TRIAGE
TRIAGE
• Adalah tindakan memilah-milah penderita
dalam suatu korban multipel atau massal,
berdasarkan kegawatan penderita
• Pemilahan tergantung dari banyak faktor :
ABCD; prognosis; tersedianya alat; waktu
yang dibutuhkan dll
• Informasi/data terbatas; tetapi jangan ada
yang tanpa keputusan akan diapakan
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PENDERITA GAWAT
DARURAT
• Prioritas Pertama (MERAH) : gangguan
ABC
• Prioritas Sedang (KUNING) : tanpa
gangguan AB tetapi dapat memburuk cepat
• Prioritas Rendah (HIJAU) : luka ringan
• Bukan prioritas (HITAM) : meninggal
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START
• Salah satu metode adalah START (Simple
Triage and Rapid Treatment)
0. Awal
1. Airway
2. Breathing
3.Circulation
4. Kesadaran
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AWAL
• Panggil semua korban yang dapat berjalan,
perintahkan pergi ke suatu tempat
Semua korban yang dapat berjalan
dan mengikuti perintah ini, dapat kartu
hijau
Sisanya periksa ABCD
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AIRWAY
• Penderita terdekat, masih bernapas?
Bernapas, penderita berikutnya
Tidak bernapas, buka airway
Tetap tidak bernapas : bendera hitam
Bernapas : bendera merah
Bisa bernapas spontan, penderita
berikut
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BREATHING
Napas spontan :
• > 30 kali permenit : bendera merah
• < 30 kali permenit : tahap berikut
Tidak bernapas : bendera hitam
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CIRCULATION
• Periksa capillary refill / pengisian kembali
kapiler tangan :
• > 2 detik : bendera merah
• < 2 detik : tahap berikut
Gelap, tidak terlihat pengisian
kapiler
• Tidak teraba : bendera merah
• teraba : tahap berikut
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KESADARAN
• Tidak dapat mengikuti perintah : bendera
• merah
Dapat mengikuti perintah : bendera
kuning
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TRIAGE TAGGING
TRIAGE
CASE STUDY
Case
• A 10 passenger bus crashes on a busy road
hitting a family of 5 in another vehicle head
on. The following are some of the victims
from the scene that you are now the triage
officer for. Triage these patients RED,
GREEN, YELLOW and BLACK according
to START criteria.
• Remember you have less then 60 seconds to
assess each victim.
VICTIM 1
• 17 yo female with large
bleeding laceration to leg
– Respirations: 20
– Pulse: 65
– Mental Status:
Screaming
Victim 2
• 51yo driver of the family
vehicle, entrapped in
wreckage with obvious
head injury and brain matter
protruding
– Respirations: NONE
– Pulse: NOT PALPABLE
– Mental status:
UNRESPONSIVE
Victim 3
• 65 yo male with
complaint of painful
breathing and bloody
bruised left chest
– Respiration: 35
– Pulse: 120
– Mental Status: Intact
Victim 4
• 3 yo unconscious
male in back seat of
car
– Respirations:
Absent
– Pulse: Weak and
thready
– Mental Status:
Diminished
Victim 5
• 26 yo female with
mild bruising of
abdomen, walking at
the scene
– Respirations: 24
– Pulse: 120
– Mental Status:
Intact
Victim 6
• 6 yo male crying no
apparent injuries
– Respirations: 35
– Pulse: 110
– Mental Status:
Intact
Victim 7
• 45 yo female
complaining for left
hand pain with obvious
deformity of wrist with
bone exposed
– Respiration: 30
– Pulse: Absent in
wrist
– Mental Status: Intact
Victim 8
• 19 yo female
unresponsive with
bleeding from ears
– Respirations: None
– Pulse: No peripheral
pulse
– Mental Status:
Unresponsive
Victim 9
• 30 yo male
complaining of neck
pain walking at the
scene
– Respirations: 25
– Pulse: 95
– Mental Status:
Intact
Victim 10
• 60 yo male with
complaining for
chest pain
– Respirations: 40
– Pulse: 110
– Mental Status:
Intact
VICTIM 1
• 17 yo female with large bleeding laceration to
leg
– Respirations: 20
– Pulse: 65
– Mental Status: Screaming
• YELLOW
– APPLY PRESSURE DRESSING AND
MOVE ON TO NEXT PERSON
Victim 2
• 51yo driver of the family vehicle, entrapped
in wreckage with obvious head injury and
brain matter protruding
– Respirations: NONE
– Pulse: NOT PALPABLE
– Mental status: UNRESPONSIVE
• BLACK
– Move to next victim
Victim 3
• 65 yo male with complaint of painful breathing
and bloody bruised left chest
– Respiration: 35
– Pulse: 120
– Mental Status: Intact
• RED
– Quick exam reveals decreased breath sounds on
left, needle decompression relieves the
pneumothorax and respiration and pulse
improve
Victim 4
• 6 yo unconscious male in back seat of car
– Respirations: Absent
– Pulse: Weak and thready
– Mental Status: Diminished
• RED
– As soon as a jaw thrust maneuver is performed
respiration is restored and patient mental status
improves
Victim 5
• 26 yo female with mild bruising of abdomen,
walking at the scene
– Respirations: 24
– Pulse: 120
– Mental Status: Intact
• YELLOW
– Mild bruising of the abdomen with elevated pulse
could signify a serious injury
Victim 6
• 3 yo male crying no apparent injuries
– Respirations: 35
– Pulse: 110
– Mental Status: Intact
• GREEN
– Respiratory rate for children in JUMPSTART is
above 45 and below 15
– Pulse is present and intact as is the mental status of
the child
Victim 7
• 45 yo female complaining for left hand pain with
obvious deformity of wrist with bone exposed
– Respiration: 30
– Pulse: Absent in wrist
– Mental Status: Intact
• YELLOW
– Even though this is a limb threatening injury., it is not life
threatening. If the patient is placed in a splint, they can
wait to be fully evaluated
Victim 8
• 19 yo female unresponsive with bleeding from
ears
– Respirations: None
– Pulse: No peripheral pulse
– Mental Status: Unresponsive
• BLACK
Victim 9
• 30 yo male complaining of neck pain
walking at the scene
– Respirations: 25
– Pulse: 95
– Mental Status: Intact
• YELLOW
– He is walking and neurologically intact
Victim 10
• 60 yo male with complaining for chest pain
– Respirations: 40
– Pulse: 190
– Mental Status: Intact
• RED
– His respirations are above 35, he has a rapid
pulse and is complaining of chest pain, so there
is a high degree of suspicion for injury
Questions
• In START triage an adult with
respirations at a rate of 36 per minute
is tagged as:
1. Red
2. Yellow
3. Green
4. Black
Questions
• In START triage, an adult with a fractured
tibia, respirations of 20, and a palpable
radial pulses and no mental impairment is
tagged
1. Red
2. Yellow
3. Green
4. Black
Questions
• The Goal when triaging a patient is to
spend less than _____ per patient
1. 10 seconds
2. 60 seconds
3. 120 seconds
4. 5 minutes
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Fase triage
TRIAGE PROCESS
TRIAGE PRIMER
Merupakan proses :
Tanya – jawab yg ringkas.
Eyeballing triage “eagle eye”.
Tanpa pemeriksaan.
Penilaian dan keputusan yg cepat.
Tanpa dokumentasi.
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TRIAGE SEKUNDER
STRUCTURAL DESIGN
Secondary Triage
50 CONCEPTUAL FRAMEWORK
OF TRIAGE & RECEPTION OF PTS IN ED
LOOKS
OK
Secondary
TRIAGE
PATIENT
NURSE
P1 TRIAGE
WAITING
WAITING ROOM IN FRONT
REGISTRATION
OUTSIDE ED OF P3
ROOM
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P1 & P2
Resuscitation Area (P1):
Life Threatening Patients
Resuscitation equipments
P1 Procedure
CALL RESUSCITATION DECIDE
DOCTOR TEAM
P1 NURSE
WHAT INVESTIGATION NEED
FURTHER PLAN FBC, CARDIAC ENZYME
ECG, X-RAY ETC
ADMIT
ROI/
OT WARD
ICU
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RED ZONE
IMMOBILIZATION
SUCTION MONITORING
SYSTEM
INTUBATION
DRUGS
DOCTOR 1
NURSE 1 DEFIB
DOCTOR 2
NURSE 2 DOCTOR 3
NURSE 3
PROCEDURE
TROLLEYS
TEAM LEADER
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RED ZONE
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P2 Procedure
EXAMINE
DECIDE
WHAT INVESTIGATED NEED
FBC, CARDIAC ENZYME
CALL DOCTOR
ECG, X-RAY ETC
FURTHER PLAN
P2 NURSE
ADMIT
PASIEN DISCHARGE BE
INTERACTION WITH
YELLOW ZONE
YELLOW ZONE
Standard Operating Procedure Of
60
P3 Pts
CHIEF COMPLAIN
NURSE P3 CALL DOCTOR
DISCHARGE
INTERACTION WITH
UP TRIAGE