Hello. Thank you for watching this webinar. Triage has been around for hundreds of years.

It can be essential in any veterinary environment, and veterinary nurses have a vital role to play. In this webinar, we're going to discuss the concept of triage, the different stages of triage from the initial telephone call from the client through to arrival at the practise and how to perform primary and secondary surveys. The term triage comes from the French triere, which translate as to separate out or to sort.

The triage process originated in the battlefield in the 1800s when two French surgeons devised a system to assess patients based on the severity of their injuries. They were classified as walking wounded, those requiring surgical intervention, and those which were beyond help. Using this classification, the casualties were then taken to the appropriate place to receive treatment with the minimum amount of delay to improve survival rates.

Whilst we're very unlikely to see mash casualties in veterinary practise, we're often presented with patients with varying degrees of illness and injury at the same time, often with limited staff resources. We can use the triage process to identify those patients which needs immediate interventions and those who clinical status will not be compromised by waiting. The triage starts with the first contact with the owner, which in many cases will be them calling into the clinic.

It is important that all members of the veterinary team, including receptionists are trained in telephone triage and can identify the common emergencies which need to be seen immediately. It is crucial to ask the right questions on the phone to establish what the problem is. Attaining a brief history can enable preparation of what will be needed when the patient arrives at the clinic, and in some cases it may be necessary to get the owner to administer first aid prior to attending or provide advice on how to move or transport the animal.

I know they may assume a situation as an emergency that we as veterinary professionals do not. However, as we cannot see what the animal is actually doing, it's very difficult to say with certainty whether it is an emergency or not. Therefore, it is worth considering the worst case scenario until the animal has been seen.

It is vital to remain calm and patient with owners who are very upset and struggling to explain the situation, or take in what you're saying. It can be advisable to ask if there's anyone else that you can speak to to get the required information in a timely manner. If there isn't anyone else available, being empathetic and using a calm voice while explaining that the information you are asking for will aid getting their pets seen sooner can help to reassure the owner.

Using a template or checklist when answering calls ensures that all relevant information is collected from and given to the owner. In emergency situations, it is easy to get distracted and forget to ask important questions or give the owner vital details. The aim is to get information.

The aim is to get enough information to be able to assess the condition of the patient as quickly as possible. We do not want to waste time discussing unnecessary details or collecting information which could be taken at the clinic if it is in the best interests of the animal to get to the clinic as soon as possible. In order to get the vital details, it's important to take control of the call and ask relevant questions.

This may need to be done using closed questions where only a yes or no answer is needed from the client to save valuable times. The name of the owner and the pet should be taken early in the call. Referring to them by name can help to calm calm clients down.

It is essential to get a contact number, ideally a mobile, so that if the call gets disconnected or the client has not arrived when you expect them to, you can contact them. As well as getting vital information from the client, it is imperative that they understand what you are saying under stress saying. Under stressful situations, people may fail to take in essential details such as location of the clinic.

This is especially important if it is not their normal branch or practise that you need them to attend. It is advisable to repeat important information such as directions more than once, and if necessary, get the client to repeat the instructions back to you. Relevant questions must be asked to establish the condition of the patient and to assess whether it is an emergency.

Remember, we are not trying to diagnose or decide whether a patient needs to be seen, but to identify how quickly the patient needs to be seen. The questions asked should be established whether the illness or injury is affecting any of the major body systems. The major body systems are the cardiovascular, respiratory, and neurological systems.

It is vital to assess these as failure of any of these systems will result in the death of the patient. It is imperative to ask questions regarding the major body systems on every call. It is easy to get taken down a path and miss path and miss a more serious condition because the client has not noticed or appreciated the significance of a sign or symptom.

Caution should be exercised in the interpretation of the owner's perception of the problem. Some may exaggerate the severity of the situation, but there are occasional ones which drastically underestimate the condition. And while some owners will be distressed and upset in emergency situations, others can be very calm, and it may not always be immediately obvious how serious the injury or illness is.

Useful questions to ask to establish a brief history and And the severity of the illness and injury are, what is the nature of the injury, injury or illness? If it was an accident or injury, did they see it happen? Are there any obvious signs of injuries such as wounds?

And for illnesses, when did the problem start and what are the signs that they've seen? And have these signs been progressing over time? How is the breathing?

Is there an increased effort? Is it faster or slower than normal? Is it open mouth breathing, gasping or panting?

Cats which are panting are a real cause for concern. What is their level of consciousness? Are they alert and responding to the responding appropriately to the owner, or are they depressed or unresponsive?

Is there any bleeding? If so, how much blood and how fast is it bleeding? Is it spurting, dripping, or oozing blood?

It can sometimes be difficult to establish just how much blood there can be. So it can be useful to ask the owner to say the word drop or drip whenever there is a drop of blood. So if you only hear one drop in sort of a 32nd a minute, period, then it's not too much of a concern.

Whereas if you're getting a client going drip drip, drip, drip, drip, then obviously that's a bit more, concerning and needs some immediate action. Can the animals stand? If they are laid down, are they able to get up, and if they're stood up, can they support their own weight?

Are they able to urinate? You need to be aware of owners that mistakenly think that the cats are constipated when in fact they're straining to pass urine because they've got a blocked bladder. And is there any abdominal distention?

Does the stomach look swollen? Are they trying to be sick or drooling? If a client's response to any of these questions gives cause for concern, they should immediately be advised to attend the clinic.

While some owners will be distressed and upset in emergency situations, others can be very calm, and it may not always be immediately obvious how serious the injury or illness is. Owners give a subjective report regarding a described condition, and it's up to us to interpret these findings without direct contact with the patient. This can sometimes be difficult, especially if we don't ask relevant questions, or clients don't describe things in the way that we would.

So these next few slides relate to cases which were brought into clinics, where the animal was advised to be seen, but what the animal presented with was not quite what we were expecting. Based on the information we gathered from the client. So in this first case, we had a gentleman that rang up to say that it's cat had cut itself and there was something poking it out.

So as I said, the clinic did establish that it needed to be seen, but they didn't go on and ask too many questions. So they'd asked if it was bleeding, and his answer was, no, not really. So they weren't expecting this to arrive when it did at the clinic.

So if more questions have been potentially asked regarding how big was the cut, and actually where the cut is, then it may have been appreciated that it was actually, it's intestines that were something that was poking out. And we may have advised them to give first aid treatment on the way into the clinic. This next case, was a phone call that I dealt with when I was working in one of the clinics, and it was an evening and a lady rang up, and she was, asking if she could give her dog some, no more non-steroidals.

So it was a nine year old, Doberman, which had been started on non-steroidals about a month ago. And the owner had been aware at the time that they were starting on the lower dose and that potentially it may need upping. So she, her, she was reporting that the dog had been a bit uncomfortable, so for sort of 48 hours, seemed a bit stiffer, and tonight was sort of struggling a bit more.

It was getting up and out of its bed, doesn't seem to be able to settle himself in a, suitable position. So the vet was just, I thought finishing up with another consult. So rather than asking him to call her back to, discuss it, I just kept the lady on the phone, and we were just chatting about, the dog's arthritis and other things like that.

And the vet took a slightly longer than I had expected. And at that point, I suddenly realised that we'd kind of drifted off down the track a bit. And one of the tricks that I used to get the the call back under control, if I think we have drifted off, is to ask, ask what the patient's doing at the moment.

So I asked the lady how the dog was doing, what he was doing at that exact minute, and she said she didn't know because he was at the bottom of the garden. Well, having worked in emergency practise for quite a while, I'd heard the term at the bottom of the garden several times, and it never usually corresponded, to good things. So I did slightly sort of perk up a bit then.

So I then asked the client, What, what was he, could anybody see him? What was he doing at the bottom of the garden? So she shouted to her husband, who shouted back that he was vomiting.

So I asked a few more details. So, what was the vomit like? Was there any blood in it or anything like that?

And then it, the response came that he wasn't actually vomiting, he was trying to be sick, but wasn't bringing anything up. Which, again, put my heart rate up slightly more. I asked the client, then, is, is his abdomen swollen at all?

And even though it wasn't obvious, when they did have a close look, it's like, Oh, I do think it is a bit more swollen at one side. Oh, and he started drooling. So, obviously, at this point, we advised them to come straight.

I advised them to come immediately down. And when he did arrive at the clinic, he was diagnosed with a GDV and went on to have surgery for the GDV. So he was fine, but there was a quite a big delay in that phone call because I got distracted by what the client was saying.

It sounded reasonable what she was saying, what she decided was the problem. And I went along with that rather than following. The usual protocol and checking actually what his major body systems were up to.

And then there's occasions where clients just underestimate their injuries. So this lady rang up and said her dog had a small wound on his side, and when it arrived at the clinic, this is what we found. So again, I don't think that that is a small wound, and I imagine most people would not describe that as a small wound.

But again, to try and sometimes get round things and different, distinguish how small or how large a wound actually is, using everyday objects, such as you might start with coins, you might use fruit, tangerines, apples, oranges, that kind of thing. Or even things like, Is it bigger than your hand, in this case would have been quite appropriate. So there are several examples of true emergencies which all staff should be aware of and know that if these are ever described, then the owner should be advised to bring the animal in immediately.

And the things, that is tend to think about are collapsed patients. So it may be that it's not a major body system that's causing the patient to be collapsed, but if not, it's usually down to pain, and if they're that painful that they're not willing to get up or can't get up, then they obviously need to be seen. Any seizures or neurological abnormalities?

Any breathing difficulties, so dyspnea, and again cautious of cats that are panting. High or low heart rates. This is, again, it's not one that I would ask the client to establish whether it's got a high or low heart rate, because most clients that we're speaking to aren't medically trained, but sometimes you will get clients reporting this.

So I've had circumstances where the heart rate has been really high and the client could actually see, its pulse beating in its neck. Another one is pale mucous membranes. Again, I wouldn't usually ask a client to assess an animal's mucous membranes, because it's quite a jug, a difficult thing to judge sometimes.

And if they're not used to looking at them, they potentially can't tell you whether they're pale or not. But if you've got a client that's ringing up and reporting that it's got pale gums, then that would be a cause for concern because they have noticed a change from what is the normal for their animal. An inability to urinate and again be careful of ones where clients are ringing up saying they've got constipated cats because quite often it does turn out that they've actually er trying to urinate rather than to defecate.

Extreme pain, any patient which is in extreme pain needs to be seen. And sometimes clients may not realise that it is extreme pain, so I've had clients that said to me, well, it doesn't seem painful, but if he's stood on three legs or he's limping, obviously that is pain, it's just that that animal's fairly stoic and isn't screaming or shouting like some may do. Toxin ingestion, especially if we're knowing that it's a toxic dose.

If we're unsure, we may need to get details as to what the toxin is to find out if it's a toxic dose. If the animal's showing signs, it's usually advisable to tell them to come straight down and just bring the product with them or the labels so we can get further information when they arrive. Any protracted vomiting, any kind of trauma, even, you get a lot of reports of patients that have been hit by something, but they seem fine.

Quite often, adrenaline sort of sets in to start with, and it may be a while afterwards when they suddenly start to decompensate, so they really need to be seen. Unproductive wretching, and well-in patients which are well-pin and have been straining continuously for more than 30 minutes. All of these should be advised appointments.

And if clients are not willing to come down or they've got further questions, the vet should be made aware so that the vet can speak to these clients. So for some conditions, it's beneficial if the owner gives first aid prior to setting off or whilst en route to prevent worsening of the condition on the journey into the practise. So this first aid advice isn't instead of coming to the veterinary practise, it's things that they need, they need to do to aid in the treatment of their pets.

So for airway obstructions, it may be. They they need to perform the Heimlich manoeuvre. This would be something that I would only recommend in cases where it's a total airway obstruction and the patient just can't breathe.

If you've got animals that have got partial obstructions and they're still managing to breathe, it's probably best to just to get them on the way as soon as possible and not to ask their owners to try and do anything. If you've got patients that you've diagnosed, identified as being dysmic over the phone, then giving them advice on how to move them. So carrying animals, trying not to force cats into cat baskets that are already stressed, and letting them think about how they position them.

Animals that are struggling to breathe will usually try and sit up or stand up. Because it makes it easier to breathe. So if owners are trying to make them lay down because they feel that would be more comfortable for them, it can make the condition worse.

And also, if they get too warm, so if you think quite often again, owners like to wrap their their animals up if they feel the poorly. And if the animal's already hot, already having trouble breathing and it's panting, if you make it hotter, then you're just gonna exacerbate the condition. If there is any bleeding, if it's bleeding significantly, do we need them to be doing something on the way?

So, is it somewhere they can elevate the wound? Is it somewhere where they can apply pressure? But again, be very careful to find out exactly where this wound is and where the bleeding is.

You don't want owners putting very tight bandages around the necks of animals or risking cutting off circulation. So stabilisation. It's not very often that we would tell owners to try and stabilise patients.

Usually, you're better just to leave them and get them on the way. If they try and manoeuvre them and things, that can quite often make things more painful. But if it is a concern that they've had some kind of spinal trauma, if they've got something a bit more rigid to hand, a blanket's fine, but if they've got something more rigid to hand, it may be, better for the patient.

So things actually like parcel shelves of cars can be used quite, well for things like that. If they've got seizures, try and avoid stimulation, and it's worth warning them that they may seizure again in the car if they've stopped, or if they are seizuring, or, and if they're still seizuring on the phone, then you're gonna have to give them some kind of advice as to how to get them in the car and how to move them. It can be difficult sometimes to work out how long these patients have been seizuring, but if you just take into account the fact that if the animals had to start, started to seizure, usually it takes the owner sort of 30 seconds to kind of get over the panic and move, and at which point they then got to fight.

The number of the vet that then got to ring the practise and if they've done all that and when you speak to them on the phone, the patient is still seizuring, that does indicate that that patient's been seizuring for a significant amount of time, so potentially more than 2 minutes. Things like penetrating foreign bodies should be advised to leave alone and leave in place, . Burns, it's advisable with burns to do something before they set off just because the burn will continue to burn whilst they're on the way into the clinic.

So if it's some kind of scold or a burn that's appropriate to put cold water on, to levage it with cold water for sort of 5 or 10 minutes before they set off, will stop that burn continuing to burn on the, journey in and prevent it from going deeper. And then heatstroke. If you think most patients that are going to be suffering from heat stroke, it's going to occur in the summer, it's gonna occur in hot weather, and they're already hot, they're already suffering, and we're likely to put them into a back of a car, which again is quite hot, so.

Before they set off, if they can douse the patient down with lukewarm water, it doesn't want to be cold in this instance. Lukewarm is better. And whilst they're doing that, turn the air conditioning on in the car.

So at least give it sort of 5 minutes before putting the dog in there, because usually it will be a dog and transporting them into the, clinic. So always advise clients to be very careful when administering first aid, as even the most placid and friendly of pets can react out of character when in pain or disorientated. And as well as first aid, simple advice such as how to use a stretcher to get the patient into the car, and gentle reassurance may need to be given.

So, if we look at these 4 cases, they've all called at the same time. So which do we need to, do we feel needs the most urgent appointment, and which could potentially wait without being compromised. So with all of them, again, we need to remember to assess the major body systems.

So we need to think about the respiratory, the cardio cardiovascular, and the neurological systems. So if we start with the first one, it's a 2 year old Labrador that's eaten a bar of milk chocolate. So it would need to be quite a large bar of milk chocolate to be poisonous to a Labrador.

If we take into account, it maybe weighs 25 kg, it would really need to be over a 250 gramme bar of milk chocolate. But it is worth checking whether it was just milk chocolate. You'll quite often get instances of other ingredients, such as raisins, and then the raisins would be a concern regardless of the dose that they've received.

And if they have taken, a toxic dose of milk chocolate because they've got into the Easter egg stash or the Christmas, chocolates or something like that, then they would need to be seen immediately because the, one of the signs, one of the, things with chocolate toxicity is that they go on to seizure, and then seizuring is obviously affecting one of, the, the neurological system. So we'd need to get it seen ASAP so you can induce a mess. If we move on to the cat, so it's a domestic short hair, 5 year old that's straining to urinate.

So at first glance, this may not seem that it's affecting any of the major body systems. But if this is a truly blocked cat and it's not able to pass any urine, then there is a, There is a chance that its potassium started to increase, depending on how long it's been blocked, and the potassium will affect its cardiovascular system, so therefore it is affecting a major body system. So, again, would need to be advised to be seen ASAP and plus it's usually a very painful condition, even if it hasn't got to the stage that the major body the cardiovascular system is affected.

We've then got an 8 year old staffageable terrier that's vomiting and diarrhoea for 3 days. With vomiting and diarrhoea, with acute onset is usually more of a concern than, more prolonged or chronic ones. So it put this staff it would need to be seen, but Potentially, it's more likely that it's got dehydration, which may make it a bit more subdued, rather than something like hypovolemia, which is then affecting its cardiovascular system.

So this may be one that you'd make an appointment for the next sort of surgery if it's in a couple of hours or something like that. And then we're on to the 3 year old collie, which is seizure. And as I've explained previously, if the dog is still seizuring by the time you're speaking to the owner on the phone, it is usually a fit that's been going on for quite a significant amount of time, and therefore, it is affecting a major body system.

And if it continues, it can lead to permanent, brain damage, therefore, this patient would need to be seen immediately. So, now that we've got the owner and the animals are on the way to the clinic, we need to get prepared. So you need to start by ensuring that the rest of the team knows that the emergency on the way down.

There's nothing worse than running through with that you're an emergency patient when they arrive to find that the vets just started a routine up, which they could have delayed if they'd known they were coming, or that the vets maybe just nipped out to go on their lunch break and they're not actually there. So make sure as soon as you're aware that there's a potential emergency, that the rest of the team are aware. It's also useful to have a .

An area or box where common emergency equipment is always ready, such as IV catheters, oxygen supplies and circuits, intravenous fluids, and also you, it's advisable to also have a crash box ready, especially in two emergency situations. And If you've always got the, these things kept in the same area, that's tend tends to be where you'd take the patients when they first arrive. And along with the equipment, it's useful to keep emergency drugs in there, along with the dosage chart, which, again, can avoid delays and reduce the risk of mistakes.

Some conditions should prompt staff to start gathering essential equipment, such as the dysneic cat where an oxygen take should be set up and ready for when they arrive, seizure in patients where anti-seizure drugs and a method of cooling them may be needed for when they get there, or largeaps collapsed dogs where staff and a trolley or stretcher may be needed to assist the owner in getting them into the clinic. So all patients should be triaged on arrival at the clinic, even ones which sounded stable on the phone, as the severity of the condition may have been missed or the patient may have deteriorated further during the journey. Animals which arrive in carriers or boxes which can't be seen as immediately as they come in the door are especially important to get checked as soon as they arrive.

So we start this initial assessment is the primary survey. So the primary survey looks at four aspects focusing on the major body systems, using the mnemonic ABCD which stands for alert, breathing, circulation, and disability. So this survey should take no more than 90 seconds, and it's sometimes just a case of doing this, in the waiting room.

So the questions you need to be asking or looking for is, is the patient conscious? Is there any respiratory effort? Does it have palpable pulses or heartbeat?

And are there any indications of major disability? This rapid primary survey will help to determine which patients require immediate intervention and which patients can wait a very short time or potentially a little bit longer. So any abnormality in any areas of the primary survey is an indication that immediate action is required and the patient should be taken straight through to the treatment area as cardiopulmonary arrest may be imminent.

For those patients which are not immediately critical, findings at the primary survey may indicate how quickly they need to be seen. Are they urgent and can wait a short period of time, or are they stable and able to wait potentially longer period of time? The primary survey can also identify patients which, whilst they're stable, it may not be appropriate for them to be in the waiting room, and they would be better taken through to the backup to put into a consult room.

For example, things like large wounds, potentially infectious diseases, excessive or unpleasant bodily charges, bodily discharges, or even, potentially patients which have deceased when they have arrived. Communication with the rest of the team is vital at this point to ensure that everybody knows who are the priorities and what is happening. This includes front of house staff who are likely to need to explain to other clients the reasons for delays or may have to keep the owner of the patient that's been rushed through to the back, updated on what's going on.

If a patient is taken through to the back for immediate treatment, the owner should be asked to wait in the consult room or somewhere private, and advised that someone will be through shortly to get a capsule hips history and update them on what is happening. Consent must be sought from the owner prior to any treatment. This may initially be done verbally until resuscitation measures have been started and written consent can be sought.

The casual history should be taken by a qualified member of staff. It should be a brief history which is relevant to the patients presenting problem. It should check the signalment of the patient or maybe needs to record it if it's not being taken during the call, and a certain, a certain events which have led up to the patient being presented.

If a trauma has occurred, was it witnessed? If so, what. Occurred, can they describe where the impact occurred on the patient?

Has it deteriorated since the incident? For toxicities, what has been eaten? Do they know how much it ate or how long ago it ate them?

And for illnesses, what are the problems, what are the signs that they've seen, when did they start, and how have they been progressing? Whilst a full medical history is not needed, it is important to ask about concurrent conditions and things that are important to, conditions such as diabetes, kidneys or cardiac disease, and epilepsy and other conditions similar. It's also important to check whether they're on any prescribed medications and to also check whether they're on any unprescribed medications or if the owner is given any meds prior to attending.

It's not uncommon for owners to give human pain meds. And depending on the patient's condition, it may also be appropriate to discuss whether they would want resuscitation to be carried out should they crash. Although this does need to be done with care, and it's not something that you can just drop into the conversation at the end of everyone, it needs to be sort of more judged.

So now we've got these 4 patients that have all arrived at the clinic at the same time. It's one of those shifts. So how are we going to classify them following on from the primary survey?

Which ones of them are emergent, immediate, need immediate attention, which ones are urgent? Which ones are potentially more stable? So again, we'll start with the cats.

So the cat's, eight year old domestic short hair that's open mouth breathing. Well, open mouth breathing obviously isn't normal, so this can be either due to, an, Problem with the respiratory system, which is a major body system and therefore would require immediate treatment, or it can also be done due to stress or it can be due to pain. But in these circumstances, it's always better to err on the side of caution, as these patients can deteriorate very, very quickly, and they have to be handled with care if, if they're going to get very stressed.

So getting them out of the waiting room, getting them into an oxygen enriched environment is going to be beneficial. We've then got a 3 month old pug which is collapsed. Well it's obviously not normal for a dog of that age to be collapsed, so therefore, there is some problem with one, if not all, of its major bodies systems.

So this one is going to require immediate intervention and should be taken straight through to the back and the veterinary surgeon made available. We've then got the 5 year old German Shepherd, who's been hit by a car, but it is standing, it's looking round, it's paying attention. So it's blatant, it's obviously got a heartbeat.

There's no obvious signs of deterioration, it's airways. Therefore, it can potentially wait, so it is urgent, but it's not desperate to be seen at that point. But somebody needs to be keeping a close eye on it to make sure it doesn't suddenly change, or it wasn't just an adrenaline rush that's got it through into the waiting room stood up.

And then finally we've got the 12 year old Weimaran with a head tilt and vomiting. So potentially, this has got, changes to its neurological system. But again, this is a patient that's pink, it's breathing OK.

And so it's not an one that's got an immediate problem that needs something doing with it. However, it may not be appropriate to leave this patient in the waiting room, because quite often it's distressing for the owners, it's just stressing for the patient to see them like this, and it's distressing for other, clients that are waiting in the waiting room. So with this case, we are probably be tempted to take it through the back and to see if I can get it into a kennel and if I can position it in that position so the head, the world's not spinning upside down and if that helps.

So a secondary sur the secondary survey, which again focuses on the major body systems, follows the primary survey. If any abnormalities of the major body system are identified during the survey, immediate action should be taken, as failure of one of the systems can result with death of the patient within minutes. The secondary survey is more in depth and involves the recording of parameters and obtaining further information about the patient's status.

It is important to record parameters, especially in critical patients where their status can rapidly change, and we're gonna keep repeating the measurements so that we can see any trends and therefore identify any deterioration or improvement quickly. Although veterinary nurses cannot make a diagnosis, having a knowledge of what is normal and abnormal will enable them to alert the veterinary surgeon to potentially life-threatening conditions. So, don't, one of the main things is to not get distracted.

So, don't get distracted by gross physical exam findings. These may not be affecting the major body systems, and concentrating on these before completing the secondary survey can result in abnormalities, abnormalities to the major body systems being missed. So whilst these images look, like the wounds should be the priority, neither of them were bleeding significantly, so we're not an immediate concern.

And however, the cat with the fractured femur had obviously been involved in a significant trauma and had an internal haemorrhage, which could easily have been missed if the secondary survey had not been completed due to concentrating on the open fracture. And as with the triage phone call, it's important to have a structure to avoid distractions and and to ensure that the major body systems are assessed as a priority. So we start with the cardiovascular system.

So assessment of the cardiovascular system gives us essential information about the hemodynamic stability of the patient. Perfusion, which is the blood flow to the tissues, is vital for normal cellular activity and therefore patient survival. The major concerns in relation to the cardiovascular system are hypo perfusion and hypoxemia.

The main perfusion parameters which should be assessed are the pulse rate, quality, and synchronicity with the heartbeat, capillary refill time and mucous membrane colour. So to start with what is the pulse rate of the patient. So normal pulse rate for a dog is 80 to 140 beats per minute, and for a cat, 150 to 200 beats per minute.

The rate should be recorded and any tachycardia or bradycardia noted. It's important to consider whether the pulse rate is appropriate. So for example, a dog which been involved in a road traffic accident and is in pain would be expected to be tachycardic.

So to get a normal heart rate in this dog would be inappropriate. Therefore, it's, it's classed as inappropriate bradycardia. It's also widely documented that cats are not small dogs, and they tend to develop bradycardia when they're in shock.

So a heart rate of 150 beats per minute in a clinic setting may be abnormal for a cat, and it may be that it's actually bradycardia and starting to go into shock, even though it is in theory in the normal range for a cat. As well as getting the pulse rate, we also need to palpate the pulse, and we need to feel what it's like. So, again, this is something that comes more with practise, but the things that you can feel are, is it got a weak pulse, which you tend to see with hypovolemic patients, and it tends, as it progresses, the pulse will get weaker and then it become, can become thready.

Other things that you may find are bounding pulses, which you can see with septic patients, or snappy pulses, which you may feel with anaemia. You need to listen to the heartbeat whilst also feeling for the pulse rate, and there should be a corresponding pulse beat for every heartbeat. And if there isn't, this is termed as a pulse deficit, and this indicates an arrhythmia.

And what is the capillary refill time? So the normal capillary refill time is 1 to 2 seconds. So a prolonged capillary refill time is over 2 seconds, and this is consistent with hypo perfusion or shock.

Whereas a rapid capillary refill time of less than 1 2nd is also normal, and it can occur in the initial stages of the sympathetic nervous system responds to hyper perfusion. However, as the cardiovascular system decompens decompensates, the capillary refill time will become more prolonged. So we also need to consider the mucous membrane colour, and usually we'll look at the gums for mucous membrane, but it is possible to use other areas such as the conjunctiva or other areas, other membranes to assess, especially if the animal's got pigmented gums which can make it difficult to see what's happening.

The normal mucous membrane colours should be pink in dogs and slightly paler in cats. And as the cardiovascular system decompensates, the mucous membranes will become increasingly pale. Pale mucous membranes will also be seen in anaemic patients.

So, the, the third eye, you can see on the top left of the screen, that's a dog, that was anaemic. So you can see that that is a really white, mucous membrane. The next picture along is a dog with very red mucous membranes.

This dog also had, a virtually an Sorry. It also had, a capillary refill time that was just like instantaneous. You could hardly count how long it took to fill in.

It was so fast. So to get red mucous membranes alongside signs of hypo perfusion, it needs to be flagged as this indicates that the peripheral vasoconstriction, which would usually occur in these circumstances, is not taking place, and therefore it can indicate widespread inflammatory responses such as sepsis or anaphylaxis. Other changes which provide information on the status of the patient include yellowing, or it, or jaundice.

So that's seen in the cat on the top right of the picture. And this is seen with increased bilirubin levels. The dog on the bottom left of the picture has got cyanosis, which is the bluey purply colour, which is indicative.

Of an extremely low level of oxygen in the blood and can rapidly progress to cardiopulmonary arrest. However, don't, so just because the patient doesn't have cyanosis doesn't mean that their oxygen levels are OK. You can still get animals that have got very low, oxygen levels in the blood and not be cyanotic.

And the final picture, is, is of a dog that's got petiation, so you can just see sort of the little bruising or the redder marks on the gums, and this is indicative of hemostatic disorder, such as a coagulopathy occurring following ingestation of rodenticides. So following on from the cardiovascular system, we move on to the respiratory system, and disruption of any part of the re respiratory system may lead to respiratory distress, abnormal breathing patterns, or respiratory arrest. A hands-off approach is extremely important in patients demonstrating signs of respiratory distress.

Lots of useful information can be gathered by observing the patient before you need to put your hands on or you need to auscultate. So to start with, what is the breathing rate? Normal for a cat and dog tends to be 20 to 40 beats per minute, but remember that increases can be seen with stress and pain as well as due to issues with the respiratory system.

So we also need to look at the body position. Patients with the respiratory compromise will commonly present internal recumbency, or they may be sitting and they've got their neck extended, elbows out and open mouth breathing like the cat in the picture. And patients in lateral recumbency or unable to settle together with signs of dysm are at risk of cardiopulmonary arrest.

Observing the pattern and noting any increased effort can aid in identifying the cause of the problem. A normal patient will have very minimal chest and abdominal movement when breathing, so increased abdominal or chest movement shows that patients having to engage its abdominal and intercostal muscles to help it breathe, and it demonstrates that there's an increased effort. Can you also, you also need to listen for audible noises, so can you hear sort of any sounds snorting, anything like that that need to be noted down cause these can help the veterinary surgeon to identify the location or the cause of the problem.

And listening to jests, this is a skill that as nurses, we should practise quite a lot. And in the, when it comes to doing a secondary survey, we should be listening to the chest on both sides and over several areas. And again, you're listening for abnormal sounds.

So, can you hear any wheezes or crackles are the usually ones that you need to note? Or is there a reduction in breath sounds, so you can't actually hear any air moving within the chest, which is in can be indicative of a pleural effusion. So if the patient is showing signs of any breathing difficulties, whilst doing this, the survey needs to be stopped, and the patient should be given oxygen whilst the veterinary surgeon is alerted.

These critical patients decompensate rapidly and require immediate but stress-free interventions. So when you're administering oxygen, it's important to choose the most appropriate method of delivery. Many patients will be very stressed by a face mask, and if they're already struggling to breathe, you stress them, it means they need even more oxygen, and it makes the situation much worse.

So most won't tolerate, face masks. Those that will tolerate face masks, it's important to remove the rubber rim to allow them to pant. So that picture of the dog with the black rubber ring.

And the face mask, it's got no space within there. It can't open its mouth when it wants to pant and again, it's gonna make the situation worse. So, in the most patients, it may be appropriate to do flow by oxygen, as demonstrated with that dog.

But if you're having to chase the dog round with your flow by oxygen, again, it's a bit of a waste of time and you're making the animal use more oxygen to try and avoid you. For small cats and dogs, for small dogs, sorry, and cats, oxygen tents or oxygen cages can be used, but just remember that they need to build up to a certain amount of oxygen. And every time you open the door or you unzip it to have a look at the patient, you're letting all the oxygen out.

So with patients that are really struggling. To breathe. It's better just to get them in some oxygen, shut it up, and do your observations externally, those that you can do, and leave the patient well alone to settle, or don't, try and implement anything else to it till it's had some kind of, treatment or intervention to make it slightly more stable.

And the final step in the neurological assessment, . Is the neuro final step, sorry, start that one again. So the final step is the neurological assessment.

The aim is not to perform a full neurological exam, but to identify significant abnormalities concerning the brain and the spinal cord. So common neurological conditions causing an animal to be presented as an emergency include seizures, head traumas, acute changes in mentation and spinal cord disease, and any patient that's is actively seizuring when it arrives, again needs to be taken through for immediate treatment and the veterinary surgeon informed. Care needs to be taken when handling patients, which may show signs of spinal issues, because, again, we don't want to make it any worse, and they can be extremely, uncomfortable.

So if you're seeing dogs that are presenting like the dog in the picture, it's obviously struggling. It's obviously got a sore back, so take great care when you're moving them. Don't try to force them into any positions.

Let it move at its own speed if it's better walking. So the first aspect, to assess with regards to your neurological system is the mentation. So normal mentation is dependent on oxygenated blood flow to the brain, therefore, the cardiovascular and respiratory system findings need to be taken into account when assessing mentation.

If blood flow is compromised, as with hypovolemic shock, there'll not be enough oxygen going to the brain, and that is what's affecting the mentation rather than a problem with the brain. So in patients, which have got neural, problems with the mentation, what you do is, if they've also got things like hyper perfusion or there's a risk of hypoxia, once you've started, those measures to, to resuscitate them, you'll repeat, assessment of the mentation to see whether it's getting better and whether it was actually a cardiovascular and respiratory compromise that was leading to changes in mentation. So the mentation's classified, through different terms.

So you can have normal. So normal means that the patient's alert, it's looking around, it's paying attention, and it's responding to people that are around it, appropriately. So, you know, Labrador's busy wagging its tail and looking, excitable animals are coming towards you to see what you're doing, things like that.

Or if they're painful, they're actually moving away from you, that kind of thing. You're getting some kind of response which is as appropriate for the condition of the patient. A depressed patient is alert, so it's watching what's happening, but it's not responsive.

So it's not trying to get away from you, and it's not doing what you'd usually expect them to do. Optundin patients are unconscious, but arousable to non-noxious stimuli. So non-noxious is, sort of shouting.

Whereas stuporous patients are unconscious and are only rousable to noxious stimuli. So noxious stimuli is when you would squeeze a toe with artery forceps. So it involves a bit of pain or something that they can feel, which makes them respond.

And then comatose patients are unconscious and not res rousable to any stimuli. And after we've assessmentation, then we, we need to go on to assess the gait. So we look at the gate if the patient's ambulant or ambulatory, or if it's not, it may be a case of trying to work out, what its spinal integrity is if the patient can't stand up.

And it can be difficult to distinguish between orthopaedic and neurological patients, problems, especially in patients that aren't moving or can't move very well. So, the abnormalities which may be observed and should be noted include things like paralysis. So paralysis is where they can't move, so something such as a limb.

And if you see paralysis, it's worth noting down where it is. So, is it in the front limbs? Is it in the back limbs?

Is it in both limbs on one side, or is it just in the one limb? Have they got paresis? So paresis is, weakness.

And again, you'd do the same as paralysis, you'd know where it is. Is the patient circling? If they are circling, are they always circling in one direction, because this can be a significance for the veterinary surgeon?

Is there any kind of triing or tremors? Is there any seizure in? Or are they rolling?

So, these patients, you may see with, dogs like the Weimarana that we discussed earlier is the case, if they've got things like vestibular problems where they just can't keep the balance, they're rolling over all the time. And then other ones to look out for a specific, positions that tend to indicate spinal, traumas or spinal injuries. So you've got, the dog on the top picture has Shiff Sherrington.

So it's got extended rigid forelimbs and paralysed flaccid hind limbs, and this syndrome indicates, can indicate a thoracollumbar spinal lesion. And then the dog on the bottom right is epistotonus. And you can see it's got hyperextension of its neck, and it's got stiff extended limbs in all four limbs.

And this can indicate impending herniation of the brain and can be a very grave prognosis. So, as well as making sure that we've, we, we've carried out these minimum, checks of the major body systems, it's also important to make sure that we have documented these results. And this not only aids with, being able to track what's going on, but it can also help, vet to pass communication between the rest of the team and report your findings to the veterinary surgeon.

So, what we tend to do in the, vets now is we have, a triage sheet. So this sheet is basically, it's quite easy to fill in, and you're following, it follows through the major body systems as you do it. So even though in this talk, I described doing the cardiovascular system, first, we put the respiratory system at the top just because we want it to be clearly flagged that if there's any kind of problem with the breathing, we're not going any further.

It gets put in the oxygen tent sort of straight away. So they go through those, and it can be filled in very quickly. It's usually just a case of documenting things in, like, the heart rate, or again, it's just circling the appropriate description.

And it's colour coded to help flag the fact when there's patients that are of a concern. So, if anything's circled that's in red, it means that this patient's requiring immediate treatment, and at that point, the rest of the sheet should stop being filled in, and it should be taken through, or the vet should be gone and got to. Get them in then we can start treatment immediately.

So that's the end of the survey, so the surveys that we do and it's the end of our triage process, after that it goes on more to the treatment and the emergency stabilisation of the patients. So in summary, triage starts from the first contact with the client, being, being able to effectively communicate with them at what can sometimes be a very upsetting time, not only allows us to establish the condition of the patient, but also means we provide the client with necessary information included any first aid advice which may be required. Asking relevant questions in relation to the cardiovascular, respiratory and neurological systems means that patients requiring immediate attention can be rapidly identified and in emergency cases, the information gathered during the call allows the rest of the team and equipment to be prepared for when the patient arrives in the clinic.

And once at the clinic using a structured approach to performing primary and secondary surveys, again, focusing on the major body systems, means that patients can be categorised to ensure that those which require remedient treatment can be prioritised. So thank you very much for watching this webinar.