TRIAGE

Sub Bagian Gawat Darurat Pediatrik

Bag.Ilmu Kesehatan Anak FK UNPAD/RSHS Bandung
DEFINISI

Seleksi pasien utk menentukan

tingkat kegawat daruratan dalam
menentukan prioritas pelayanan
medis

Pelaksana: Dokter atau Perawat

terlatih PPGD dgn pengalaman
minimal 2 tahun
Klasifikasi pasien
Pada keadaan sehari-hari :
Pasien dipilah berdasarkan prioritas

P1: Pasien dengan ancaman kematian karena ggn

respirasi atau memerlukan tindakan RJP
segera. Tindakan harus dilakukan < 10 menit

P2: Pasien dengan ancaman kematian karena ggn

sirkulasi dan memerlukan resusitasi cairan
atau gangguan hemodinamik karena
gangguan jantung yang memerlukan
pemberian obat. Tindakan harus dilakukan <
30 menit
P3: Pasien dengan ancaman kematian atau
kecacatan karena gangguan kesadaran
(koma), gangguan neurologis, gangguan
metabolisme penyebab lain yang
memerlukan tindakan segera. Tindakan
harus dilakukan < 60 menit

P4: Pasien yang perlu tindakan tetapi tidak

ada ancaman kematian. Harus dilakukan
tindakan dalam waktu 2 jam. Dengan
catatan pelayanan pasien P4 tidak boleh
mengganggu pelayanan pasien P1, P2, P3
pada jam kerja, P4 dilayani di poliklinik
 Pada keadaan bencana (korban massal)

Pasien diberi label, untuk tingkat

kegawat daruratannya untuk
memberikan prioritas dalam pelayanan,
sebagai berikut:
Pasien P1, P2: label merah
Pasien P3 : label kuning
Pasien P4 : label hijau
Meninggal : label hitam
TRIAGE (WHO)

Emergency

Priority

Non-urgent
 Emergensi
Pasien

Dengan ancaman
Kematian
(gawat darurat)

Ruang resusitasi Ke pendaftaran

OK NICU PICU

R Rawat
 Priority
Pasien

Perlu pertolongan segera (darurat)

R Tindakan pendaftaran

R Rawat R Observasi/
SW

PICU/NICU/RR
 Non-Urgent
Pasien

Tidak ada ancaman kematian dan tidak perlu pertolongan segera

Pendaftaran

Poliklinik
R Tindakan Poli umum
Jam kerja
24 jam
Pulang
Poli spesialis
R Rawat Pulang

R Observasi/SW
PICU/NICU R Gawat
Stages in the management of the sick child
admitted to hospital: summary of key elements
TRIAGE
(present)
Check for emergency signs give EMERGENCY TREATMENT until stable

(absent)
Check for priority signs or conditions

HISTORY AND EXAMINATION

(including assessment of immunization status, nutritional status and feeding)
Check children with emergency and priority conditions first

LABORATORY AND OTHER INVESTIGATIONS, if required

List and consider DIFFERENTIAL DIAGNOSES

Select MAIN DIAGNOSES (and secondary diagnose)

 Plan and begin INPATIENT TREATMENT Plan and begin OUTPATIENT TREATMENT
(including supportive care)

MONITOR for signs of

- Improvement
- complication
- failure of treatment Arrange FOLLOW-UP, if required

(not improving or (improving)

new problem)

Continue treatment
REASSESS
for causes of PLAN DISCHARGE
failure of treatment Note: see treatment guidelines for young
infants and children with sever malnutrition
DISCHARGE HOME
Arrange continuing care or Note: always check immunization status,
REVISE FOLLOW-UP at hospital or nutritional status, feeding and the mothers
TREATMENT in community understanding of and ability to continue
care at home
Triage of all sick children
EMERGENCY SIGNS
If any sign positive: give treatment(s), call for help, draw blood for emergency laboratory investigations
(glucose, malaria smear, Hb)
TREAT
IF FOREIGN BODY ASPIRATION
1. ASSES: Obstructed breathing or Manage airway in choking child
AIRWAY AND Central cyanosis or
ANY SIGN
IF NO FOREIGN BODY ASPIRATION
BREATHING Severe respiratory distress Manage airway
POSITIVE
Give oxygen
Make sure child is warm

C Stop any bleeding

Cold hands
o with:
2. ASSES: Capillary refill longer than Give oxygen
CIRCULATION l Make sure child is warm
2 seconds, and ANY SIGN
Weak and fast pulse POSITIVE IF NO SEVERE MALNUTRITION:
Check for severe Insert IV and begin giving fluids rapidly
malnutrition If no able to insert peripheral IV, insert
an external jugular or intraosseous line
IF SEVERE MALNUTRITION:
If lethargic or unconscious:
Give IV glucose
Insert UV line and give fluids
 If not lethargic or unconscious:
Give glucose orally or by NG tube
Proceed immediately to full
assessment and treatment

Coma or Manage airway

COMA
Convulsing (now) If convulsing, give diazepam or
CONVULSING
IF COMA OR paraldehyde rectally
CONVULSING Position the unconscious child (if head or

neck trauma is suspected, stabilize the

neck first)
Give IV glucose
SEVERE Diarrhoea plus any two of these
DIARRHOEA Make sure child is warm
DEHYDRATION Lethargy
(only in child with Sunken eyes Plus TWO SIGNS
Diarrhoea) Very slow skin pinch POSITIVE IF NO SEVERE MALNUTRITION:
d Chedk for severe Insert IV line and begin giving fluids
malnutrition rapidly and diarrhoea treatment plan C
I
in hospital

IF SEVERE MALNUTRITION:
Do not insert IV
Proceed immediately to full assessment
and treatment
PRIORITY SIGNS These children need prompt assessment and treatment
Visible severe wasting
Note If a child has trauma or other surgical
Oedema of both feet problems, get surgical help or follow
Severe palmar palor surgical guidelines
Any sick young infant (< 2 montha
of age)
Lethargy
continually irritable and restless
Major burn Check for head/neck trauma before treating child-
Any respiratory distress or do not move neck if cervical spine injury possible
An urgent referral note from
another facility

NO- URGENT
Proceed with assessment and for treatment according to the childs priority
Assessment of Children in
Emergencies

Committee on Pediatric Resuscitation,

The Indonesian Society of Pediatrician
1. PAT
2. ABCDE
 The PAT

Wo
rk
e
nc

of
ra

Bre
ea
p

at h
Ap

ing
Circulation to Skin
 Appearance
(Tickles =TICLS)
Tonus

e
Interactiveness

nc
ar a
Consolability

pe
Ap
Look/Gaze
Speech/Cry
Young infants
Work of Breathings
Wo
rk Abnormal airway
of
sounds
Abnormal positioning
Bre
ath

Retractions
ing

Nasal flaring
s
Applying The PAT for WOB
 Respiratory Effort

Retraction The Sniffing PositionThe Tripod Position

Seesaw
Respiration
 Circulation to Skin

Pallor
Mottling
Cyanosis
Circulation to Skin
 Respiratory distress Shock

N N
N

N N

Primary CNS Cardiopulmonary

dysfunction/
metabolic abnormality failure

N N N /

N N
The ABCDEs

Airway
Breathing
Circulation
Disability
Exposure
Airway Assessment
Clear
Maintainable
Unmaintainable
without
intubation
Obstructed
Breathing Assessment
Rate
Effort /
mechanics
Air entry
Skin color
Respiratory Rate by Age

Age Respiratory rate

(years) (breaths per minute)
<1 30-40
2-5 20-30
5-12 15-20
>12 12-16
Retraction and the use of Accessory
Muscle
Circulation Assessment
Heart rate
Systematic perfusion
Peripheral pulses
Skin perfusion
Appearance
(Urine output)
Blood pressure
Heart Rate by Age

Age Range
Newborn 3 85 200
mos bpm
3 mos 2 yrs 100 190
bpm
2 10 yrs 60 140
bpm
Central & Distal Pulses
Skin Perfusion
Extremity temperature
Capillary refill
Color
Pink
Mottled
Pale
Blue
Skin Perfusion Examination
Minimal Systolic Blood
Pressure by Age
Age Fifth percentile
mmHg
Systolic BP
0 1 Mo 60
> 1 mo 1 yr 70
> 1 yr 70 + (2 x age in
years)
 Disability
(neurologic status)

Cerebral cortex
Brain Stem
Motor activity
Level of Consciousness

A = Awake
V = Responsive to voice
P = Responsive to pain
U = Unresponsive
Brain Stem

Posture
Central respiration
Pupil response
Cranial nerve
Motor Activity

Symmetrical
movements
Seizures
Posturing
Flaccidity
 Exposure
Skin rashes
Bruises

Excoriation

etc.
Classification of Physiologic
status
Stable
Respiratory dysfunction
Potential respiratory failure
Probable respiratory failure
Shock
Compensated
Decompensated
Cardiopulmonary failure
Decompensated Shock
Definition of Cardiopulmonary Failure
Deficits in
Ventilation
Oxygenation
Perfusion
Resulting in
Agonal respiration
Bradycardia
Cardiopulmonary arrest
Priorities in Initial Management of Stable
Child

Begin further workup

Provide specific therapy as indicated
Reassess frequently
 Priorities in Initial Management of
Respiratory Dysfunction
Potential Respiratory Failure Probable Respiratory Failure
Keep with caregiver Separate from caregiver
Position of comfort Control airway
Oxygen as tolerated 100 % FiO2
Nothing by mouth Assist ventilation
Monitor pulse oximetry Nothing by mouth
Consider cardiac monitor Monitor pulse oxymetry
Cardiac monitor
Establish vascular access
 Keep with
Caregiver !!
Priorities in Initial Management of
Shock

Administer oxygen (FiO2 = 1.0) and ensure

adequate airway and ventilation
Establish vascular access
Provide volume expansion
Monitor oxygenation, heart rate, and urine output
Consider vasoactive infusions
Priorities in Initial Management of
Cardiopulmonary failure

Oxygenate, ventilate, monitor

Reassess for
Respiratory failure
Shock
Obtain vascular access