The Art of TriageThe Art of Triage

Armelle de Laforcade, DVM, DACVECCArmelle de Laforcade, DVM, DACVECC

Tufts University School of Veterinary MedicineTufts University School of Veterinary Medicine

DefinitionDefinition

Origin: French “Trier” – to sortOrigin: French “Trier” – to sort Dictionary: the sorting of and allocation of Dictionary: the sorting of and allocation of

treatment to patients and especially battle treatment to patients and especially battle and disaster victims according to a system and disaster victims according to a system of priorities designed to maximize the of priorities designed to maximize the number of survivors number of survivors

Evaluation of the animal to determine if Evaluation of the animal to determine if immediate care is indicated immediate care is indicated

Emergency or Not?Emergency or Not?

Telephone TriageTelephone Triage

AdviceAdvice

InstructionsInstructions

ReassuranceReassurance

Telephone TriageTelephone Triage

Brief history

TraumaCollapseRespiratory distressBleeding

Needs to be seen immediately

Ask more questions:SignalmentPast medical historyOnset of clinical signs

Determine need to be seen immediately

Telephone Triage: GoalsTelephone Triage: Goals

Brief (!) historyBrief (!) history TraumaTrauma Major underlying diseasesMajor underlying diseases

Stability of major organ systemsStability of major organ systems BreathingBreathing Check gumsCheck gums Ability to walkAbility to walk

Determine need for immediate attentionDetermine need for immediate attention

Telephone Triage: ChallengesTelephone Triage: Challenges

Asking the right questionsAsking the right questions Resisting urge to provide diagnosisResisting urge to provide diagnosis Maintaining control of the conversationMaintaining control of the conversation Knowing your limitsKnowing your limits

TimeTime Cage availabilityCage availability Exotics/wildlifeExotics/wildlife

Telephone Triage: Client ServiceTelephone Triage: Client Service

If the client thinks that it is an emergency, If the client thinks that it is an emergency, then it is an emergency!then it is an emergency!

TransitionTransition

Front desk staffFront desk staff

Prepare ER staffPrepare ER staff

Prepare suppliesPrepare supplies

Waiting Room TriageWaiting Room Triage

Perform immediately!Perform immediately!

Assess major body Assess major body systemssystems

Brief historyBrief history

Goal of TriageGoal of Triage

Assess major body systemsAssess major body systems Heart, brain, lungsHeart, brain, lungs

Stable or not stableStable or not stable

Urgency of further treatmentUrgency of further treatment

HeartHeart

Heart rateHeart rate Heart rhythmHeart rhythm Mucous Mucous

membranesmembranes Femoral pulsesFemoral pulses

StrongStrong WeakWeak BoundingBounding

HeartHeart

Changes in heart rateChanges in heart rate Heart disease (arrhythmia)Heart disease (arrhythmia) Congestive heart failure (tachycardia)Congestive heart failure (tachycardia) AnemiaAnemia ShockShock PainPain

Example 1Example 1

Signalment: 8 year old Great Signalment: 8 year old Great DaneDane

Two day history of lethargy, Two day history of lethargy, restlessnessrestlessness

Triage: Triage: HR 180 bpmHR 180 bpm Irregular with pulse deficitsIrregular with pulse deficits PantingPanting Alert Alert

Stable or not stable?Stable or not stable?

Example 2Example 2

10 year old German 10 year old German shepherdshepherd

2 day history of lethargy2 day history of lethargy TriageTriage

AlertAlert HR 130, RR 28HR 130, RR 28 Mucous membranes: pinkMucous membranes: pink Pulses: weakPulses: weak

Stable or not stable?Stable or not stable?

Example 2Example 2

10 year old German 10 year old German shepherdshepherd

2 day history of lethargy2 day history of lethargy TriageTriage

AlertAlert HR 130, RR 28HR 130, RR 28 Mucous membranes: pinkMucous membranes: pink Pulses: weakPulses: weak

Stable or not stable?Stable or not stable?

BrainBrain

MentationMentation SeizuresSeizures Awareness of Awareness of

environmentenvironment

Example 1Example 1

3 year old Golden Retriever3 year old Golden Retriever No previous problemsNo previous problems First grand mal seizure, lasted < 2 minFirst grand mal seizure, lasted < 2 min Triage:Triage:

HR 100, RR 20, mm pinkHR 100, RR 20, mm pink Pulses strong and synchronousPulses strong and synchronous Alert, appropriateAlert, appropriate

Stable or not stable?Stable or not stable?

Example 2Example 2

6 year old Golden Retriever6 year old Golden Retriever Epileptic x 2 years, on phenobarbitalEpileptic x 2 years, on phenobarbital Complaint: 4 seizures today, last one in carComplaint: 4 seizures today, last one in car Triage:Triage:

HR 110, strong pulses, mm pinkHR 110, strong pulses, mm pink RR panting heavilyRR panting heavily Recumbent, dullRecumbent, dull

Stable or not stable?Stable or not stable?

LungsLungs

Respiratory rate, effortRespiratory rate, effort Short, shallow breathsShort, shallow breaths

Pleural space diseasePleural space disease Rapid deep breathsRapid deep breaths

Parenchymal diseaseParenchymal disease

Example 1Example 1

3 month old Welsh Corgi3 month old Welsh Corgi Kennel cough 3 weeks agoKennel cough 3 weeks ago Decreased appetite x 2 daysDecreased appetite x 2 days Short of breath todayShort of breath today Triage:Triage:

HR 120, regularHR 120, regular RR 50, increased effortRR 50, increased effort AlertAlert

Stable or unstable?Stable or unstable?

Example 2Example 2

7 year old CM DSH7 year old CM DSH Acute onset dyspneaAcute onset dyspnea Too dyspneic to evaluateToo dyspneic to evaluate

Action step:Action step: Place in oxygen cagePlace in oxygen cage

OrganizationOrganization

Now What?Now What?

Unstable PatientsUnstable Patients

Place on treatment table or in oxygen Place on treatment table or in oxygen cage cage

Place IV catheter, collect pre-treatment Place IV catheter, collect pre-treatment samples and begin fluids (if no heart samples and begin fluids (if no heart disease)disease)

Give supplemental oxygenGive supplemental oxygen ECG (Continuous if available)ECG (Continuous if available) Start recording events/informationStart recording events/information

Unstable: Cardiovascular SystemUnstable: Cardiovascular System

Determine if cardiogenic shock (ie heart Determine if cardiogenic shock (ie heart failure or pericardial effusion) or failure or pericardial effusion) or hypovolemiahypovolemia

If heart failure, treat with oxygen and If heart failure, treat with oxygen and diureticsdiuretics

If hypovolemia, begin IV fluidsIf hypovolemia, begin IV fluids

Unstable: Respiratory SystemUnstable: Respiratory System

Give oxygenGive oxygen Assess for upper airway problems (loud Assess for upper airway problems (loud

noisy breathing)noisy breathing) Assess for signs of pleural space diseaseAssess for signs of pleural space disease

Be careful with cats!!Be careful with cats!!

Unstable: Neurological SystemUnstable: Neurological System

Check for metabolic causes of weaknessCheck for metabolic causes of weakness Low blood sugar or anemiaLow blood sugar or anemia

Evaluate and record mental statusEvaluate and record mental status

Evaluate and record ability to walkEvaluate and record ability to walk

IV CatheterIV Catheter

Minimum Data BaseMinimum Data Base

Packed cell volumePacked cell volume Total solidsTotal solids Blood glucoseBlood glucose Azo stickAzo stick

ElectrolytesElectrolytes LactateLactate

PCV/TSPCV/TS

Heparinized microhematocrit tubesHeparinized microhematocrit tubes ClayClay Microhematocrit centrifugeMicrohematocrit centrifuge

Percent red blood cellsPercent red blood cells Dog: 37-55%Dog: 37-55% Cat: 35-45%Cat: 35-45%

Packed Cell VolumePacked Cell Volume

Too LowToo Low Blood lossBlood loss HemolysisHemolysis Bone marrow failureBone marrow failure

Packed Cell VolumePacked Cell Volume

Too highToo high HemoconcentrationHemoconcentration PolycythemiaPolycythemia

Total ProteinTotal Protein

RefractometerRefractometer Normal: 6-7.5g/dlNormal: 6-7.5g/dl Albumin and globulinAlbumin and globulin Inspect plasma componentInspect plasma component

LipemiaLipemia IcterusIcterus HemolysisHemolysis

Total ProteinTotal Protein

Too lowToo low Blood lossBlood loss

Protein losing conditionProtein losing condition Gastrointestinal, renalGastrointestinal, renal

Dilution from fluid therapyDilution from fluid therapy

Total ProteinTotal Protein

Too highToo high HemoconcentrationHemoconcentration

LipemiaLipemia

Increased globulinsIncreased globulins

PCV/TS GuidelinesPCV/TS Guidelines

Decreased Total protein is OFTEN the fist Decreased Total protein is OFTEN the fist indicator of internal bleedingindicator of internal bleeding

Any pet with TP < 6 (without chronic Any pet with TP < 6 (without chronic disease) requires recheck within 3-4 hoursdisease) requires recheck within 3-4 hours

Blood GlucoseBlood Glucose

Whole bloodWhole blood

DipstickDipstick

GlucometerGlucometer

HyperglycemiaHyperglycemia

Blood glucose >120mg/dlBlood glucose >120mg/dl

Diabetes mellitusDiabetes mellitus Ketoacidosis?Ketoacidosis?

StressStress Lack of stress hyperglycemia in cats is abnormal!Lack of stress hyperglycemia in cats is abnormal!

Hyperglycemia: TreatmentHyperglycemia: Treatment

None requiredNone required

Check history for signs of diabetesCheck history for signs of diabetes PU/PD?PU/PD?

Recheck in 12 hoursRecheck in 12 hours

HypoglycemiaHypoglycemia

Blood glucose <60mg/dlBlood glucose <60mg/dl

SepsisSepsis Insulin overdose, Insulin overdose,

insulinomainsulinoma NeonatesNeonates

Interference from high Interference from high hematocrithematocrit

Hypoglycemia: TreatmentHypoglycemia: Treatment

0.5-1ml/kg of 50% dextrose 0.5-1ml/kg of 50% dextrose Dilute in LRS or NaClDilute in LRS or NaCl

NO HARM in treating hypoglycemiaNO HARM in treating hypoglycemia

Potential significant long term Potential significant long term consequences of not treating consequences of not treating hypoglycemiahypoglycemia

Azo-StickAzo-Stick

Indicator of BUNIndicator of BUN Rough estimate of renal functionRough estimate of renal function RangesRanges

5-155-15 15-26 15-26 30-4030-40 50-8050-80

Normal: <26mg/dlNormal: <26mg/dl

Azo-StickAzo-Stick

Elevated with Elevated with Azotemia (pre-renal, renal, post renal)Azotemia (pre-renal, renal, post renal) GI bleedingGI bleeding

Decreased withDecreased with Liver diseaseLiver disease PU/PDPU/PD

Normal Azo does not rule out problemsNormal Azo does not rule out problems

Same Tests, Different FluidSame Tests, Different Fluid

Abdominal fluidAbdominal fluid PCV: Confirm hemoabdomenPCV: Confirm hemoabdomen

Azo: Higher than blood suggests uroabdomenAzo: Higher than blood suggests uroabdomen

Glucose: Lower than blood suggests sepsisGlucose: Lower than blood suggests sepsis

Blood SmearBlood Smear

Evaluate Evaluate Red blood cellsRed blood cells White blood cellsWhite blood cells PlateletsPlatelets

Red Blood CellsRed Blood Cells

White Blood CellsWhite Blood Cells

NumbersNumbers Parvo viral enteritisParvo viral enteritis SepsisSepsis

TypesTypes

ChangesChanges

NeutrophilsNeutrophils

LymphocytesLymphocytes

PlateletsPlatelets

SummarySummary

TriageTriage Index of suspicion is criticalIndex of suspicion is critical

Minimum data baseMinimum data base Completes initial evaluationCompletes initial evaluation

Combination allows for prompt targeted therapy Combination allows for prompt targeted therapy that enhances survival of the emergency patientthat enhances survival of the emergency patient