How to triage sick exotic veterinary patients

While you may not be planning on seeing extremely sick or emergent exotic patients initially, it’s very possible you will have a critical patient show up at your door or even come in for a planned sick visit in a much more critical condition than expected. Even if you don’t feel fully equipped to deal with exotic patient emergencies, there are some basic tenets of triage that are good to remember. 

Triage starts on the phone and with the front desk staff, so make sure they are prepared with some basic knowledge. If you aren’t regularly taking emergency cases, they should have a list of other nearby exotics emergency clinics to which to refer clients. Review a list of basic questions they should ask when scheduling to determine if a patient is critical and make sure they are aware of key differences with exotics. A rabbit or guinea pig not eating for 8-12 hours is MUCH more concerning than a dog or cat not eating in that same time frame. Alternatively, a reptile may not eat for weeks without any underlying issues. 

If a patient is brought in collapsed or with obvious respiratory distress, make sure the front desk staff is aware to immediately bring them to the treatment area and alert the doctor of a potentially unstable patient. It is much better to be overly cautious with a stable patient than to realize a patient is in critical condition too late. 

When the patient presents, they should be briefly visually assessed to evaluate mentation, body condition, ambulation, and for respiratory distress or visible traumatic injuries. 

If the patient is not bright, alert and responsive, it should be assessed using the ABCDE protocol, described below. This process allows for a stepwise evaluation of the patient. If there are concerns, each should be addressed prior to moving on to the next step.

1. Airway

   1. Assess for signs of obstruction, increased respiratory effort, cyanosis, stridor and open mouth breathing.

   2. A common finding is mucus externally obstructing the nasal passages in rabbits with respiratory disease.

   3. Provide oxygen therapy and remove obstructions if present.

2. Breathing

   1. Assess the depth, frequency and pattern of respirations

   2. Perform thoracic auscultation

   3. Provide oxygen therapy if any concerns

3. Circulation

   1. Check the pulse quality, mucus membrane color/capillary refill time and for the presence of abnormal heart sounds or rhythms

   2. Check for hemorrhage and control if present

   3. Start fluid replacement if indicated - this is often with subcutaneous fluids if the patient is unstable; if the patient is obtunded, consider placing an IV catheter or moving straight to IO catheter depending on the species

4. Disability (mentation)

   1. Assess mentation and reflexes (menace response is typically absent in rabbits/rodents)

   2. Check pupil size/symmetry

5. Exposure of environment

   1. Check for external wounds/injuries

   2. Assess temperature in appropriate species

   3. Treat any wounds if present and if the patient is stable

Remember that many exotic patients are prey species, therefore they are incredibly good at hiding how sick they are from not only their owners, but also veterinary staff. Often by the time they present as a ‘sick’ visit, they have been declining for weeks without the owner realizing it, and they can easily slip over into the critical category. Just traveling to and being present in a veterinary setting is stressful and can tip them over the edge. It’s important to use restraint cautiously to minimize stress but prevent escape - this means utilizing low-stress handling techniques including chemical restraint, and working slowly but efficiently.

Once the basic assessment is completed, consider administering heat support, oxygen support and/or fluid support depending on patient condition. Birds and reptiles almost always benefit from heat support; critical mammals can be either hypothermic or have an elevated temperature, so rely on vital signs to determine if heat supplementation is appropriate. Hypothermia carries a guarded prognosis in most exotic mammals and makes other treatments less effective so warming is vital. Certain mammals like chinchillas and ferrets can be easily overheated so close monitoring is warranted.

If breathing is labored on initial observational exam, stop and place the patient in oxygen support and consider administering mild sedation. Butorphanol and midazolam administered IM work very well for this, dosed based on stability/age of the patient from 0.25 - 1 mg/kg each. 

If the patient has a suspected or known painful condition, administer opioids, but consider a dose on the lower end of the recommended range if the patient is unstable. For exotic companion mammals, I prefer buprenorphine or methadone. For most avian species, butorphanol is the best choice. Reptiles are a mixed bag - we don’t have great efficacy data on many drugs/species, but check your formulary for the best option for the species you are dealing with.

Once the patient has been assessed (or during the initial exam if you have adequate staff), a thorough history should be obtained from the owner. Many clues to help determine the primary differentials can be found in the pet’s history. Determine the presenting complaint, how long it has been present, how frequent the signs occur, any behavior changes, and if there have been any diet or elimination changes? What is the primary diet? How is the animal housed? What type of bedding? How often is it cleaned? The age/sex/neuter status? Is it around other pets? If so, do they have contact with the patient, and are they showing signs? 

Alternatively, clients can fill out a detailed paper or electronic questionnaire for the history.

The primary takeaway here is to GO SLOW. Provide heat, oxygen and fluid support as needed along the way. Don’t worry about getting diagnostics or even performing a full physical exam immediately. I often advise the owner that their pet will be staying with us most of the day and explain that we take things very slow to minimize risk. I also make sure to explain the severity of the situation and get a CPR code from the owner. This is a delicate conversation, but I explain to them that if resuscitation is indicated, we need to be able to proceed immediately rather than trying to get in contact with them prior to starting. 

Seeing exotic patients on emergency can be daunting, but most DVMs are already confident in these concepts when treating dogs and cats, and the same principles can often be applied to exotic patients.