CPR LECTURE SERIES-130911 THIS LECTURE SLIDES CONTAIN COPYRIGHT MATERIAL

INTERNATIONAL NURSING WEBINAR: BTCLS & HDM (8 – 9 APRIL 2023) :

PERSATUAN PERAWAT NASIONAL INDONESIA

HDM: TRIAGE
ASSOC PROF DR. HJ. ABDUL ALI BIN RAJA MOHAMED, ASA, PSK, PPL
◼ASSOC PROF IN EMERGENCY MEDICINE, HEAD OF EMERGENCY MEDICINE,
◼DIRECTOR, MAHSA CENTRE FOR CLINICAL SKILLS EDUCATION AND TRAINING,
◼HEAD, SCHOOL OF EMERGENCY MEDICAL SERVICES & SCIENCES.
◼FACULTY OF MEDICINE, MAHSA UNIVERSITY.
◼ MEMBER NATIONAL EXECUTIVE BOARD,VICE-CHAIRMAN,MRCS. & DEPUTY CHAIRMAN MRCS SELANGOR
◼ (1989-2008 : HEAD OF TRAUMA & EMERGENCY CENTRE, UMMC, UNIVERSITY MALAYA)
◼ (DIRECTOR, ACADEMY OF PARAMEDICAL SCIENCES, CUCMS:2008-2011)
◼ (PRINCIPAL/CEO, CYBER PUTRA COLLEGE, CYBERJAYA:2011-2016)
◼ INTL. MEMBER-AMERICAN COLLEGE OF EMERGENCY PHYSICIANS (ACEP)
◼ INTL. MEMBER- NATIONAL ASSOCIATION OF EMS PHYSICIANS (NAEMSP)
◼ PREMIUM PROF. MEMBER, COUNCIL ON CARDIOPULMONARY & CRITICAL CARE, AMERICAN HEART ASSOCIATION
◼ ADVISOR, MALAYSIAN ASSOCIATION OF PREHOSPITAL PARAMEDIC PRACTITIONERS
◼ AHA ECC BLS/ACLS INSTRUCTOR
◼ PRESIDENT, MEDICALERT FOUNDATION MALAYSIA.
C-aarm
Abu Huraira reported: The Messenger of Allah, peace and blessings be upon him, said,
“Whoever travels a path in search on knowledge, Allah will make easy for him a path to Paradise.”
Source: Ṣaḥīḥ Muslim 2699

KUALA LUMPUR

C-aarm
Leaders in
Nursing, Paramedical,
MBBS, Dental DDS
 UNIVERSITY MALAYA MEDICAL CENTRE (UMMC), UNIVERSITY MALAYA, KL

#59 in QS Global World Rankings 2022

UMMC EMERGENCY CENTRE
 Learning Outcomes:

◼ Meaning and History of Triage

◼ Usefulness of Triage
◼ Types of Triage
◼ Triage used by various Specialties
◼ Methods of using Triage in the ED and Disasters
Triage is the prioritization of patient care (or victims during a
disaster) based on illness/injury, severity, prognosis, and resource
availability.

The purpose of triage is to identify patients needing

immediate resuscitation; to assign patients to a predesignated
patient care area, thereby prioritizing their care; and to initiate
diagnostic/therapeutic measures as appropriate.

IT IS A DYNAMIC PROCESS
History:
The term triage originated from the French verb trier which means to sort.

18th Century France: Wool trade,

Coffee trade: Best beans
Middling beans
Broken beans

Egyptian Wars: Documented proof of use

“Structured Triage”: Roman armies/wars - high priority given to Officers > Low-ranked > Civilians

Napoleonic Wars: Dr Pearcy, Dr DJ Larrey : Flying Ambulance

World War I: French doctors- Treating the wounded

World War II: Field Medics in many countries used it to prioritize the wounded
•What do triage nurses do?
•Triage nurses help evaluate patients and decide the priority of care in an emergency room
and other medical settings. They update the medical team on the patient's status and
provide emergency care when needed.

•What is telephone triage?

•With telephone triage, a nurse listens to your symptoms and assesses your need for care
over the phone. They let you know whether you should see a doctor, go to the emergency
room, or try at-home treatment.
Effective triage is a unifying thread through a
functioning trauma system. Systems that perform
daily care and train disciplines together provide the
best preparation for disaster and mass
casualty incidents—surge capacity and capability are
practiced regularly.
TRIAGE BRINGS ABOUT CHAOS TO CALM

John Armstrong, David G. Burris, in

Current Therapy of Trauma and Surgical Critical Care, 2008
TRIAGE – OVER CROWDED REGISTRATION:
What is the Priority??
BUSY WARD
TRIAGE – Important for Nurses ….. DYNAMIC PROCESS

VERY BUSY
STAFF
NURSE
BUT
ALWAYS
TRIAGING
IN HER
MIND

“Are you alright now?”

BUSY EMERGENCY DEPARTMENT
COMMUNICABLE
DISEASES: TRIAGE IN THE ED
COVID-19
BIRD FLU H1R1
MERC
• OUTSIDE THE ED

• PRIMARY TRIAGE
AT ENTRANCE
BY HISTORY, S & S

• SECONDARY
TRIAGE
ROOM
BY VITAL SIGNS
 UNIVERSITY MALAYA MEDICAL CENTRE (UMMC), UNIVERSITY MALAYA, KL

#59 in QS Global World Rankings 2022

UMMC EMERGENCY CENTRE
 UNIVERSITY MALAYA MEDICAL CENTRE

TRIAGE
DONE
HERE
 UNIVERSITY MALAYA MEDICAL CENTRE
KAWASAN BILIK
2 OPERASI BENCANA
DEWAN
RESUSITASI

KAWASAN
3
DEWAN AMC

KAWASAN
SECONDARY KAWASAN
4
DEWAN KONSULTASI
5
TRIAGE WAD PEMERHATIAN

KAWASAN
1
PRIMARY KAUNTER TRIAGE

TRIAGE 19
TYPES OF TRIAGE:
TYPES FUNCTION

1 SIMPLE TRIAGE Used in scene of Multi-casualty incident

“START TRIAGE” Simple triage tags used

2 ADVANCED TRIAGE Used by trained doctors, nurses, paramedics

Prioritizing management and admissions using Vital Signs
Used in the Emergency Dept, Disaster, MCI in terrorist attack, mass shootings, earthquakes etc
3 PRIMARY TRIAGE Used by doctors, nurses, paramedics, search & rescue personal
Prioritizing urgency of care using the History, Symptoms and Signs
Used in the Emergency Dept, Disaster, MCI in terrorist attack, mass shootings, earthquakes etc
4 SECONDARY TRIAGE Used by trained doctors, nurses, paramedics using Vital signs
Prioritizing management in ED
Used in the Emergency Dept, Disaster, MCI in terrorist attack, mass shootings, earthquakes etc
5 REVERSE TRIAGE- Used by doctors
Discharging patients early when the medical system is stressed, usually the non-critical patients are sent
home to come back later
6 UNDERTRIAGE Underestimating the severity of injury or illness.
Example a Red case as a Yellow case….should be less than 5%
Occurs in the Learning curve and experience of a New nurse.
7 OVERTRIAGE Overestimating the severity of injury or illness
Example a Yellow case as a Red case….should be less than 50%
Occurs in the Learning curve and experience of a New nurse.
8 TELEPHONE TRIAGE Used by trained doctors, nurses, paramedics
Decision making over the telephone and providing directives
Using Standard Protocols
COMMON TRIAGE: example
TRIAGE: “SORTING OUT PATIENTS ACCORDING TO THE URGENCY AND TYPE OF MEDICAL/TRAUMA CARE NEEDED”
“P” “T” Description Color
Characteristics
Code Code Code Code
1) Life-threatening Illness or Injury
1 1 Immediate Red 2) Life saving intervention required
3) First to Treat
1) Serious but not Life-threatening illness or injury
2 2 Urgent Yellow 2) Delaying treatment 1 hour will not affect outcome
3) Second to treat
1) Minor illness or injury
3 3 Delayed Green 2) Walking wounded
3) Third to treat
1) Not expected to survive

4 Expectant Blue
2) Comfort care
3) Maybe upgraded to red if new resources are available
4) May be downgraded to dead

Dead Dead Dead Black

1) Dead
2) Medico-Legal consideration

MINIMAL,IMMEDIATE,DELAYED,EXPECTANT,CONTAMINATED ----(NATO CBN Patient Triage)) AP Dr Abdul Ali

ZON MERAH-
KRITIKAL
ZON KUNING –
SEPARAH KRITIKAL
ZON HIJAU –
BUKAN
KRITIKAL
ED-TRIAGE: While waiting pt can improve or deteriorate !!!
TRIAGE- ORANGE ?

VITAL SIGNS
TRIAGE: ISO Q-STANDARD……..WAITING TIME?
 TRIAGE IN VARIOUS COUNTRIES:
AUSTRALIAN TRISAGE SCALE CANADIAN TRIAGE ACUITY SCALE (CTAS)

Le L
Should be seen by provider
v Description e
within Should be seen by provider
el v Description
within
1 Resuscitation 0 minutes e
l
2 Emergency 10 minutes
3 Urgent 30 minutes 1 Resuscitation 0 minutes

4 Semi-Urgent 60 minutes 2 Emergency 15 minutes

5 Nonurgent 120 minutes
3 Urgent 30 minutes
4 Less Urgent 60 minutes

5 Non Urgent 120 minutes

 What to do?
Category Meaning Consequences Examples
Immediate treatment, Arterial lesions,
GERMAN T1 (I) Acute danger for life transport as soon as internal haemorrhage,
TRIAGE SYSTEM possible major amputations
Constant observation Minor amputations,
and rapid treatment, flesh wounds,
T2 (II) Severe injury
transport as soon as fractures and
practical dislocations
Treatment when
Minor injury or no practical, transport Minor lacerations,
T3 (III)
injury and/or discharge when sprains, abrasions
possible
Severe injuries,
Observation and if
uncompensated blood
No or small chance of possible
T4 (IV) loss, negative
survival administration of
neurological
analgesics
assessment
Injuries not compatible
Collection and with life, no
guarding of bodies, spontaneous breathing
Deceased
identification when after clearing of
possible airway, downgraded
from
FRANCE: Prehospital Triage
In France, the Prehospital triage in case of a disaster uses a four-
level scale:

•DCD: décédé (deceased), or urgence dépassée (beyond urgency)

•UA: urgence absolue (absolute urgency)
•UR: urgence relative (relative urgency)
•UMP: urgence médico-psychologique (medical-psychological
urgency) or impliqué (implied, i.e. lightly wounded or just
psychologically shocked).
SINGAPORE- Patient Acuity Category Scale
Category (Priority Level) Category Name Description Example
Multiple major trauma, head injury
State of cardiovascular collapse or in
with loss of consciousness, shortness
P1 Critically ill and requires resuscitation imminent danger of collapse and
of breath, unconsciousness from any
require immediate medical attention.
cause
unable to walk and are in some form
Chest pain, major limb fractures,
of distress, appear stable on initial
major joint dislocations, spinal cord
P2 Major emergency examination, and are not in imminent
injury, trunk injury with stable vital
danger of collapse, requires very early
signs
attention

All sprains, mild constant abdominal

pain, fever with cough for several
days, insect stings or animal bites (not
able to walk, have mild to moderate
in severe distress), superficial injuries
P3 Minor emergency symptoms and require early
with or without mild bleeding, minor
treatment
head injury (alert, no vomiting),
foreign object in ear, nose, or throat,
urinary tract infections, headaches.

Old injury or condition that has been Chronic lower back pain, high
P4 Nonemergency
present for a long time. cholesterol, acne.
USA- Triage Category

Immediate: The casualty requires immediate medical attention and will not survive if not treated soon.
Any compromise to the casualty's respiration, hemorrhage control, or shock control could be fatal.

Delayed: The casualty requires medical attention within 6 hours. Injuries are potentially life-threatening,
but can wait until the Immediate casualties are stabilized and evacuated.

Minimal: "Walking wounded," the casualty requires medical attention when all higher priority patients
have been evacuated, and may not require stabilization or monitoring.

Expectant: The casualty is expected not to reach higher medical support alive without compromising the
treatment of higher priority patients. Care should not be abandoned, spare any remaining time and
resources after Immediate and Delayed patients have been treated
TRIAGE FOR PUBLIC KNOWLEDGE:
Triage in Children:

Paediatric Triage Tape

 ATLS : TRAUMA FIELD TRIAGE

STEPS S/S
STEP 1 GCS <13
BP < 90 mmHg
RR <10 or >30
STEP 2 Abnormal Anatomy with
severe injury
STEP 3 History - Mechanism of
Injury
STEP 4 Special Situations
<5 yrs or >55yrs ,
Pregnancy, Coagulopathy,
Burns
TRIAGE - CARDIOLOGY
TRIAGE- STROKE:

Door to CT Scan = 30 min

Door to Needle Time = 60 min
Door to Admission = 3 Hours
Triage for Psychiatric Patient:
Triage - Obstetric :
TRIAGE- COVID-19 PANDEMIC:
Terrorist Incident: Chaotic
Principles of triage
Primary triage is carried out in the bronze area, and patients are usually re-triaged (secondary triage)
at the casualty clearing station.
Triage for transport will be carried out before patients leave the site in order to ensure the most
appropriate distribution of casualties to receiving units.
Triage categories

Immediate category
These casualties require immediate life-saving treatment.
Urgent category
These casualties require significant intervention as soon as possible.
Delayed category
These patients will require medical intervention, but not with any urgency.
Expectant category
Expectant patients are those whose injuries are so severe that attempting to save them would divert
precious resources from other casualties with a greater chance of survival, with no significant chance
of a successful outcome.
Responding to a Terrorist Incident
Ian Greaves, Paul Hunt in Responding to Terrorism, 2010
REVISED TRAUMA SCORE
QUALITY CONTROL & STATISTICS
National Early Warning Score (NEWS) 2 | RCP
London

https://www.rcplondon.ac.uk/projects/outputs/natio
nal-early-warning-score-news-2
Dec 19, 2017 - NEWS2 is the latest version of the
National Early Warning Score (NEWS), first
produced in 2012 and updated in December 2017
Functions:-
CSCATTT
•Command and
Control
•Safety
•Communication
•Assessment
•Triage
•Treatment
•Transport
 UNIVERSITY MALAYA MEDICAL CENTRE
KAWASAN
2 BILIK
DEWAN
RESUSITASI OPERASI BENCANA

KAWASAN
3
DEWAN AMC

KAWASAN
SECONDARY KAWASAN
4
DEWAN KONSULTASI
5
TRIAGE WAD PEMERHATIAN

KAWASAN
1
PRIMARY KAUNTER TRIAGE

TRIAGE 48
49
TRIAGE SIEVE: this is the process of sorting patients in order
of priority for treatment and evacuation. “Saringan”
 MAJLIS KESELAMATAN NEGARA
ARAHAN –NO.20
PENGURUSAN DAN BANTUAN BENCANA DI TEMPAT KEJADIAN
MENGIKUT ZON

PUSAT TEMPAT
PENGURUSAN MAYAT
MEDIA

LAIN LAIN
AGENSI
PENYELAMAT
ATM

PERTAHANAN
AWAM

KAWASAN PERKHIDMATAN
PERUBATAN TEMPAT
KEJADIAN KECEMASAN REHAT

KAWASAN OPERASI
JALAN MASUK UNIT-UNIT KHAS BOMBA
MENCARI DAN MENYELAMAT

PDRM

PUSAT
SMART
POS KAWALAN KELUARGA
TEMPAT MANGSA
KEJADIAN
TEMPAT BEKALAN (PKTK)
MAKANAN

PUSAT AGENSI BANTUAN DAN

KAUNSELING PEMULIHAN DAN
BADAN SUKARELA

KKN
TRIAGE-
DISASTER

TRIAGE
OF
VICTIMS
 DISASTER MANAGEMENT – In The Field

Major
Incidents
RED ZONE
2 5
1. Report

TRIAGE 2. Authorization proceed

triage
Incident
Black
Command 3 dead
3. Triage and Casualties
brought to a First Aid
post
Area. Only the first aid
YELLOW ZONE Red Yellow Green and simple life saving
First Aid Area procedures done.

GREEN ZONE 1 4 5 4. Transport

5. Police , forensic
Ambulance area pathologist

4
HOSPITAL
Triage sieve: “START” Triage

“Simple Triage and

Rapid Transport” Triage

“Saringan”
What is the triage sort? (Menggolongkan, Menyorti, Menjeniskan)
The triage officer uses the ‘Sieve’ triage process to facilitate the prioritization of
treatment and patient movement from the impact area to the casualty clearing post.
This is referred to as ‘SORT’ which uses the patient’s GCS, respiratory rate and systolic BP
to arrive at a score corresponding to a priority level.
TRIAGE TAGS:
Triage Tag:

There are over 120 triage label systems in use internationally.

Following Criteria:

(1) It must attach securely to each casualty’s body,

(2) it must be easy to write on,
(3) it must be weather-proof,
(4) it should permit the documentation of the patient’s name, gender, injuries,
interventions, care-provider IDs, casualty triage score, and an easily
visible overall triage category.
(5) It must also permit changes to be made, because triage is always dynamic
Hogan and Burstein
CRUCIFORM
CLIP TAGS
METTAG

EMERGENCY TRIAGE LIGHT

BAR CODE
SCANNERS
Triage System Management
Response:
SMARTTAG
TRIAGED FLOOR MATS:
TRIAGED TENTS

TRIAGED TREATMENT AREA-

FIRST-AID POST 64
2P2R
Functions:-
P CSCATTT
•Command and
Control

R RISK REDUCTION •Safety

•Communication
•Assessment
•Triage
•Treatment

P
CRISIS MANAGEMENT
•Transport

R
 PHYSICAL TRAUMA
( MECHANICAL,THERMAL,ELECTRICAL,CHEMICAL,RADIATION,CONTAMINATION )
PSYCHOLOGICAL TRAUMA
( GRIEF – PTSD – SUICIDE )

67
 DISASTER MANAGEMENT – In The Field

Major
Incidents
2 5
TRIAGE
Incident 1. Report
Command 2. Authorization proceed
Black
post 3 dead triage
3. Triage and Casualties
Red Yellow Green brought to a First Aid
First Aid Area Area. Only the first aid
and simple life saving

1 4 5 procedures done.

Ambulance area 4. Transport

5. Police , forensic
4 pathologist

HOSPITAL
SEARCH AND RESCUE 69
LIMA Show: Plane Crash Excercise
INCIDENT COMMAND POST
SEARCH AND RESCUE and TRIAGE
71
TRIAGE AND
COLLECTION POINT

72
TRIAGED TREATMENT AREA-
FIRST-AID POST 73
TRANSPORT AREA
 EMERGENCY & DISASTER MANAGEMENT:

Disaster plan
TRIAGE & TRANSPORT :
• Correct Triage
• Right transport
• Right patient
• Right place
• Right time
• GOLDEN HOUR
• THE MOST EXPERIANCED & BEST TRAINED PERSONNEL
AVAILABLE SHOULD MAKE THESE FIELD TRIAGE DECITIONS
SUMMARY:
KERJA SARINGAN (TRIAGE)
MESTI ADA PEMIMPIN
 THE NOBLE QURA’AN -
BENEFIT Surah 41-Fussilat, Ayat-46
TO
OWNSELF
 THANK YOU
FOR HAVING THE PASSION
TO ‘SAVING LIVES’