Triage in the Emergency Room

Harold Davis, BA, RVT, VTS (Emergency & Critical Care)


Triage occurs both by telephone and in hospital. Clients often call the hospital seeking advice for the care of their pet; the veterinary technician will need to be able to ascertain useful information about the pet in a short period of time. In addition the technician will need to have the knowledge to provide the appropriate advice. The information obtained during the telephone conversation will also be useful in preparing for the arrival of the patient. On Initial presentation to the hospital the veterinary technician may be the first to receive the patient. It will be their responsibility to triage the patient(s). The technician will need to determine if the patient needs immediate care, or in the case of multiple patients, prioritize treatment based upon medical need.

Telephone Triage

Telephone triage requires the ability of the technician to determine the urgency of a pet's problem and give advice based on that determination. Caution should be exercised in interpretation of the owner's perception of the animal's problem. In general, any patient that has suffered a traumatic injury should be seen immediately.

Figure 1  Triage questions for medical situations.

1.  How is the animal breathing?

2.  What color are the gums?

3.  What is the level of consciousness?

4.  Is there any vomiting or diarrhea; if so, what is the frequency and duration; what does it look like?

5.  Is there any abdominal distension?

6.  What is the patient's ability to urinate?

7.  What medications if any is the patient receiving?

Figure 2  Triage questions for trauma related situations

1.  What is the nature of the injury?

2.  How is the animal breathing?

3.  What color are the gums?

4.  Is there any bleeding?

5.  What is the level of consciousness?

6.  Is the animal ambulatory?

7.  Are there any obvious fractures?

8.  Are there any obvious wounds?

Figure 3  Problems requiring attention by the veterinary health care team

Respiratory distress

Bleeding from body orifices

Pale mucous membranes

Weakness

Neurological abnormalities

Rapid abdominal distension

Protracted vomiting

Inability to urinate

Severe coughing

Ingestion of toxins

The signalment (breed, sex, age and weight) should be determined. The types of questions asked of the owners may be slightly different depending upon whether the problem is medical (Figure 1) or traumatic (Figure 2) based. Each case is different so the technician will need to be able to ask the appropriate followup questions for the given situation. Based on the information, advice can be given on first aid, assuming that the problem can be clearly defined and is simple. See figure 3 for a list of problems requiring attention by the veterinary health care team without delay.

Information gathered during the phone conversation can aid the veterinary technician in preparation for the arrival of the patient at the hospital. Simply knowing the animal's breed or weight can enable the technician to select the appropriate IV catheter size, volume of fluids, endotracheal tube size etc.

Owners should be provided with information about the safe transport of the pet to the clinic.

Hospital Triage

Three major body systems are assessed during the triage; they are respiratory, cardiovascular, and neurological. Triage can begin as you approach the patient. Visually assess ventilation effort and pattern; presence of blood or other foreign material about the patient; and the patient's posture and level of consciousness (LOC). Note if there are audible airway sounds (with and without a stethoscope). Note whether or not the animal responds to you as you approach. If the animal is conscious, ask the owner about the patient's temperament and take the appropriate precautions (Physical restraint, muzzling (do not muzzle a patient in respiratory distress) etc.). If time permits a brief history should be obtained.

A reasonable approach to triage is the use of the ABCDE's of emergency care. The ABCDE's of emergency care are: A) airway, B) breathing, C) circulation D) for dysfunction or disability of the central nervous system, and E) for examination. Patient's displaying respiratory distress or arrest; signs of hypovolemic shock or cardiac arrest; unconscious or altered LOC, ongoing seizure activity should be immediately taken to the treatment area for immediate medical attention. Conditions that affect other body systems are generally not life threatening in and of themselves but their effects on the three major body systems may be life-threatening. For example: the hypovolemia that results from a fractured femur bleeding into the leg. The following is a list of problems that also require immediate medical attention:

•  Exposure to toxins (Ingested or topical)

•  Prolapsed Organs

•  Sever Hypothermia / hyperthermia

•  Dehiscence

•  Excessive bleeding

•  Dystocia

•  Open fractures

•  Trauma

•  Snake bite

•  Burns

Airway/Breathing

Assessment of the respiratory system and correction of abnormalities as rapidly as possible is critical in obtaining an optimal outcome for patients. First, patency of airway and adequacy of ventilation should be assessed. This is done by visualization, auscultation, and palpation. When looking at the animal, you can determine if the animal is tachypneic or having difficulty breathing. Some animals with respiratory distress may assume a posture with the head and neck extended with abducted elbows. Additional signs include absent chest wall motion, exaggerated ventilatory effort, flaring of the nares, open mouth breathing and paradoxical breathing. Cyanosis may be seen, indicating hypoxemia. Animals with small and large airway problems may have noisy breathing, either stridor / sonorous or wheezes which is suggestive of partial airway obstruction or bronchoconstriction respectively. They may also have absent or diminished breath sounds, which are suggestive of pleural filling problems. The chest wall may be palpated to assess chest wall integrity. Crepitus about the body may be due to subcutaneous emphysema, which can be caused by tracheal tears, or chest wall defects. Life-threatening airway/breathing problems may be due to apnea, airway obstruction, open chest wounds, pneumothorax, and pleural effusion.

Assessment questions to ask yourself:

•  Is the patient having difficulty breathing?

•  Are you able to auscult breath sounds?

•  Are facial injuries interfering with the airway?

•  Has a bite wound disrupted the larynx or trachea?

•  Is subcutaneous emphysema present?

•  What is the color of the mucous membranes?

•  Does the dyspnea get worse with positional changes of the patient?

•  Is there evidence of thoracic penetration or is there a flail chest?

Circulation

Circulation is assessed by visualization, palpation, and auscultation. Mucous membrane color may vary with circulatory related problems. Mucous membrane color may be pale or white do to blood loss anemia or vasoconstriction. Brick red or injected mucous membranes are a result of vasodilation and can be seen with hyperthermia or sepsis. Grey mucous membranes are seen with stagnation of blood. Prolonged capillary refill time is also a result of peripheral vasoconstriction and causes decreased peripheral perfusion. Palpation of the artery provides information about the animal's heart rate and rhythm. In addition, pulse quality is an indicator of stroke volume, the amount of blood pumped out of the heart with each beat. Ideally, the pulse should be full, regular and strong. Cool extremities are a result of vasoconstriction. Auscultation of the heart also provides information about the rate and rhythm. In addition, murmurs can be detected. Auscultation of the heart and palpation of an artery should occur simultaneously, so that pulse deficits can be determined. Pulse deficits are suggestive of arrhythmias.

Many of the signs that we see suggestive of decreased cardiac output are a result of a compensatory sympathetic reflex which helps maintain arterial blood pressure. There is a release of norepinephrine, epinephrine, and cortisol from the adrenal gland. Epinephrine and norepinephrine cause an increase in heart rate and contractility, arteriolar constriction that increases systemic vascular resistance and redirects blood flow to the heart and brain and away from skin, muscle, kidneys and gastrointestinal tract. Clinical signs suggestive of decreased cardiac output include: tachycardia, pale or grey mucous membranes, prolonged capillary refill, poor pulse quality, cool extremities, and decreased urine production. Decreased cardiac output may be due to hypovolemia as a result of external blood loss or concealed blood loss (loss into a body cavity or limb). It may also be due to intrinsic heart failure, arrhythmias, and cardiac tamponade.

Assessment questions to ask yourself:

•  Is there evidence of hemorrhage?

•  Is there swelling associated with an extremity fracture?

•  Are the mucous membranes pale?

•  Is the capillary refill prolonged?

•  Are the femoral pulses weak and rapid?

•  Are the extremities cold?

Dysfunction / Disability

Dysfunction/disability refers to the neurological status of the patient. This may be assessed through visualization and palpation. A cursory neuro exam is performed focusing on the patient's level of consciousness, pupillary light reflex, posture, and response to pain (superficial and/or deep). Depressed mentation may be a result of poor oxygen delivery or trauma to the brain. Seizure activity may be due to intra (brain tumors or trauma, encephalitis etc.) or extracranial (toxins, hypoglycemia, hepatic encephalopathy) causes.

Assessment questions to ask yourself:

•  Is the animal bright, alert and responsive, obtunded or comatose?

•  Are the pupils dilated, constricted, of equal size, and responsive to light?

•  What is the posture of the animal?

•  Are there any abnormal breathing patterns?

•  Does the animal respond to painful stimuli?

•  Is there any seizure activity?

Examination

Finally, a rapid whole body examination is performed. The goal is to determine and address any additional problems.

Assessment questions to ask yourself:

•  Are there lacerations / wounds / punctures?

•  Is there bruising and is it getting worse?

•  Are there any fractures?

•  Is the abdomen painful or distended?

•  Is there evidence of debilitation or other signs of disease?

The ability to assess accurately and rapidly marks the difference between a good veterinary technician and an excellent one. In some emergencies, minutes count. The goal is rapid evaluation and intervention for hypoxia and shock as well as the rapid assessment to identify other life-threatening conditions.