Triase System dan Peran Petugas

Triase saat evakuasi dan resusitasi

PUSBANKES 118 PERSI D.I YOGYAKARTA

 Triase :
1. Pria, 40 th, fraktur terbuka femur kanan,darah
masih merembes keluar dari lukanya
2. Pria 22 tahun pengendara sepeda motor, luka
perdarahan di pelipis kanan, lecet di bahu, suara
napas ngorok.
3. Pria, 30 th, # iga kanan, sesak nafas dengan
keluhan nyeri dada saat bernapas.
4. Pria, 29 th, luka bakar gr 2-3 : 30%, berteriak teriak
histeris.
5. Wanita 40 th, hamil besar, perdarahan pervaginam.
 Sistem triage dunia
• Australasian Triage Scale (ATS)
• Manchester Triage Scale (MTS)
• Canadian Triage and Acuity Scale (CTAS)
• Emergency Severity Index (ESI)
 Triage
• Suatu proses yg mana pasien digolongkan menurut
tipe dan tingkat kegawatan kondisinya
• untuk mendapatkan :
– pasien yg benar ke
– tempat yg benar pada
– waktu yg benar dengan
– tersedianya perawatan yg benar
 Triage
• Nondisaster: Untuk menyediakan perawatan sebaik mungkin
bagi setiap individu pasien
• Disaster: Untuk menyediakan perawatan yg lebih efektif
untuk pasien dalam jumlah banyak
 Sejarah Triage
 “trier” merupakan asal kata “triage”
 awalnya dipakai untuk suatu proses memilah, sekitar tahun 1792, oleh
Baron Dominique Jean Larrey, seorang ahli bedah di Napoleon’s Imperial
Guard.
 Baron Francois Percy juga mempunyai kontribusi dalam sistem organisasi
perawatan korban perang.
 Konsep awal triage adalah fokus terhadap situasi korban masal
 Dilaksanakan di ruang gawat darurat dari 1950 / 1960 karena 2 alasan :
 Kunjungan
 penggunaan utk non urgen
 Konsep Triage
• Triage merupakan proses formal dalam penilaian dan
pemilahan pasien yang sifatnya segera.
• Sistem triage bertujuan untuk memastikan pasien yang ingin
mendapatkan perawatan emergensi akan menerima
perhatian yang tepat, di lokasi yang tepat, yang sesuai dengan
derajat kegawatannya
• Sistem triage IRD yang ideal secara akurat memprioritaskan
pasien berdasarkan intervensi kegawatannya untuk
menghindari under-triage atau over-triage
• Single Triage
• START triage
• SAVE
Triage 9
The Triage Zone
 Triage
• SIT :
– Single Triage
• START :
– Simple Triage and Rapid
Treatment
• SAVE :
– Secondary Assessement of Victims
Endpoint

HOPE ( Hospital Preparedness for Emergencies and Disaster )

 Single Triage :

• Untuk pasien tunggal

• Kategori pasien
– Immediate
• ( AMI, Perdarahan dalam )
– Urgent
• ( Stroke, Apendisitis )
– Non Urgent
• ( Luka, Dislokasi, Fraktur )
Triage 13
 Single Triage

Immediate Tindakan langsung

Urgent Tindakan secepatnya

KORBAN

Petugas
Tindakan dg
Non Urgent
persiapan

Meninggal Km Mayat
 Simple Triage and Rapid Treatment
( START )

• Untuk korban dalam jumlah banyak

• Triase + tindakan singkat untuk diagnostik maupun
resusitasi
• Triage Officer bisa lebih dari satu
• Kategori korban pada START :
– Hijau : “ walking wounded “
– Merah : gangguan airway berat dan syok
– Kuning : “ delay “
– Hitam : Meninggal
• Ada prioritas pada kelompok merah
 A Simple Approach
The Triage Tag

Simple A Tag is placed on each patient once they

have been assessed. The tag displays the
Triage patient’s current status and advises those
providing treatment with one of the four
And possible treatment priorities:

Rapid Minor
Treatment Delayed
Immediate
Deceased

There are a variety styles and sizes of Triage Tags

 A Simple Approach
The Triage Tag

Simple Each tab is distinctly color-coded allowing fast

patient priority identification from a distance
Triage
And DECEASED
Rapid
IMMEDIATE
Treatment
DELAYED

MINOR
 A Simple Approach
The Triage Tag

Simple A Tag is placed on each patient once they

have been assessed. The tag displays the
Triage patient’s current status and advises those
providing treatment with one of the four
And possible treatment priorities:

Rapid Minor
Treatment Delayed
Immediate
Deceased

There are a variety styles and sizes of Triage Tags

 A Simple Approach
The Triage Tag

Simple Triage Tags are designed with tear-off

tabs. Unused tabs are removed and the
Triage last remaining tab designates the patient’s
priority.
And
Rapid
Treatment
Last remaining tab
indicated patient priority
In this case IMMEDIATE

Unused tabs torn off

 A Simple Approach
The Triage Tag

Simple Each tab is distinctly color-coded allowing fast

patient priority identification from a distance
Triage
And DECEASED
Rapid
IMMEDIATE
Treatment
DELAYED

MINOR
 Where to START

Upon your arrival, first make sure the scene is safe.

Then begin by directing the walking wounded away
from the immediate scene to a pre-determined
evaluation and treatment area.

Tag them as MINOR (GREEN)

 Where to START

Do not spend too much time on any one patient.

Move quickly from one patient to the next.
Assess each patient’s RPMs

Respirations
Perfusion
Mental Status
 One Patient at a Time

RPM
ASSESS RESPIRATIONS

If the patient is not breathing then Open the Airway

If the patient is still not breathing

then tag them as DECEASED (BLACK)

Move on to the next patient...

 One Patient at a Time

RPM
ASSESS RESPIRATIONS

If breathing is present then Assess the Rate

If the rate is greater than >30

then tag them as IMMEDIATE (RED)

Move on to the next patient…

If the rate is less than <30

then assess PERFUSION
 One Patient at a Time

RPM
ASSESS PERFUSION

If a radial pulse is absent (or)

the capillary refill is greater than > 2 seconds
then tag them as IMMEDIATE (RED)

Move on to the next patient…

If a radial pulse is present (or)

the capillary refill is less than < 2 seconds
then assess MENTAL STATUS
 One Patient at a Time

RPM
ASSESS MENTAL STATUS

If the patient cannot follow simple commands (or)

has an altered mental status (or)
is unconscious
then tag them as IMMEDIATE (RED)

Move on to the next patient…

If patient is able to follow simple commands

then tag them as DELAYED (YELLOW)

Move on to the next patient…

 One Patient at a Time

RPM
ASSESS MENTAL STATUS

If the patient cannot follow simple commands (or)

has an altered mental status (or)
is unconscious
then tag them as IMMEDIATE (RED)

Move on to the next patient…

If patient is able to follow simple commands

then tag them as DELAYED (YELLOW)

Move on to the next patient…

START Triage Algorithm
 Secondary Assessement for Victims Endpoint
( SAVE )

• Dilakukan bila jumlah korban luar biasa dan

jauh melampaui kapasitas penolong.
• Kategori korban :
– Yang akan selamat apapun tindakan
yang dilakukan
– Yang akan tidak selamat apapun tindakan
yang dilakukan
– Yang tidak termasuk kedua golongan
diatas
Re Triage !!
 Peran petugas triase
• Evakuasi ?
• Resusitasi ?
 Kesimpulan
• Pengembangan triase tergantung dari
pengetahuan, kemampuan petugas serta
ketersediaan fasilitas
• Perawat memiliki fungsi strategis dalam triase