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Triage Armelle

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  • 1. The Art of Triage Armelle de Laforcade, DVM, DACVECC Tufts University School of Veterinary Medicine
  • 2. Definition
    • Origin: French “Trier” – to sort
    • Dictionary: the sorting of and allocation of treatment to patients and especially battle and disaster victims according to a system of priorities designed to maximize the number of survivors
    • Evaluation of the animal to determine if immediate care is indicated
  • 3. Emergency or Not?
  • 4. Telephone Triage
    • Advice
    • Instructions
    • Reassurance
  • 5. Telephone Triage Brief history Trauma Collapse Respiratory distress Bleeding Needs to be seen immediately Ask more questions: Signalment Past medical history Onset of clinical signs Determine need to be seen immediately
  • 6. Telephone Triage: Goals
    • Brief (!) history
      • Trauma
      • Major underlying diseases
    • Stability of major organ systems
      • Breathing
      • Check gums
      • Ability to walk
    • Determine need for immediate attention
  • 7.  
  • 8. Telephone Triage: Challenges
    • Asking the right questions
    • Resisting urge to provide diagnosis
    • Maintaining control of the conversation
    • Knowing your limits
      • Time
      • Cage availability
      • Exotics/wildlife
  • 9. Telephone Triage: Client Service
    • If the client thinks that it is an emergency, then it is an emergency!
  • 10. Transition
    • Front desk staff
    • Prepare ER staff
    • Prepare supplies
  • 11. Waiting Room Triage
    • Perform immediately!
    • Assess major body systems
    • Brief history
  • 12. Goal of Triage
    • Assess major body systems
      • Heart, brain, lungs
    • Stable or not stable
    • Urgency of further treatment
  • 13. Heart
    • Heart rate
    • Heart rhythm
    • Mucous membranes
    • Femoral pulses
      • Strong
      • Weak
      • Bounding
  • 14. Heart
    • Changes in heart rate
      • Heart disease (arrhythmia)
      • Congestive heart failure (tachycardia)
      • Anemia
      • Shock
      • Pain
  • 15. Example 1
    • Signalment: 8 year old Great Dane
    • Two day history of lethargy, restlessness
    • Triage:
      • HR 180 bpm
      • Irregular with pulse deficits
      • Panting
      • Alert
    • Stable or not stable?
  • 16. Example 2
    • 10 year old German shepherd
    • 2 day history of lethargy
    • Triage
      • Alert
      • HR 130, RR 28
      • Mucous membranes: pink
      • Pulses: weak
    • Stable or not stable?
  • 17. Example 2
    • 10 year old German shepherd
    • 2 day history of lethargy
    • Triage
      • Alert
      • HR 130, RR 28
      • Mucous membranes: pink
      • Pulses: weak
    • Stable or not stable?
  • 18. Brain
    • Mentation
    • Seizures
    • Awareness of environment
  • 19. Example 1
    • 3 year old Golden Retriever
    • No previous problems
    • First grand mal seizure, lasted < 2 min
    • Triage:
      • HR 100, RR 20, mm pink
      • Pulses strong and synchronous
      • Alert, appropriate
    • Stable or not stable?
  • 20. Example 2
    • 6 year old Golden Retriever
    • Epileptic x 2 years, on phenobarbital
    • Complaint: 4 seizures today, last one in car
    • Triage:
      • HR 110, strong pulses, mm pink
      • RR panting heavily
      • Recumbent, dull
    • Stable or not stable?
  • 21. Lungs
    • Respiratory rate, effort
    • Short, shallow breaths
      • Pleural space disease
    • Rapid deep breaths
      • Parenchymal disease
  • 22. Example 1
    • 3 month old Welsh Corgi
    • Kennel cough 3 weeks ago
    • Decreased appetite x 2 days
    • Short of breath today
    • Triage:
      • HR 120, regular
      • RR 50, increased effort
      • Alert
    • Stable or unstable?
  • 23. Example 2
    • 7 year old CM DSH
    • Acute onset dyspnea
    • Too dyspneic to evaluate
    • Action step:
      • Place in oxygen cage
  • 24. Organization
  • 25. Now What?
  • 26. Unstable Patients
    • Place on treatment table or in oxygen cage
    • Place IV catheter, collect pre-treatment samples and begin fluids (if no heart disease)
    • Give supplemental oxygen
    • ECG (Continuous if available)
    • Start recording events/information
  • 27. Unstable: Cardiovascular System
    • Determine if cardiogenic shock (ie heart failure or pericardial effusion) or hypovolemia
    • If heart failure, treat with oxygen and diuretics
    • If hypovolemia, begin IV fluids
  • 28. Unstable: Respiratory System
    • Give oxygen
    • Assess for upper airway problems (loud noisy breathing)
    • Assess for signs of pleural space disease
    • Be careful with cats!!
  • 29. Unstable: Neurological System
    • Check for metabolic causes of weakness
      • Low blood sugar or anemia
    • Evaluate and record mental status
    • Evaluate and record ability to walk
  • 30. IV Catheter
  • 31. Minimum Data Base
    • Packed cell volume
    • Total solids
    • Blood glucose
    • Azo stick
    • Electrolytes
    • Lactate
  • 32. PCV/TS
    • Heparinized microhematocrit tubes
    • Clay
    • Microhematocrit centrifuge
    • Percent red blood cells
      • Dog: 37-55%
      • Cat: 35-45%
  • 33. Packed Cell Volume
    • Too Low
      • Blood loss
      • Hemolysis
      • Bone marrow failure
  • 34. Packed Cell Volume
    • Too high
      • Hemoconcentration
      • Polycythemia
  • 35. Total Protein
    • Refractometer
    • Normal: 6-7.5g/dl
    • Albumin and globulin
    • Inspect plasma component
      • Lipemia
      • Icterus
      • Hemolysis
  • 36. Total Protein
    • Too low
      • Blood loss
      • Protein losing condition
        • Gastrointestinal, renal
      • Dilution from fluid therapy
  • 37. Total Protein
    • Too high
      • Hemoconcentration
      • Lipemia
      • Increased globulins
  • 38. PCV/TS Guidelines
    • Decreased Total protein is OFTEN the fist indicator of internal bleeding
    • Any pet with TP < 6 (without chronic disease) requires recheck within 3-4 hours
  • 39. Blood Glucose
    • Whole blood
    • Dipstick
    • Glucometer
  • 40. Hyperglycemia
    • Blood glucose >120mg/dl
    • Diabetes mellitus
      • Ketoacidosis?
    • Stress
        • Lack of stress hyperglycemia in cats is abnormal!
  • 41. Hyperglycemia: Treatment
    • None required
    • Check history for signs of diabetes
      • PU/PD?
    • Recheck in 12 hours
  • 42. Hypoglycemia
    • Blood glucose <60mg/dl
    • Sepsis
    • Insulin overdose, insulinoma
    • Neonates
    • Interference from high hematocrit
  • 43. Hypoglycemia: Treatment
    • 0.5-1ml/kg of 50% dextrose
      • Dilute in LRS or NaCl
    • NO HARM in treating hypoglycemia
    • Potential significant long term consequences of not treating hypoglycemia
  • 44. Azo-Stick
    • Indicator of BUN
    • Rough estimate of renal function
    • Ranges
      • 5-15
      • 15-26
      • 30-40
      • 50-80
    • Normal: <26mg/dl
  • 45. Azo-Stick
    • Elevated with
      • Azotemia (pre-renal, renal, post renal)
      • GI bleeding
    • Decreased with
      • Liver disease
      • PU/PD
    • Normal Azo does not rule out problems
  • 46. Same Tests, Different Fluid
    • Abdominal fluid
      • PCV: Confirm hemoabdomen
      • Azo: Higher than blood suggests uroabdomen
      • Glucose: Lower than blood suggests sepsis
  • 47. Blood Smear
    • Evaluate
      • Red blood cells
      • White blood cells
      • Platelets
  • 48. Red Blood Cells
  • 49. White Blood Cells
    • Numbers
      • Parvo viral enteritis
      • Sepsis
    • Types
    • Changes
  • 50. Neutrophils
  • 51. Lymphocytes
  • 52. Platelets
  • 53. Summary
    • Triage
      • Index of suspicion is critical
    • Minimum data base
      • Completes initial evaluation
    • Combination allows for prompt targeted therapy that enhances survival of the emergency patient