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  • ATS Triage Priority Levels

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    Melvina Larissa Januar
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    The document outlines 5 levels of triage (ATS I-V) based on the urgency of a patient's condition, with ATS I being the most urgent requiring immediate assessment within 10 minutes. Each level provides criteria for evaluating aspects of the patient's condition including airway status, breathing, circulation, mental status, pain level, and mental cooperation. Guidelines are also provided for catheter sizes and their common clinical applications as well as a pain scale (FLACC) for assessing pain in children.

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    The document outlines 5 levels of triage (ATS I-V) based on the urgency of a patient's condition, with ATS I being the most urgent requiring immediate assessment within 10 minutes. Each level provides criteria for evaluating aspects of the patient's condition including airway status, breathing, circulation, mental status, pain level, and mental cooperation. Guidelines are also provided for catheter sizes and their common clinical applications as well as a pain scale (FLACC) for assessing pain in children.

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    © All Rights Reserved
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    11 views6 pages

    ATS Triage Priority Levels

    Uploaded by

    Melvina Larissa Januar
    The document outlines 5 levels of triage (ATS I-V) based on the urgency of a patient's condition, with ATS I being the most urgent requiring immediate assessment within 10 minutes. Each level provides criteria for evaluating aspects of the patient's condition including airway status, breathing, circulation, mental status, pain level, and mental cooperation. Guidelines are also provided for catheter sizes and their common clinical applications as well as a pain scale (FLACC) for assessing pain in children.

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    © All Rights Reserved
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    of 6

    ATS I ATS II ATS III ATS IV ATS V

    Pengkajian Immediate Emergency (10 menit) Urgent (30 menit) Less-Urgent (60 menit) Non-urgent (120 menit)
    Jalan Napas Obstruksi Total/Parsial* Paten Paten Paten Paten
    Distress napas/henti Distress napas sedang Distress napas ringan Normal Normal
    Pernapasan napas**
    Gangguan hemodinamik Gangguan hemodinamik Gangguan Stabil Stabil
    Sirkulasi berat/perdarahan tak sedang # hemodinamik ringan
    terkontrol***
    Kesadaran GCS < 9 GCS 9 – 12 GCS > 12 Normal Normal

    Nyeri Sangat Berat (VAS 10) Berat (VAS 7 – 9) Sedang (VAS 4 – 6) Minimal (1 - 3)

    Kondisi Mental Tidak kooperatif Tidak kooperatif Kooperatif Kooperatif

    Keterangan :

    * obstuksi total jalan napas, stidor (oklusi 75% jalan napas), kejang masuk dalam kategori ATS I
    ** laju napas < 10 x/menit, atau SaO2 <90% masuk dalam kategori ATS I
    ***sistolik < 80, hentik jantung, atau nyeri dada masuk dalam kategori ATS I
    # hr < 50 atau > 150 pada dewasa masuk dalam kategori ATS II
    Ukuran Kateter (gauge) Warna Aplokasi Klinis
    14 G Cokelat Trauma, Pembedahan, Tranfusi darah
    16 G Abu-abu Trauma, Pembedahan, Tranfusi darah
    18 G Hijau Trauma, Pembedahan, Tranfusi darah
    20 G Pink Infus continue/intermittent, Tranfusi darah
    22 G Biru Infus intermittent umum, anak-anak, pasien lansia
    24 G Kuning Vena Fragil untuk infus intermittent/kontinu

    FLACC Scale 0 1 2
    Occasional grimace or frown, withdrawn, Frequent to constant frown,
    Face No particular expression or smile
    disinterested clenched jaw, quivering ching
    Legs Normal position or relaxed Uneasy, restless, tense Kicking, or legs drawn up
    Lying quietly, normal position,
    Activity moves easily
    Squirming, shifting back and forth, tense Arched, rigid or jerking
    Crying steadily screams or sobs
    Cry No crying (awake or asleep) Moans or whimpers, occasional complaint
    frequent complaints
    Reassured by occasional touching, huggin or
    Consolability Content, relaxed
    being talked to, distractible
    Difficult to console or comfort
    Factor for Assessment Answer elicting questionnsire
    P – for palliative factors What makes it better?

    – for provocative factors What makes it worse?


    Q – Quality What exactly is it like?
    R – Radiation Does it spread anywhere
    S – Severity How severe is it?

    How much does it affect your life?


    T – Temporal factors Is it there all the time or dose it come and go?

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