, GI signs (V or D) | Administering parenteral/enteral nutrition, tempting to eat, patience, not force-feeding, creating food aversion |
| 17. Pain control* | Patients crying out, shivering, hiding, tachycardic, febrile, hypertensive, tachypneic, aggressive, submissive, attention-seeking | Assessing pain using scoring systems, objective/subjective criteria, PRN orders, re-assessing after analgesic medications given |
| 18. Nursing care/patient mobilization* | Recumbent patient, neurologic, orthopedic patient | Walks, PROM, recumbent care, eye/ear care |
| 19. Wound care/bandage care* | Patient with bandage present | Bandage changes/checks |
| 20. Tender loving care* | Talking, petting, sitting with patients, providing owner visits, familiar toys, other items |
*can be assessed or performed directly by technicians and reported to the veterinarian.
Analgesic therapy
Analgesics that are best used in the acute care setting are the opioid medications. Withholding pain medication until the patient is more stable is not necessary. The pure mu opioid medications have very few side effects and are regarded as cardiovascularly-sparing at published doses.
Evaluation
Mr. Liss concluded by saying that once the patient has received its first set of interventions, it is time to see if they worked. The evaluation step involves both medical and nursing models to reduce morbidity and mortality. While the medical side involves re-running lab work, ordering additional diagnostic tests, etc., the nursing model will focus on the patient, not the disease, to see if interventions are effective.CVT
