Triage Armelle

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Triage Armelle

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