Triage n. A process for sorting injured people into groups based on their need for or likely benefit from immediate medical treatment. From the Old French trier, meaning to sort.

There are many different species and types of birds, all requiring a slightly different approach to triage and initial emergency care. Practices may treat parrots, passerines (song birds), raptors, waterfowl, poultry or zoo birds, but the focus of this presentation will be on the more commonly seen birds such as parrots (which includes budgies) and birds of prey, especially those from the wild.

First Point of Contact

With birds, triage should begin with the initial phone call. Both nurses and receptionists should be trained to recognise which cases need to be seen urgently. Unlike dogs and cats, birds are not domesticated species therefore they hide the signs of illness in the early stages of disease. This means that chronic conditions can present as genuine emergencies. When an owner notices their bird is sick, then it usually needs seeing ASAP. Therefore, something that is not urgent in a dog could be life-threatening in a bird if not treated promptly. Figure 1 lists cases that should be seen immediately.

Figure 1. If the owner reports any of the following signs then the bird should be seen immediately.

 Bleeding from anywhere

 Breathing difficulties or abnormal respiratory noises

 Change or loss of voice

 Failure to empty crop (especially birds of prey)

 Fluffed-up appearance

 Regurgitation

 Having seizures

 Falling off perch

 Sitting on the bottom of the cage

 Sudden inappetence

 Sudden onset swellings or enlargement of any part of the body

 Any trauma

 Sudden change in appearance of droppings

 Depressed behaviour or interaction

Other presentations such as gradual loss of condition, feather picking or damaged feathers, nail and beak trimming or routine health checks can usually be scheduled for the next available appointment. With wild bird presentations contact details of the rescuer should be obtained, along with details of how and where found, and whether the rescuer wants to be involved in treatment and/ or rehabilitation.

It is important to decide if an appropriately skilled avian vet is available to see such emergencies, and if not, you should know where best to send the client. Where possible the bird should be presented to the surgery in its own cage, or with a sample of the paper from the cage floor. The owner should also bring the food that is being fed, any treatments and any supplements. Establishing the species and sex of the bird is also important prior to presentation. Certain species present with different problems, and knowing if a bird is male or female will help to rule out some problems (e.g., egg binding), thereby allowing you to be fully prepared.

At the Surgery

On arrival the sick bird should be directed to a quiet, secure and dimly lit waiting area. It is important that the bird is not forced to wait near barking dogs or cats licking their lips! Triage must be performed immediately by an experienced nurse or vet, since prompt, accurate treatment is essential for a favourable outcome. Where there is obvious blood loss, head trauma, seizures or respiratory distress it is recommended that an avian vet should triage the bird if at all possible. The type of triage will, to some degree, depend on whether the bird is wild or a pet. All birds should initially be assessed for shock and stabilised, but with wild birds we also have to consider the likelihood for successful release.

Injured or traumatised birds should be minimally handled until shock has been addressed. Do not do too much too soon otherwise the bird may well deteriorate despite your efforts.

Initially it might be useful to consider the approach to a dog and cat emergency by thinking of A (airway), B (breathing) and C (circulation).

Breathing problems should be evident from visual inspection. Circulation is more difficult to assess, since mucous membrane colour and capillary refill time (CRT) are difficult to check. Look for any evidence of bleeding, and the refill time of the ulnar vein (under the wing distal to the elbow) can be assessed; it is normally rapid (<1 second).

Breathing Problems

Birds with respiratory distress are on a knife edge. The stress of handling can push them over the edge. Therefore birds with breathing difficulties should be immediately placed in a warm, dark, quiet space and provided with supplemental oxygen (i.e., oxygen tent or chamber). Many of these birds will improve after 15-20 minutes of oxygen therapy and then further assessment can be made. During this time, a thorough history can be obtained from the owner, and a poor prognosis given. If the bird dies in this period, then inevitably the stress of handling would also have resulted in death.

Shocked Birds

Any traumatised bird is likely to be experiencing some degree of circulatory shock. This can be judged by mental status, capillary (or vein) refill time and heart rate (initially rapid, but may be slow prior to death). If considered to be in shock, perform a very brief clinical examination; this can be repeated more thoroughly when the patient is more stable (Figure 2).

Any bird that is shocked, depressed or fluffed-up should be placed in a warm, dark environment with the optimum temperature being 29-30°C. Oral fluid support can be initiated with 10 ml/kg of warm fluids plus electrolyte given by gavage tube, which can be repeated after 2 hours. In the majority of cases analgesia is beneficial to the traumatised patient using butorphanol 1-2 mg/kg i.m.

Many sick or injured birds will benefit from supportive measures such as oxygen supplementation, fluid therapy, analgesia and observation for the first few hours in a dark, quiet, warmed environment before diagnostic testing. Broad-spectrum antibiotics, antifungals and nutritional support may also be beneficial if full assessment by an avian vet is likely to be delayed.

Figure 2. Brief overview of the avian clinical examination (should be shortened if bird is very shocked).

 Whether or not to do examination? Depending on the severity of the injury, it may be better to postpone examination in favour of supportive treatment.

 Beak: shape, colour, lesions, bleeding, dusty appearance.

 Oral cavity: smooth and moist with no foul smells, plaques or discharges. Check slit at roof of mouth (choana) for foreign bodies. Fleshy mobile tongue in parrots.

 Eyes: 30% trauma cases have ocular lesions. These may have been caused by the trauma, or could have been the cause of the trauma. Assess if the bird looks like it can see. Look for symmetry, discharges, clear and bright cornea. Examine the posterior chamber with an ophthalmoscope and assess the pectin.

 Ears: hidden by feathers, just behind the eyes. Check for blockages of the ear canal or bleeding.

 Nares: discharge, foreign bodies, rhinoliths/plugs.

 Crop: right side of the bird's neck. Should be some food present. Check skin, consistency of contents, foreign body, thickening of the wall.

 Keel: palpate to assess muscle and fat (body condition). Haemorrhage, fractures. Site for intramuscular injections.

 Coelomic cavity (abdomen): distension, muscle wall rupture.

 Vent: prolapsed organs (oviduct, colon, cloaca, ureter), faecal soiling.

 Legs and feet: fractures, joint swellings, limb deformities, sores on feet, weak grip, muscle atrophy.

 Wings: ability to fly, weakness, wing drop, fractures, muscle atrophy, feather quality.

 Feathers: stage of moulting, broken or missing feathers, oiled feathers.

 Skin: wounds or deficits, infected areas, inflammation, lumps.

 Cardiovascular system: refill time of ulnar vein, heart auscultation over pectoral muscles or dorsum, heart rate faster than mammals (100-350 bpm).

 Respiratory system: rate and effort, abdominal component to breathing, inspiratory stridor, tail bobbing, coughing, auscultation of air sacs dorsally and laterally over ribs.

Birds with Fractures and Wounds

Wild birds often present with wounds and/or fractures following trauma. It is important to remember that treatment (and rehabilitation if necessary) for successful release is always the aim when treating wildlife cases and, on welfare grounds, birds would only be rehabilitated for captivity if they were of significant conservational value. To be released these birds have to be able to fly, see, hunt, kill and feed well enough to survive. Injured wild birds will be shocked and extremely stressed at being handled, so clinical examination should be brief, and some consider it to be safer under anaesthesia. Initially, check the bird for bleeding (and stop it!), then cover any open wounds to prevent desiccation and further infection. Evaluate the birds for fractures (both open and closed) by palpating all the wing and leg bones, and taking a radiograph if necessary. Fractures should be temporarily stabilised to prevent further pain and damage and the bird should be given analgesia (see above) and antibiotic cover (e.g., amoxicillin/ clavulanate 125-150mg/kg i.m. or enrofloxacin 2.5% 15-30 mg/kg i.m.). Oral fluids and food (gavage feed 10-15 ml/kg Hill's a/d for raptors) can also be given.

Steroids are rarely indicated since they cause marked immunosuppression in birds and are not proven to be effective in shock. After triage and stabilisation, they should be placed in a warm, dark, quiet area (away from other predators and busy areas).

Orphans

Where possible they should be returned to the nest immediately or where they were found unless in immediate danger or injured. Otherwise, in order of preference, they should be returned to another wild nest of the same species under DEFRA license, reared in captivity under foster parents of the same species, in a crèche or by a different species, or hand-reared with puppet feeding; all with the aim of release when fully fledged (feathered).