triage Panum FKK UMJ.pdf

TRIAGE

Kuliah Kepaniteraan Umum

FKK Universitas Muhammadiyah Jakarta

2014

1

Dr Mohammad Adib Khumaidi, SpOT

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

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

7

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

8

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

10

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

13

KESADARAN

• Tidak dapat mengikuti perintah : bendera

• merah

Dapat mengikuti perintah : bendera

kuning

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15

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TRIAGE TAGGING

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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

44

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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Proactive Triage Static Triage

TRIAGE PROCESS

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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.

STRUCTURAL DESIGN

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Secondary Triage

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PTS ARRIVE

PRIMARY TRIAGE

PATIENT

RELATIVES

REGISTRATION WAITING ROOM

OUTSIDE ED

Secondary TRIAGE

NURSE TRIAGE

CHECK: PR BP RR TEMP ECG

By paramedics

P1

P2

P3

WAITING IN FRONT

OF P3 ROOM

CONCEPTUAL FRAMEWORK OF TRIAGE & RECEPTION OF PTS IN ED

LOOKS OK

P1

SEVERE ILL

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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

CALL DOCTOR

RESUSCITATION TEAM

FURTHER PLAN

DECIDE

WHAT INVESTIGATION NEED FBC, CARDIAC ENZYME

ECG, X-RAY ETC

ADMIT

OT ROI/ ICU

WARD

NURSE

P1 Procedure

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RED ZONE

Pasien dgn kondisi mengancam nyawa, memerlukan evaluasi dan intervensi segera

Pasien dibawa ke Ruang Resusitasi

Waktu tunggu nol

Triage 20

• 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

• Shock tipe apapun

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GOLF SWING ERGONOMICS

ENVIRONMENT

CRITICAL CARE ZONE

55 RESUSCITATION BAY FLOOR PLAN IMMOBILIZATION

PROCEDURE

TROLLEYS

TEAM LEADER

DOCTOR 3

NURSE 3

DOCTOR 1

NURSE 1

DOCTOR 2

NURSE 2

MONITORING

SYSTEM

DRUGS

DEFIB

SUCTION INTUBATION

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RED ZONE

57

P2

CALL DOCTOR

FURTHER PLAN

DECIDE WHAT INVESTIGATED NEED

FBC, CARDIAC ENZYME ECG, X-RAY ETC

ADMIT

DISCHARGE BE INTERACTION WITH

ARRANGE FOR FOLLOW UP

PASIEN

RELATIVES MEDICAL ADVICE

OT ROI/ ICU

WARD

EXAMINE

NURSE

P2 Procedure

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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

60 Standard Operating Procedure Of

P3 Pts

NURSE CHIEF COMPLAIN

CALL DOCTOR P3

DECIDE

WHAT INVESTIGATION NEED, IF ANY

(FBC, CXR, ECG, ETC).

FURTHER PLAN

UP TRIAGE

CARE OF MINOR TRAUMA

DISCHARGE INTERACTION WITH

PATIENT RELATIVES ARRANGE FOR FOLLOW UP

MEDICAL ADVICE

Pasien yg biasanya

dapat berjalan dgn masalah

medis yang minimal

Luka lama

Kondisi yang timbul

sudah lama

Area Ambulatory /

Ruang P 3

Waktu tunggu 30 menit

Minor injuries

Seluruh kasus - kasus

ambulant / jalan

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NON KRITIS /GREEN ZONE

Conclusion

• Learn triage classifications

• Apply the classifications in a

timely manner

• Remember that children are

different from adults

VIDEO KASUS DI IGD

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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?