Triage Armelle
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Transcript of Triage Armelle
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