triage and stabilisation

triage

Triage examinations can be used to sort cases into order of priority

OR

Recognise genuinely sick patients who need further interventions to prevent deterioration

common triage systems

ABCD

ATT - animal trauma triage system

ABCD system

easy and commonly used

A = airway

B = breathing

C = circulation

D = disability

ATT system

The Animal Trauma Triage Score (ATT) is a veterinary illness severity score used to classify degree of trauma. This scoring system has 6 categories: perfusion, cardiac, respiratory, eye/muscle/integument, skeletal, and neurological.

Each category is given a score of 0 to 3 and total score is calculated ranging from 0 to 18. A higher score indicates greater severity of injury

timeline

emergency - immediate assessment

distended abdomen with non-productive retching

breathing difficulties

seizure lasting > 5 mins

collapsed animal

major bleeding

male cat unable to urinate

dystocia with pup/kitten stuck

toxin ingestion within last 2hrs

not exhaustive - if unsure assess and have them wait if patient stable

potentially serious - triage when available

persistent vomiting and diarrhoea with lethargy

wounds without major bleeding

acute lameness

acute onset painful eye

not exhaustive

if stable can wait for vet appointment

assessment of respiratory system

RR

effort

pattern

• open mouth breathing in cats

• inspiratory vs expiratory dyspnoea

• parasoxical patterns

noise

auscultations

• areas of dullness

• lung sounds - normal, increased, decreased

• abnormal sounds in thorax e.g gut sounds in a diaphragmatic hernia case

pulmonary auscultation

cardiovascular system

HR

rhythm

pulse quality

• consistent or variable

• synchronous with HR

mucous membrane colour

CRT

auscultation

• murmur present

• normal or muffled heart sounds

CRT

mucous membrane colour

muffled heart sounds - causes and key clinical considerations

pleural or pericardial effusion

consider emergency thorax POCUS scan

pulse quality - weak - causes and key clinical considerations

hypoperfusion/ vasoconstriction/ thrombus

assess other parameters of perfusion

pulse quality - bounding - causes and key clinical considerations

anaemia, hyperdynamic shock

check PCV and look for supporting evidence of hyperdynamic shock

pulse quality - irregular - causes and key clinical considerations

arrhythmia

ECG recommended

what is hyperdynamic shock

early stage of shock characterized by fast HR, high cardiac output and vasodilation leading to brick-red mm and bounding pulses. Often seen in sepsis

neurological assessment

mentation

• alert and responsive

• quiet

• dull

• obtunded

• comatose

• seizuring

ambulatory

not a full neurology examination - checking CNS for basic signs

• if signs of significant dysfunction then consider more detailed assessment

• modified Glasgow coma scale

neurological stabilisation for these problems

respiratory stabilisation for dyspnoea

reduce stress - hands off, consider sedation

provide oxygen - flow by/mask/ oxygen tent/ nasal prongs

respiratory stabilisation for obstruction

remove foreign body ASAP, consider GA or tracheostomy

respiratory stabilisation for upper respiratory inspiratory effort

reduce swelling e.g dexamethasone IV

minimise stress, consider butorphanol IM

actively cool

respiratory stabilisation for pleural space

thoracocentesis if fluid/ air, surgery if diaphragmatic rupture

types of shock

cardiogenic

• primary cardiac causes

hypovalemic

• blood and fluid losses

obstructive

• impeded venous return

distributive

• abnormal vasomotor tone

cardiogenic shock

Cardiogenic shock occurs when cardiac output is reduced.

Systolic and diastolic dysfunction and cardiac arrhythmias may cause decreased stroke volume and/or abnormal heart rates. It is important

to note that not all patients in congestive heart failure are in cardiogenic shock, while most animals in cardiogenic shock will concurrently be in congestive heart failure.

The prognosis is typically guarded for patients in

cardiogenic shock, except when it is caused by a reversible underlying disease such as sepsis-induced myocardial dysfunction.

Cardiogenic shock is usually treated with medications

hypovolaemic shock

shock resulting from a decrease in blood volume and is the most common form of shock seen in small animal practice

It may occur with volume loss due to:

• Haemorrhage (internal or external)

• Loss of other bodily fluids (e.g. vomiting, diarrhoea, polyuria)

• Due to decreased intake (e.g. restricted access, regurgitation, vomiting, dysphagia)

hypovolaemia

used to refer to a fluid deficit in the intravascular space, while the term ‘dehydration’ is used to refer to a deficit in the interstitial space. It is very important to make a clinical distinction between a patient that demonstrates interstitial dehydration and one that is hypovolaemic. Hypovolaemia is life-threatening and must be treated immediately with acute resuscitative fluid therapy (e.g. boluses), while interstitial dehydration is not and can be corrected more slowly, over 24 hours

how to stabilise hypovolaemic shock

isotonic crystalloid boluses (via a large bore peripheral IV) – given as 10ml/kg boluses over 10 minutes (60-90ml/kg/hour)

If you have a very large patient (Great Dane etc.) you can use hypertonic saline – 5ml/kg as a single bolus (3ml/kg as a single bolus in cats with raised ICP)

dehydration IVFT

1. Maintenance requirement (fluid lost via normal mechanisms) - 2ml/kg/hr or 50ml/kg/24hr

2. Deficit: Volume in ml = % dehydration (0.05-0.12) x bodyweight (kg) x 1000

3. Ongoing losses:

• Estimate volume lost (e.g. though V+ or D+) each time = 4ml/episode x weight (kg)

• Estimate frequency of loss over 24-hour period e.g. vomiting four times a day

• Volume in ml = volume of loss per episode (ml) x frequency of loss per 24 hours

From this you can then calculate the volume of fluid per minute and the drip rate

obstructive shock

results from physical obstruction to blood flow, either to or from the heart, or through the great vessels.

causes of obstructive shock

GDV

pericardial tamponade

tension pneumothorax

pulmonary or aortic thromboembolism

how to stabalise obstructive shock

removing the obstruction, e.g. remove gas from stomach in a GDV and give shock rate fluids as for hypovolaemia.

Always cannulate the front legs in GDV patients. If you

cannulate the back legs, none of the fluids will get to the heart because of the obstruction caused by the dilated stomach

distributive shock

defined as a maldistribution of blood flow, most commonly inappropriate vasodilatation due to

sepsis or the SIRS response.

It is clinically distinct from other forms of shock in that it

initially results in a hyperdynamic state, which in dogs is characterised by increased cardiac output and peripheral vasodilatation. As distributive shock worsens it usually progresses from a hyper- to hypodynamic state.

Non-infectious SIRS may be caused by insults such as

trauma, pancreatitis, shock, surgery or burns.

To stabilise treat the cause if possible:

• Steroids and chlorphenamine for anaphylaxis

• Address overwhelming infections with IV antibiotics (e.g. cefuroxime)

• Reduce inflammatory drive (remove necrotic tissue if possible)

Use vasoactive drugs if available and shock rate fluids as for hypovolaemia