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TRIAGE

Dr Mohammad Adib Khumaidi, SpOT

Kuliah Kepaniteraan Umum


FKK Universitas Muhammadiyah Jakarta
2014
Kelinci >< Kura – kura :
Kelinci & Kura – kura balap lari. Kelinci
lari cpt, istirahat & Tertidur 
Kura – kura menang.
Moral Message : Kelinci Kompeten tp
tdk Konsisten.
Kelinci >< Kura – kura :

Kelinci Sadar &


menantang balap
lari lg  Menang.
Moral Massage :
Kelinci Kompeten
& Konsisten
Kelinci >< Kura – kura :

Kura – kura tdk puas &


Menantang balap lari
lagi dng rute lain.
Kelinci lari cpt & sampai d sungai tp
tidak bs berenang
Datang Kura –kura  berenang menyeberangi
sungai Kura – kura menang krn memakai
otak.
Moral Message : Be Smart
Kelinci & Kura – kura
duduk bersama & BERUNDING :
 Sepakat :
 Balapan lagi dng rute yg
sama  Kura kura
digendong kelinci & lari
cepat, sampai di sungai
Kelinci naik Kura – kura
& berenang 
Kelinci & Kura – kura
sampai bersama – sama
Moral Message : Be Smart,
Teamwork One System &
One Command
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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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45

Fase triage

Triage yang proaktif & maju ke


depan. Triage primer – terletak di
luar IGD.
Statis (konter) triage primer.
Triage sekunder.
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TRIAGE PROCESS

Proactive Triage Static Triage


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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

Merupakan proses pemeriksaan :


tanda vital.
pemeriksaan fisik sederhana.
pertolongan pertama.
ECG.
GDA
Laborat dasar.
Re – triage.
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STRUCTURAL DESIGN
Secondary Triage
50 CONCEPTUAL FRAMEWORK
OF TRIAGE & RECEPTION OF PTS IN ED
LOOKS
OK
Secondary
TRIAGE
PATIENT

NURSE
P1 TRIAGE

PTS PRIMARY SEVERE CHECK: P1


TRIAGE ILL
ARRIVE PR
BP
RR P2
TEMP
ECG
RELATIVES
By paramedics P3

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

Critical Area (P2):


Urgent urgent
Oxigen, circulation, & drugs equipments
Minor OT
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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

Pasien dgn kondisi mengancam nyawa,


memerlukan evaluasi dan intervensi segera
Pasien dibawa ke Ruang Resusitasi
Waktu tunggu nol
• Perdarahan berat
• asfiksia, cervikal, cedera pada maxilla
• Trauma kepala dgn koma dan proses shock yg cepat
• Fr. Terbuka & Fr. Compound
• Luka bakar > 30 % / Extensive burn
• Crush injury
Triage 20
• Shock tipe apapun
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CRITICAL CARE ZONE

GOLF SWING ERGONOMICS


ENVIRONMENT
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RESUSCITATION BAY FLOOR PLAN

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

ARRANGE FOR MEDICAL


RELATIVES
FOLLOW UP ADVICE
ROI/
OT WARD
ICU
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YELLOW ZONE

Pasien dgn penyakit yg akut


Mungkin membutuhkan trolley, kursi
roda atau jalan kaki
Waktu tunggu 15 menit
Area Critical care

• Trauma thorax Non asfiksia


• Fr. Tertutup pada tulang panjang
• Luka bakar terbatas ( < 30 % dari TBW )
• Cedera pada bagian / jaringan lunak
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YELLOW ZONE
Standard Operating Procedure Of
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P3 Pts
CHIEF COMPLAIN
NURSE P3 CALL DOCTOR

WHAT INVESTIGATION NEED,


IF ANY
DECIDE (FBC, CXR, ECG, ETC).

FURTHER PLAN CARE OF MINOR TRAUMA

DISCHARGE
INTERACTION WITH

UP TRIAGE

PATIENT RELATIVES MEDICAL ARRANGE FOR


ADVICE FOLLOW UP
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  Pasien yg biasanya  Minor injuries


dapat berjalan dgn masalah  Seluruh kasus - kasus
medis yang minimal ambulant / jalan
  Luka lama
  Kondisi yang timbul
sudah lama
  Area Ambulatory /
Ruang P 3
  Waktu tunggu 30 menit
62

NON KRITIS /GREEN ZONE


Conclusion
• Learn triage classifications
• Apply the classifications in a
timely manner
• Remember that children are
different from adults
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VIDEO KASUS DI IGD


Kasus
1. Di tengah jalan, seorang pria tidak sadarkan
diri, setelah dilakukan LLF didapatkan suara
gurgling.. Tidak terdapat hematoma di daerah
cervical, tidak didapatkan perdarahan dari
telinga maupun hidung. Apa yang dilakukan?
Kasus
2. Seorang pria dibawa ke UGD, krn di tengah
jalan tidak sadarkan diri akibat kecelakaan,
terdapat trauma maksilofasial, setelah dilakukan
LLF didapatkan suara snoring.. Tidak terdapat
hematoma di daerah cervical, tidak didapatkan
perdarahan dari telinga maupun hidung (gidung
tidak ada edema, deviasi, perdarahan dan
lainnya). Apa yang dilakukan?.
Kasus
3. Seorang pria dibawa ke ugd, telah dipasang
guedel (OPA) dan diberikan oksigen 3 L sejak
1/2 jam yang lalu, penderita tidak sadarkan diri,
dan ditemukan di tengah jalan akibat kecelakaan,
setelah dinilai saturasinya mencapai 68%.. Tidak
terdapat hematoma di daerah cervical, tidak
didapatkan perdarahan dari telinga maupun
hidung. Apa yang dilakukan?
Kasus
4. Seorang pria dibawa ke UGD, telah dipasang guedel
(OPA) dan diberikan oksigen 3 L sejak 1/2 jam yang lalu,
penderita tidak sadarkan diri, dan ditemukan di tengah
jalan akibat kecelakaan, setelah dinilai saturasinya
mencapai 78%.. Dokter UGD selanjutnya merencanakan
pemasangan ETT, tetapi tidak dapat dilakukan krn terdapat
edema laring, tidak terdapat hematoma di daerah cervical,
tidak didapatkan perdarahan dari telinga maupun hidung.
Apa yang dilakukan, sementara saturasi makin menurun?