The document outlines the Malaysian Triage Scale process for emergency departments. It describes the primary and secondary triage process which involves a critical first look, rapid assessment of vital signs, complaints and initial tests to assign a triage level between 1 and 5. Level 1 is resuscitation, level 2 is emergency, level 3 is urgent, level 4 is early care and level 5 is routine. The primary triage officer ensures safety by identifying infectious diseases, hazardous exposures, aggressive or violent patients and resolving issues before they enter the emergency department.
This document provides information on the Malaysian Triage Category (MTC) system used in emergency departments in Malaysia. The MTC system classifies patients into three categories - Red (Critical), Yellow (Semi-Critical), and Green (Non-Critical) - based on the urgency of their condition. The Red category includes life-threatening conditions requiring treatment within 5 minutes. Yellow indicates conditions that could become life-threatening without treatment within 30 minutes. Green covers non-emergent conditions treatable within 90 minutes. Each category has further subcategories to aid in prioritizing patient flow and resource allocation in emergency departments.
Disaster and field triaging ppw 2014 selvaSelvendra Shan
This document discusses disaster and field triage. It defines disasters as complex incidents resulting in loss of life, property damage, or disruption to daily life. Several types of disasters are described, including natural disasters, industrial accidents, and transportation accidents. The document outlines Malaysia's disaster management structure and the agencies involved in response. Two triage systems are explained - START and JumpSTART. START triages patients into immediate, delayed, minor, and deceased categories based on breathing, perfusion, and mental status. JumpSTART is modified for pediatric patients and includes a brief ventilation trial for non-breathing children with a pulse.
This guideline was developed by the ALS Subcommittee of the National Committee On Resuscitation Training in Malaysia. It provides an updated Advanced Life Support Training Manual for healthcare workers in Malaysia. The manual covers topics such as airway management, ECG rhythms, electrical therapy, drugs in resuscitation, ALS algorithms, resuscitation in specific circumstances, post-resuscitation care, and ethics of resuscitation. It aims to provide the latest evidence-based recommendations to enhance resuscitation skills and knowledge.
1) A 25-year-old male was in a high-speed head-on collision as an unrestrained driver and is unresponsive upon arrival with abnormal vital signs and injuries.
2) During the primary survey, the team will follow the ATLS protocol to simultaneously assess and treat the patient's airway, breathing, circulation, disability, and exposure (ABCDEs).
3) Adjuncts like diagnostic tools, vital sign monitoring, and urinary/gastric catheters will be used as needed during primary survey and resuscitation before proceeding to secondary survey and definitive care, with continuous re-evaluation of the stabilized patient.
An Introduction To Pre-Hospital Care in MalaysiaChew Keng Sheng
This document provides information on pre-hospital emergency care, including transport modes, ambulance equipment types, response times, patient assessment, trauma management principles, and mass casualty incident response. It discusses concepts like the golden hour and platinum 10 minutes for trauma patients, and outlines standards for scene size-up, patient packaging and sorting in multi-casualty events.
Initial management of polytrauma patients requires a systematic approach with airway, breathing, and circulation as top priorities. The primary survey assesses these areas to identify life-threatening injuries, while the secondary survey provides a full head-to-toe examination to identify all injuries and guide further treatment. Trauma mortality follows a trimodal distribution with immediate deaths from major vascular or brain injuries within an hour, early deaths from hemorrhage or respiratory failure within hours, and late deaths after 3 days often from sepsis or organ failure.
This document provides information on the Malaysian Triage Category (MTC) system used in emergency departments in Malaysia. The MTC system classifies patients into three categories - Red (Critical), Yellow (Semi-Critical), and Green (Non-Critical) - based on the urgency of their condition. The Red category includes life-threatening conditions requiring treatment within 5 minutes. Yellow indicates conditions that could become life-threatening without treatment within 30 minutes. Green covers non-emergent conditions treatable within 90 minutes. Each category has further subcategories to aid in prioritizing patient flow and resource allocation in emergency departments.
Disaster and field triaging ppw 2014 selvaSelvendra Shan
This document discusses disaster and field triage. It defines disasters as complex incidents resulting in loss of life, property damage, or disruption to daily life. Several types of disasters are described, including natural disasters, industrial accidents, and transportation accidents. The document outlines Malaysia's disaster management structure and the agencies involved in response. Two triage systems are explained - START and JumpSTART. START triages patients into immediate, delayed, minor, and deceased categories based on breathing, perfusion, and mental status. JumpSTART is modified for pediatric patients and includes a brief ventilation trial for non-breathing children with a pulse.
This guideline was developed by the ALS Subcommittee of the National Committee On Resuscitation Training in Malaysia. It provides an updated Advanced Life Support Training Manual for healthcare workers in Malaysia. The manual covers topics such as airway management, ECG rhythms, electrical therapy, drugs in resuscitation, ALS algorithms, resuscitation in specific circumstances, post-resuscitation care, and ethics of resuscitation. It aims to provide the latest evidence-based recommendations to enhance resuscitation skills and knowledge.
1) A 25-year-old male was in a high-speed head-on collision as an unrestrained driver and is unresponsive upon arrival with abnormal vital signs and injuries.
2) During the primary survey, the team will follow the ATLS protocol to simultaneously assess and treat the patient's airway, breathing, circulation, disability, and exposure (ABCDEs).
3) Adjuncts like diagnostic tools, vital sign monitoring, and urinary/gastric catheters will be used as needed during primary survey and resuscitation before proceeding to secondary survey and definitive care, with continuous re-evaluation of the stabilized patient.
An Introduction To Pre-Hospital Care in MalaysiaChew Keng Sheng
This document provides information on pre-hospital emergency care, including transport modes, ambulance equipment types, response times, patient assessment, trauma management principles, and mass casualty incident response. It discusses concepts like the golden hour and platinum 10 minutes for trauma patients, and outlines standards for scene size-up, patient packaging and sorting in multi-casualty events.
Initial management of polytrauma patients requires a systematic approach with airway, breathing, and circulation as top priorities. The primary survey assesses these areas to identify life-threatening injuries, while the secondary survey provides a full head-to-toe examination to identify all injuries and guide further treatment. Trauma mortality follows a trimodal distribution with immediate deaths from major vascular or brain injuries within an hour, early deaths from hemorrhage or respiratory failure within hours, and late deaths after 3 days often from sepsis or organ failure.
This document provides an overview of basic trauma life support. It defines trauma as any bodily injury caused by external energy sources. The primary survey involves a quick assessment of the patient's airway, breathing, circulation, disability, and exposure to identify life-threatening issues. The secondary survey involves a more focused physical exam and history to identify hidden injuries. Key skills covered include spinal immobilization, bleeding control techniques, wound management principles like RICE, and splinting. The overall goal is to rapidly identify and treat life-threatening injuries before transporting the patient to definitive care.
Pre-hospital care aims to reduce morbidity and mortality for patients outside the hospital by providing immediate medical care at the scene and during transport. It involves various providers like paramedics, nurses, and doctors who are specially trained to treat patients in pre-hospital settings. The philosophy is to intervene appropriately and transport patients safely to definitive care in a timely manner. An effective pre-hospital care system requires coordination between various stakeholders including emergency responders, hospitals, and policymakers to ensure patients receive optimal care from the scene to the hospital.
The document discusses triage tools used in emergency departments to prioritize patients based on severity of illness or injury. It provides background on the history of triage, challenges with overcrowding emergency departments, and describes common triage systems including 3-tier, 4-tier, 5-tier scales. The 5-tier Emergency Severity Index scale used in the US assigns expected time targets to be seen by a doctor to ensure patients are prioritized appropriately.
The document discusses emergency triage in a hospital emergency department. It describes triage as a process where a nurse rapidly evaluates patients upon arrival to determine the level of acuity and priority for care. The triage nurse assesses factors like chief complaint, appearance, vital signs, history and assigns the patient to one of five standardized triage levels, from level 1 being life-threatening to level 5 being non-urgent, with corresponding timeframes for clinician assessment. The primary role of the triage nurse is to make decisions about priority of care while monitoring for communicable diseases or violence.
Role and responsibility of First Responders In MOHdrnikahmad
Dokumen tersebut membahas tentang tugas, tanggung jawab, dan etika first responder dalam memberikan perawatan pertolongan pertama. Ia menjelaskan bahwa first responder adalah orang pertama yang tiba di tempat kejadian dan terlatih untuk memberikan perawatan awal. Dokumen tersebut juga membahas tentang nilai-nilai integritas seperti kejujuran, tanggung jawab, dan komitmen dalam pelaksanaan tugas first responder.
Triage is the process of sorting patients based on the urgency of their condition to provide the right care to the patients who need it most. It involves an initial assessment of patients upon arrival to identify life-threatening issues and prioritize patients into categories based on need. The document outlines the goals and categories of triage in both emergency and disaster situations, with categories ranked from resuscitation to non-urgent based on the threat to life, limb, or function. It also describes the key components of triage including an initial across-the-room assessment and ongoing re-assessments to adjust patient priority as needs change.
the emergency assessment to be done carefully and immediately .the emergency nurse have quick review and deliver the health carein the quality manner in all the fields of health care as medical,surgical, paediatric ,and obstertics .
This document provides information on triage systems and procedures. It defines triage as sorting patients based on treatment priority. The START and JumpSTART triage systems categorize patients as red/immediate, yellow/delayed, green/minor, or black/deceased based on their respiration, pulse, and mental status. It outlines how to rapidly assess and tag patients in a mass casualty event using these criteria in 3 sentences or less per patient to maximize survivability. The document recommends clearing walking patients first and prioritizing life-saving interventions for immediate patients before movement or additional treatment.
The document discusses the secondary survey performed on trauma patients. The secondary survey is a complete head-to-toe physical exam done after initial resuscitation to identify all anatomical injuries. It involves examining each body region for injuries like fractures, lacerations, and internal bleeding. Regions like the abdomen, pelvis, and extremities are high-risk for missed injuries from blunt or penetrating trauma and require thorough examination. The physical exam evaluates things like breathing, circulation, sensation and movement to diagnose potential injuries from trauma.
The document discusses guidelines for safely transporting critically ill patients within the hospital. It notes that transport increases risks from disconnecting life support equipment and monitoring. To minimize risks, transports require careful planning, qualified personnel, and appropriate equipment. The guidelines recommend at least two trained caregivers accompany patients, along with vital sign monitors, ventilation equipment, emergency drugs, IV pumps and backups. Ongoing communication and matching the pre-transport level of care and monitoring during transport are also emphasized. The document concludes that following these guidelines can help reduce adverse events, which occur in 6-71% of transports without interventions.
The document discusses preparation for trauma patients and performing the primary survey. It outlines assembling a trauma team, preparing equipment, and the key components of the primary survey including vital signs, adjuncts like ABGs and imaging, and potential pitfalls. The role of preparation, a systematic team approach, and effective communication are emphasized to reduce errors in the initial reception and resuscitation of trauma patients.
This document discusses the management of a polytrauma patient presenting with blunt abdominal trauma at POF Hospital. It describes the patient's presentation with shock and a grade 3 spleen injury found on FAST scan. Exploratory laparotomy revealed additional injuries including a grade 5 splenic injury and grade 4 renal injury. Definitive surgical management included splenectomy, nephrectomy, and sigmoid colostomy. The patient recovered well after multiple blood transfusions and other supportive care. Key components of polytrauma management include primary and secondary surveys, resuscitation, diagnostic studies like FAST scan, and definitive surgical or conservative treatment of injuries.
Triage in emergency department 100121135547-phpapp01-170528183022abdul mannan
Triage is the process of sorting patients based on the urgency of their condition to provide the right care to the patients who need it most. It involves an initial assessment of patients upon arrival to identify life-threatening issues and prioritize patients into categories based on need. The document outlines the goals and categories of triage in both emergency and disaster situations, with categories ranked from resuscitation to non-urgent based on the threat to life, limb, or function. It also describes the key components of triage including an initial across-the-room assessment and ongoing re-assessments to manage patient flow efficiently and address needs as conditions may change.
The document outlines protocols for responding to cardiopulmonary arrests, known as Code Blues. It describes initiating Basic Life Support, Advanced Cardiac Life Support, or Pediatric Advanced Life Support depending on the patient. It provides details on activating emergency codes, assembling code teams, performing immediate interventions like CPR and defibrillation, notifying physicians, and transferring patients to the emergency department. Crash carts and equipment are also discussed, including obtaining replacement carts and charging used items.
Triage is the process of prioritizing patients according to the urgency of their need for care. It aims to ensure patients are treated in order of clinical urgency and receive timely care. There are three main types of triage - primary triage in the field, secondary triage in the emergency department, and tertiary triage by specialists. The START and SAVE methods are used for disaster triage in the field to categorize patients into immediate, delayed, or minimal care/expectant groups. In the ED, patients are assigned colors based on their condition - red for most urgent, yellow intermediate, green less urgent, and black for deceased. Documentation, equipment, and designated triage teams are needed to properly conduct triage
Advanced trauma and life support (atls)anu_sandhya
The document outlines the steps of the Advanced Trauma Life Support (ATLS) protocol for assessing and treating multiply injured patients, including performing a primary and secondary survey to evaluate the airway, breathing, circulation, disability, and exposure of patients and providing resuscitation and monitoring before delivering definitive care. It emphasizes following the ABCDE approach to treat the greatest threats to life first and stabilizing patients before making a definitive diagnosis.
The document summarizes several updates to the 8th edition of ATLS (Advanced Trauma Life Support) guidelines compared to the 7th edition, including:
1) Additional guidance on assessing and managing difficult airways, including use of the LMA, carbon dioxide detectors, laryngeal tube airways, and gum elastic bougies.
2) Updates to fluid resuscitation guidelines for hemorrhagic shock based on new evidence, including use of warmed fluids and a more cautious approach to fluid administration before hemorrhage is controlled.
3) Expanded guidance on angioembolization, thoracotomy indications, and evaluation of pelvic fractures, brain injuries, and cervical spine injuries.
Initial assessment of a trauma patient involves a primary survey using the ABCDE approach to identify life-threatening injuries. For the described trauma scenario, the initial steps would be:
1) Assess the airway and give high-flow oxygen. The patient's ability to speak suggests his airway is not compromised.
2) Evaluate breathing and circulation. His breathing is compromised as shown by the low respiratory rate and high pulse.
3) Expose the patient fully to identify injuries and monitor for hypothermia. The abrasion on his chest indicates potential internal injuries.
4) Begin resuscitation with IV fluids and monitor vitals closely given his unstable condition from potential internal bleeding and shock.
5)
This document provides information on triage and EMTALA regulations. It discusses the following key points:
1. EMTALA requires hospitals to provide a medical screening exam and stabilizing treatment to anyone who presents with an emergency medical condition. Triage does not constitute a medical screening exam which must be done by an ED MD or PA.
2. EMTALA regulations apply to anyone seeking emergency care on hospital property, including areas within 250 yards. Hospitals can face penalties for violating EMTALA.
3. The ESI triage system categorizes patients into 5 levels based on acuity - from level 1 requiring resuscitation to level 5 for non-urgent conditions. It considers factors like life threats, resources needed
This document provides guidelines for various quality and safety practices at a hospital. It discusses proper patient identification procedures, guidelines for verbal and telephone orders, procedures for high alert medications, surgical checklists including site marking and time outs, hand hygiene practices, fall risk assessment and prevention measures, occurrence variance reporting for documenting incidents, and the focus-PDCA methodology for quality improvement. Key areas of focus include correctly identifying patients, improving communication, ensuring surgery and medication safety, reducing healthcare associated infections and patient harm from falls.
This document provides an overview of basic trauma life support. It defines trauma as any bodily injury caused by external energy sources. The primary survey involves a quick assessment of the patient's airway, breathing, circulation, disability, and exposure to identify life-threatening issues. The secondary survey involves a more focused physical exam and history to identify hidden injuries. Key skills covered include spinal immobilization, bleeding control techniques, wound management principles like RICE, and splinting. The overall goal is to rapidly identify and treat life-threatening injuries before transporting the patient to definitive care.
Pre-hospital care aims to reduce morbidity and mortality for patients outside the hospital by providing immediate medical care at the scene and during transport. It involves various providers like paramedics, nurses, and doctors who are specially trained to treat patients in pre-hospital settings. The philosophy is to intervene appropriately and transport patients safely to definitive care in a timely manner. An effective pre-hospital care system requires coordination between various stakeholders including emergency responders, hospitals, and policymakers to ensure patients receive optimal care from the scene to the hospital.
The document discusses triage tools used in emergency departments to prioritize patients based on severity of illness or injury. It provides background on the history of triage, challenges with overcrowding emergency departments, and describes common triage systems including 3-tier, 4-tier, 5-tier scales. The 5-tier Emergency Severity Index scale used in the US assigns expected time targets to be seen by a doctor to ensure patients are prioritized appropriately.
The document discusses emergency triage in a hospital emergency department. It describes triage as a process where a nurse rapidly evaluates patients upon arrival to determine the level of acuity and priority for care. The triage nurse assesses factors like chief complaint, appearance, vital signs, history and assigns the patient to one of five standardized triage levels, from level 1 being life-threatening to level 5 being non-urgent, with corresponding timeframes for clinician assessment. The primary role of the triage nurse is to make decisions about priority of care while monitoring for communicable diseases or violence.
Role and responsibility of First Responders In MOHdrnikahmad
Dokumen tersebut membahas tentang tugas, tanggung jawab, dan etika first responder dalam memberikan perawatan pertolongan pertama. Ia menjelaskan bahwa first responder adalah orang pertama yang tiba di tempat kejadian dan terlatih untuk memberikan perawatan awal. Dokumen tersebut juga membahas tentang nilai-nilai integritas seperti kejujuran, tanggung jawab, dan komitmen dalam pelaksanaan tugas first responder.
Triage is the process of sorting patients based on the urgency of their condition to provide the right care to the patients who need it most. It involves an initial assessment of patients upon arrival to identify life-threatening issues and prioritize patients into categories based on need. The document outlines the goals and categories of triage in both emergency and disaster situations, with categories ranked from resuscitation to non-urgent based on the threat to life, limb, or function. It also describes the key components of triage including an initial across-the-room assessment and ongoing re-assessments to adjust patient priority as needs change.
the emergency assessment to be done carefully and immediately .the emergency nurse have quick review and deliver the health carein the quality manner in all the fields of health care as medical,surgical, paediatric ,and obstertics .
This document provides information on triage systems and procedures. It defines triage as sorting patients based on treatment priority. The START and JumpSTART triage systems categorize patients as red/immediate, yellow/delayed, green/minor, or black/deceased based on their respiration, pulse, and mental status. It outlines how to rapidly assess and tag patients in a mass casualty event using these criteria in 3 sentences or less per patient to maximize survivability. The document recommends clearing walking patients first and prioritizing life-saving interventions for immediate patients before movement or additional treatment.
The document discusses the secondary survey performed on trauma patients. The secondary survey is a complete head-to-toe physical exam done after initial resuscitation to identify all anatomical injuries. It involves examining each body region for injuries like fractures, lacerations, and internal bleeding. Regions like the abdomen, pelvis, and extremities are high-risk for missed injuries from blunt or penetrating trauma and require thorough examination. The physical exam evaluates things like breathing, circulation, sensation and movement to diagnose potential injuries from trauma.
The document discusses guidelines for safely transporting critically ill patients within the hospital. It notes that transport increases risks from disconnecting life support equipment and monitoring. To minimize risks, transports require careful planning, qualified personnel, and appropriate equipment. The guidelines recommend at least two trained caregivers accompany patients, along with vital sign monitors, ventilation equipment, emergency drugs, IV pumps and backups. Ongoing communication and matching the pre-transport level of care and monitoring during transport are also emphasized. The document concludes that following these guidelines can help reduce adverse events, which occur in 6-71% of transports without interventions.
The document discusses preparation for trauma patients and performing the primary survey. It outlines assembling a trauma team, preparing equipment, and the key components of the primary survey including vital signs, adjuncts like ABGs and imaging, and potential pitfalls. The role of preparation, a systematic team approach, and effective communication are emphasized to reduce errors in the initial reception and resuscitation of trauma patients.
This document discusses the management of a polytrauma patient presenting with blunt abdominal trauma at POF Hospital. It describes the patient's presentation with shock and a grade 3 spleen injury found on FAST scan. Exploratory laparotomy revealed additional injuries including a grade 5 splenic injury and grade 4 renal injury. Definitive surgical management included splenectomy, nephrectomy, and sigmoid colostomy. The patient recovered well after multiple blood transfusions and other supportive care. Key components of polytrauma management include primary and secondary surveys, resuscitation, diagnostic studies like FAST scan, and definitive surgical or conservative treatment of injuries.
Triage in emergency department 100121135547-phpapp01-170528183022abdul mannan
Triage is the process of sorting patients based on the urgency of their condition to provide the right care to the patients who need it most. It involves an initial assessment of patients upon arrival to identify life-threatening issues and prioritize patients into categories based on need. The document outlines the goals and categories of triage in both emergency and disaster situations, with categories ranked from resuscitation to non-urgent based on the threat to life, limb, or function. It also describes the key components of triage including an initial across-the-room assessment and ongoing re-assessments to manage patient flow efficiently and address needs as conditions may change.
The document outlines protocols for responding to cardiopulmonary arrests, known as Code Blues. It describes initiating Basic Life Support, Advanced Cardiac Life Support, or Pediatric Advanced Life Support depending on the patient. It provides details on activating emergency codes, assembling code teams, performing immediate interventions like CPR and defibrillation, notifying physicians, and transferring patients to the emergency department. Crash carts and equipment are also discussed, including obtaining replacement carts and charging used items.
Triage is the process of prioritizing patients according to the urgency of their need for care. It aims to ensure patients are treated in order of clinical urgency and receive timely care. There are three main types of triage - primary triage in the field, secondary triage in the emergency department, and tertiary triage by specialists. The START and SAVE methods are used for disaster triage in the field to categorize patients into immediate, delayed, or minimal care/expectant groups. In the ED, patients are assigned colors based on their condition - red for most urgent, yellow intermediate, green less urgent, and black for deceased. Documentation, equipment, and designated triage teams are needed to properly conduct triage
Advanced trauma and life support (atls)anu_sandhya
The document outlines the steps of the Advanced Trauma Life Support (ATLS) protocol for assessing and treating multiply injured patients, including performing a primary and secondary survey to evaluate the airway, breathing, circulation, disability, and exposure of patients and providing resuscitation and monitoring before delivering definitive care. It emphasizes following the ABCDE approach to treat the greatest threats to life first and stabilizing patients before making a definitive diagnosis.
The document summarizes several updates to the 8th edition of ATLS (Advanced Trauma Life Support) guidelines compared to the 7th edition, including:
1) Additional guidance on assessing and managing difficult airways, including use of the LMA, carbon dioxide detectors, laryngeal tube airways, and gum elastic bougies.
2) Updates to fluid resuscitation guidelines for hemorrhagic shock based on new evidence, including use of warmed fluids and a more cautious approach to fluid administration before hemorrhage is controlled.
3) Expanded guidance on angioembolization, thoracotomy indications, and evaluation of pelvic fractures, brain injuries, and cervical spine injuries.
Initial assessment of a trauma patient involves a primary survey using the ABCDE approach to identify life-threatening injuries. For the described trauma scenario, the initial steps would be:
1) Assess the airway and give high-flow oxygen. The patient's ability to speak suggests his airway is not compromised.
2) Evaluate breathing and circulation. His breathing is compromised as shown by the low respiratory rate and high pulse.
3) Expose the patient fully to identify injuries and monitor for hypothermia. The abrasion on his chest indicates potential internal injuries.
4) Begin resuscitation with IV fluids and monitor vitals closely given his unstable condition from potential internal bleeding and shock.
5)
This document provides information on triage and EMTALA regulations. It discusses the following key points:
1. EMTALA requires hospitals to provide a medical screening exam and stabilizing treatment to anyone who presents with an emergency medical condition. Triage does not constitute a medical screening exam which must be done by an ED MD or PA.
2. EMTALA regulations apply to anyone seeking emergency care on hospital property, including areas within 250 yards. Hospitals can face penalties for violating EMTALA.
3. The ESI triage system categorizes patients into 5 levels based on acuity - from level 1 requiring resuscitation to level 5 for non-urgent conditions. It considers factors like life threats, resources needed
This document provides guidelines for various quality and safety practices at a hospital. It discusses proper patient identification procedures, guidelines for verbal and telephone orders, procedures for high alert medications, surgical checklists including site marking and time outs, hand hygiene practices, fall risk assessment and prevention measures, occurrence variance reporting for documenting incidents, and the focus-PDCA methodology for quality improvement. Key areas of focus include correctly identifying patients, improving communication, ensuring surgery and medication safety, reducing healthcare associated infections and patient harm from falls.
The document discusses principles of first aid and emergency care for trauma patients, including assessing and managing the ABCs (airway, breathing, circulation). It covers common emergencies like asphyxia, wounds, shock, and their signs, causes, and first aid treatments. The Heimlich maneuver and other airway management techniques like endotracheal intubation are described for establishing an open airway in emergency situations.
The document discusses triage protocols for mass casualty incidents (MCIs). It describes several triage tools and systems used in emergency medicine to prioritize patient care based on severity of injury, including START, SALT, and ABCDE approaches. The goal of triage is to maximize survival by allocating limited healthcare resources to patients with the most life-threatening injuries first. Patients are assigned triage tags or sorted into categories like Red (immediate), Yellow (delayed), Green (walking wounded), and Black (deceased/expectant).
The document discusses the National Incident Management System (NIMS) and its role in coordinating response to mass casualty incidents. NIMS was created to provide a unified approach for managing large-scale emergencies involving multiple jurisdictions. It establishes standardized command structures under the Incident Command System (ICS). The ICS directs response operations and organizes responders into functional sections. For mass casualty incidents, the ICS oversees all response aspects including triage, treatment and transportation of patients. First responders are trained in their roles within the ICS to effectively manage resources during large-scale emergencies.
The document discusses the importance of preoperative assessment and preparation of patients prior to surgery. Key aspects of assessment include taking a thorough medical history, conducting a physical examination, evaluating nutritional status, ordering relevant investigations, and determining surgical risk. Important elements of preparation are obtaining informed consent, preventing cardiovascular and respiratory complications, reducing risk of aspiration, preparing the bowels if needed, and ensuring adequate sleep, skin preparation, catheterization and pre-medication when applicable. The goals are to identify risk factors, optimize the patient's health status, and reduce postoperative complications.
This document provides information on emergency care and triage. It discusses the principles of emergency care which include providing care without delay and using triage to prioritize patients. Triage involves sorting patients into categories of emergent, urgent, and non-urgent based on the seriousness of their conditions. The document then describes the triage process in more detail, including the different color codes used to categorize patients and the criteria for each category. It also discusses the roles of triage team members and how to set up an effective triage system.
This document provides information on emergency care and triage. It discusses the principles of emergency care which include providing care without delay and using triage to prioritize patients. Triage involves sorting patients into categories of emergent, urgent, and non-urgent based on the seriousness of their conditions. The document then describes the triage process in more detail, outlining the different color codes used to categorize patients and the types of injuries that fall under each code. It also discusses the purposes of triage, how it is performed, and the roles of triage team members in an emergency situation.
The triage protocol creates an objective process to guide healthcare professionals in making the difficult determination of how to allocate resources to critically ill adult and pediatric patients when there are not enough critical care resources for everyone.
Triage is the process of prioritizing patients according to the severity of their condition in order to ensure those with the most serious injuries receive care first when resources are limited. It involves classifying patients into categories based on initial assessments and then reassessing as needed. The goal is to do the most good for the most people using available resources. Triage methods like START and SAVE are used in disaster situations to rapidly assess and prioritize patients into categories to determine who should receive immediate care, delayed care, or comfort care only. In the emergency department, a triage team assesses all patients and assigns a color code category of red, yellow, green or black to indicate treatment priority and direct patients to the appropriate care area
Handling the emergencies in radiology and first aid in the x ray departmentAnupam Niraula
1) Emergency departments are designed to treat acute medical issues without appointments and are staffed by trauma physicians. They classify patients into non-urgent, urgent, and acute categories to prioritize care.
2) For trauma patients, MDCT is often the preferred imaging method and should be located near the emergency room along with radiography. Interventional radiology may perform procedures like embolization to stop hemorrhaging.
3) In reaction emergencies, treatments vary based on symptoms but may include oxygen, antihistamines, epinephrine, saline, and moving the patient to stabilize their condition. Staff are trained to recognize and respond to different types and severities of reactions.
This document outlines several goals and safety measures to reduce patient harm at a hospital. It discusses identifying patients correctly, improving communication, safely managing high-alert medications, preventing wrong-site procedures, reducing healthcare-associated infections, and minimizing falls. Specific strategies are provided, such as conducting vulnerability assessments, monitoring high-risk patients more frequently, using safety checklists, and keeping patients accompanied and call bells within reach. The overall aim is to establish a culture of safety and reporting of any adverse events.
This presentation on Triage and transport deals with how we should we deal with the patients who are attending the emergency department and to provide best treatment for the needy patients at appropriate time.
I hope this will be helpful to nurses, paramedics, graduate and under graduate students and emergency doctors and team.
INITIAL ASSESSMENT AND INTENSIVE CARE IN TRAUMA.pptxMahima Shanker
This document discusses the initial assessment and intensive care of trauma patients. It covers the trimodal distribution of trauma deaths, the importance of the "golden hour" period, and the steps of the primary and secondary surveys using the ABCDE approach. The primary survey involves assessing the airway, breathing, circulation, disability, and exposure. Key points include techniques for airway management and control of hemorrhage. Overall it provides an overview of the critical principles and processes for stabilizing trauma patients in the initial emergency period.
Triage is the process of sorting patients based on the urgency of their condition to provide the right care to the right patient at the right time. It involves initially assessing patients at arrival to identify those needing immediate care, determine the appropriate treatment area, and avoid congestion. The goals are to treat the most severely injured first while maximizing survival in a mass casualty event. Triage categories range from resuscitation to non-urgent to ensure critical patients receive rapid medical attention. Reassessment is important as a patient's condition may deteriorate while waiting.
This document provides an overview of initial assessment and management of trauma patients in remote environments. It discusses the primary survey using CABCDE to rapidly identify life threats, including controlling hemorrhage, maintaining the airway, and assessing breathing and circulation. It also covers the secondary survey, prolonged field care, definitive care, and obtaining a thorough history including mechanism of injury to help predict injuries. The systematic approach outlined aims to stabilize patients and prepare them for evacuation.
The document discusses triage in emergency nursing. It defines triage as sorting patients based on acuity to provide the most urgent care first when resources are limited. A triage nurse must quickly identify life-threatening issues and determine each patient's priority level using standardized rating systems. The document outlines the primary and secondary assessments emergency nurses conduct to evaluate patients and identify issues requiring immediate treatment versus those that can wait. The goal of triage is to do the greatest good for the greatest number.
The document summarizes the student's observation of the trauma center at Abilene Regional Hospital. It describes various medical cases seen including abdominal pain, chest pain, and injuries from an automobile accident. It discusses the goals of triage in the trauma center to prioritize patients based on need. It also outlines safety guidelines followed in the trauma center including security protocols and monitoring systems. Finally, it describes the critical role of trauma nurses in providing fast, knowledgeable care under stressful conditions to stabilize patients and prevent further health deterioration.
Similar to Malaysian Triage Scale New Revised 2019-1.pdf (20)
How to Add Chatter in the odoo 17 ERP ModuleCeline George
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1. MALAYSIAN TRIAGE SCALE
FOR EMERGENCY AND TRAUMA DEPARTMENTS
(NEW REVISED VERSION 2019)
OVERVIEW OF TRIAGE PROCESS IN EMERGENCY AND TRAUMA DEPARTMENTS
Appendix 8 - Malaysian Triage Scale (New Revised Version 2019)
PRIMARY
TRIAGE
OVERALL TRIAGE PROCESS IN ADULTS
• Critical First Look
• Rapid Assessment
• Safety
SECONDARY
TRIAGE
• Vital Signs
• Complaints List
• Initial Tests
LEVEL 1 - RESUSCITATION
LEVEL 2 - EMERGENCY
LEVEL 3 - URGENT
LEVEL 4 - EARLY CARE
LEVEL 5 - ROUTINE
OVERALL TRIAGE PROCESS IN PAEDIATRICS
PRIMARY
TRIAGE
• Critical First Look
• Paed Assessment Triangle
• Safety
SECONDARY
TRIAGE
• Paeds Vital Signs
• Paeds Complaints List
• Initial Tests
LEVEL 1 - RESUSCITATION
LEVEL 2 - EMERGENCY
LEVEL 3 - URGENT
LEVEL 4 - EARLY CARE
LEVEL 5 - ROUTINE
2. OVERVIEW STATEMENTS
• The Triage Services are the first point of contact for all patients accessing the services of the
Emergency and Trauma Department. These protocols are designed to sort out patients
according to their degree of severity, in order to ensure that they are seen in a timely manner
and allocated appropriate resources.
• Triage processes are designed to be conducted rapidly within a few minutes in order to assign
a triage level, which will determine priority, resources and treatment zones. This is vital to
facilitate patient flow through the Emergency Department and avoid unnecessary congestion.
• Triage does not make specific diagnoses, and is not meant to identify all medical needs.
• Triage levels are assigned based on severity of the patients condition, and urgency of
treatment needs, which is determined by rapid assessment, type of complaints and certain
specific modifiers.
• Time to Treatment1 standards relevant to Triage Levels are as follows
‣ Level 1 - Resuscitation - 0 minutes (requires rapid team activation mechanism)
‣ Level 2 - Emergency - under 10 minutes
‣ Level 3 - Urgent - under 30 minutes
‣ Level 4 - Early Care - under 60 minutes
‣ Level 5 - Routine - under 90 minutes
• The number of treatment zones in Emergency Departments may vary according to size of
hospital, number of ED attendances, availability of Emergency Physicians and degree of
interventions carried out in the ED. A treatment zone may be designated to manage patients
from different triage levels. This decision should be made at each individual ED based on its
number of treatment zones and availability of staffing for those zones. Although treatment
zones may vary according to hospitals, triage levels remain the same.
• Paediatric Triage takes into considerations the different challenges and presentations specific
to the Under-12 population and is therefore described separately.
• The Triage process is meant to be repeated when new symptoms develop, symptoms worsen
or the patientʼs condition appears to change. It is also recommended that patients are
reassessed every hour, if they have not been seen by doctors yet.
• This guide is meant as a tool to facilitate the training and performance of triage processes by
healthcare providers.
Appendix 8 - Malaysian Triage Scale (New Revised Version 2019)
1 Time to Treatment - Time from registration to Time first seen by treating doctor
3. PRIMARY TRIAGE
• The Primary Triage Officer, stationed at or near the front entrance of the ED, identifies critically
ill or injured patients and diverts them immediately to treatment areas. Specifically, the Primary
Triage Officer performs the following roles
‣ Performs a Critical First Look and determines rapidly if the patient requires resuscitation
or immediate emergency care
CRITICAL FIRST LOOK
CRITICAL FIRST LOOK
CRITICAL FIRST LOOK
CRITICAL FIRST LOOK
CRITICAL FIRST LOOK
LOOK FOR
LEVEL 1 -
RESUSCITATION
LEVEL 2 -
EMERGENCY
LEVEL 3 -
URGENT
SECONDARY
TRIAGE
APPEARANCE
• Cardiac Arrest
• Not Breathing
• Major Trauma in
Shock
• Severe Resp Distress
• Not responding to
call
• Severe Chest Pain
• Severe Pain
• Ongoing Seizures
• Altered mental state
• Cannot communicate
• Cannot sit / stand
unsupported
• Walking
• Talking
• Not distressed
• Not aggressive
‣ Performs a Rapid Assessment looking for Respiratory Distress, Shock State, Decreased
Conscious Levels and / or Active Bleeding that requires resuscitation, immediate
emergency care or urgent attention.
RAPID ASSESSMENT
RAPID ASSESSMENT
RAPID ASSESSMENT
RAPID ASSESSMENT
RAPID ASSESSMENT
CHECK FOR
LEVEL 1 -
RESUSCITATION
LEVEL 2 -
EMERGENCY
LEVEL 3 -
URGENT
SECONDARY
TRIAGE
RESPIRATORY
DISTRESS
• Airway
breathing
• SpO2
• Abnormal sounds
• Excessive work of
breathing, sweating
• Cannot speak; one-
word reply
• Confused, lethargic
• Require assisted
breathing
• SpO2 < 90% room air
• Difficulty to breath
• Short phrases only
• Agitation, anxious
• SpO2 90 - 92% room
air
• Wheeze, expiratory
rhonchi; airway intact
• SpO2 92 - 94% room
air
• Need O2 support
• Not
breathless
• Sp02 > 94%
• No need O2
SHOCK STATE
• Peripheries
• Pulses
• AVPU
• Pale, cyanosed, cold
peripheries
• Severe Tachycardia /
Bradycardia
• Absent Radial Pulse
• Tachycardia, Weak
Pulses
• Confused
• Septic / Toxic
• CRT > 2 seconds
• Peripheries warm,
CRT normal
• Cannot stand / walk
unsupported
• Warm, pink,
pulses normal
• Alert, walking
CONSCIOUS
LEVELS
• Airway
• AVPU
• Brief Neuro
• Unresponsive
• Airway unprotected
• Confused, agitated,
disoriented
• Obvious Neuro
deficits
• Ongoing Seizures
• Abnormal posturing
• Not fully conscious
• Cannot sit
unsupported
• Alert
• Sit upright
Appendix 8 - Malaysian Triage Scale (New Revised Version 2019)
4. RAPID ASSESSMENT
RAPID ASSESSMENT
RAPID ASSESSMENT
RAPID ASSESSMENT
RAPID ASSESSMENT
CHECK FOR
LEVEL 1 -
RESUSCITATION
LEVEL 2 -
EMERGENCY
LEVEL 3 -
URGENT
SECONDARY
TRIAGE
BLEEDING
• Seen
External
• Suspect
Internal
• Bleeding
Disorders
• Anti-
coagulant
therapy
• Arterial Limb Bleeding
• Active uncontrolled
bleeding
• Massive Vaginal
bleed
• Severe Facial Injury
• Severe Pelvic Injury
• Active Vomit / Cough
Blood
• Suspected vascular
injury
• Suspected Intra-
Abdominal Bleeding /
Ectopic / AAA
• Compartment
syndrome
• Bleeding fr Fractures/
Dislocations / Joints /
Wounds
• Menorrhagia
• ENT Bleeding
• Expanding
haematoma
• Bleeding Disorders
• Minimal / No
active
bleeding
‣ Ensures safety of the patient, healthcare providers and other persons in the ED by
identifying all patients with potentially infectious diseases or at-risk exposures which may
create harm or hazards to others, including highly contagious respiratory spread or
contact spread infections and dangerous toxin exposures, in order to ensure isolation
and other infection control measures, or decontamination can be carried out.
INFECTIOUS DISEASES / HAZMAT
INFECTIOUS DISEASES / HAZMAT
INFECTIOUS DISEASES / HAZMAT
DISEASES / EXPOSURE TO BE PLACED AT INITIAL ACTIONS
MERS Co-V / Pandemic Influenza and
other emerging viruses
Isolation (Negative Pressure) Patient / Relatives wear surgical mask
Wash hands with alcohol
Active Tuberculosis, untreated Isolation (Negative Pressure) Patient wear surgical mask
Meningococcaemia Isolation (Negative Pressure) Patient / Relatives wear surgical mask
Wash hands with alcohol
CRE, MRSA, other multi-drug resistant
infections
Isolation Room Patient wear surgical mask
Wash hands with alcohol
EBOLA and other re-emerging viruses Isolation Room Patient wear surgical mask
Wash hands with alcohol
Organophosphates and similar
compounds
Decontamination Removal of clothes
External shower decontamination
Chemical exposure to Eyes, ENT Any external area Immediate and continuing wash-off
HAZMAT - chemical, dry or liquid Decontamination Removal of clothes
Removal of any dry contaminant
External shower decontamination for
liquid contaminants
HAZMAT - inhaled Isolation (Negative Pressure) Identify potential exposure
Early Airway support
Consider early Antidote
Appendix 8 - Malaysian Triage Scale (New Revised Version 2019)
5. INFECTIOUS DISEASES / HAZMAT
INFECTIOUS DISEASES / HAZMAT
INFECTIOUS DISEASES / HAZMAT
DISEASES / EXPOSURE TO BE PLACED AT INITIAL ACTIONS
HAZMAT - radioactive Decontamination Removal of clothes
Removal of any dry contaminant
External shower decontamination
Radiation survey performed urgently
Note: In all of the scenarios above, senior clinicians must be involved early on. All staff must wear appropriate PPE.
All movement of patients should be restricted to reduce risk to others.
Note: In all of the scenarios above, senior clinicians must be involved early on. All staff must wear appropriate PPE.
All movement of patients should be restricted to reduce risk to others.
Note: In all of the scenarios above, senior clinicians must be involved early on. All staff must wear appropriate PPE.
All movement of patients should be restricted to reduce risk to others.
‣ Ensures safety of all persons in the vicinity by seeking urgent measures to resolve highly
aggressive or potentially violent patients, or persons, before allowing them to proceed
into the ED
AGGRESSIVE / POTENTIALLY VIOLENT PERSONS
AGGRESSIVE / POTENTIALLY VIOLENT PERSONS
CONDITIONS POTENTIAL ACTIONS
Aggressive Persons Verbal de-escalation measures / Safety of other patients, persons
Activation of Trained Personnel / KIV Activation of Police
Physical Restraint measures
Medications eg. Olanzepine (rapid onset Tolanz), Midazolam (intra-nasal, IM)
Potentially Violent Verbal de-escalation measures / Safety of other patients, persons
Activation of Trained Personnel / Activation of Police
Code GREY activation
Physical Restraint measures / Holding Room
Medications eg. Olanzepine (rapid onset Tolanz), Midazolam (intra-nasal, IM)
followed by IV sedatives
Violent Persons / Weapons Verbal de-escalation measures / Safety of other patients, persons
Activation of Trained Personnel / Immediate Activation of Police
Code GREY activation
Physical Restraint measures / Holding Room / Police Holding Cell
Medications eg. Olanzepine (rapid onset Tolanz), Midazolam (intra-nasal, IM)
followed by IV Sedatives
Note: In all of the scenarios above, senior clinicians must be involved early on. Activation of trained teams are
essential (protocols and drills are needed).
Note: In all of the scenarios above, senior clinicians must be involved early on. Activation of trained teams are
essential (protocols and drills are needed).
‣ Facilitates the placement and movement of patients brought in by ambulances, patients
requiring the One-Stop Crisis Center (OSCC), OKT brought by the Police etc.
• The Primary Triage Officer assigns Triage Levels for Levels 1, 2 and 3 only and immediately
diverts these patients to the designated treatment areas. Patients who do not satisfy the
criteria for these Triage Levels proceed to Registration followed by Secondary Triage.
• In a small group of patients with presentations that are non-urgent and non-emergency, which
can be better addressed in other outpatient services, the patients may be triaged-away. It is
necessary to ensure their vital signs are normal and provide them with a note recording down
their complaints and vital signs readings.
Appendix 8 - Malaysian Triage Scale (New Revised Version 2019)
6. SECONDARY TRIAGE
• The Secondary Triage Officer performs additional assessment of patients who did not initially
qualify for Levels 1, 2, 3 at Primary Triage. Patients may still be assigned these levels if
warranted by abnormalities of vital signs, initial tests or if they have high risk complaints.
• Specifically, the Secondary Triage Officer performs the following actions
‣ Measures vital signs (BP, HR, RR, SpO2, Temp, GCS, Pain Score)
‣ Performs initial tests for ECG, and Glucose estimation
‣ Assesses the patients complaints and identifies modifiers which most appropriately
describe their symptoms. If modifiers do not differentiate between two triage levels, the
higher triage level modifier should be selected.
• The Secondary Triage Officer can assign triage levels from Level 2 - 5. The final triage level
assigned takes into consideration all of the selected parameters ie. Primary Triage, Vital Signs,
Complaints List and Initial Tests.
VITAL SIGNS (ADULT)
VITAL SIGNS (ADULT)
VITAL SIGNS (ADULT)
VITAL SIGNS (ADULT)
VITAL SIGNS (ADULT)
LOOK FOR
LEVEL 2 -
EMERGENCY
LEVEL 3 -
URGENT
LEVEL 4 -
EARLY CARE
LEVEL 5 -
ROUTINE
VITAL SIGNS
• BP
• HR
• RR
• SpO2
• SBP < 90
• HR > 120
• RR > 30
• BP > 220/130 with
symptoms
• SpO2 < 92%
• HR 100 - 120
• RR 20 - 30
• BP > 220/130 No
symptoms
• BP > 180/110 Mild
symptoms
• SpO2 92 - 94%
• Vital Signs within
normal limits
• BP > 180/110 No
symptoms
• Vital Signs within
normal limits
VITAL SIGNS
• Temp
• GCS
• Pain Score
• Temp > 39 or < 36
• Appears Septic, Ill
• Immunocompromised
• Severe Pain (8 - 10)
• GCS < 13 or drop > 2
• Temp 37.5 - 39 C
• Pain Score 4 - 7
• Appears unwell
• History of Fever
• No documented
fever
• No Fever
• No Pain
ECG
• 12-lead
ECG
• Wide Complex
Tachycardia
• Narrow Complex
Tachycardia > 150 /
min
• Bradycardia < 40
• ST elevations or
depressions
• Atrial Fibrillation > 100
• Frequent ectopics
• Blocks / Sinus Pauses
• Tall Tented T waves
• No ECG findings;
continuing chest
pain
• Normal ECG
• No ST-T wave
changes
GLUCOSE
• Levels
• Symptoms
• < 2.5 mmol/L and
symptoms
• > 18 mmol/L and
symptoms
• < 2.5 mmol/L no
symptoms
• > 18 mmol/L no
symptoms
• 2.5 - 4.0 mmol/L
• 12 - 18 mmol/L
• Normal Limits
Appendix 8 - Malaysian Triage Scale (New Revised Version 2019)
7. COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
ABDOMINAL
PAIN
• Bleeding PR or PO
• Tense Rigid Abdomen
• Pain Score 8 - 10
• Elderly > 65
• Pain Score 4 - 7
• Very sudden onset
• Associated Back Pain
• Possibly Pregnant
• Colicky Pain only
• Vomiting,
repeated
• Chronic or
repeated
episodes
• Pain reduced /
subsided
ALLERGY /
ANAPHYLAX
IS
• Face / Tongue
oedema
• Unable to swallow
• Speaking difficulty
• Near-fainting
• Skin Rash / Blisters
• Abdo pain
• Vomit / Diarrhoea
• Chemical / Toxin
• Pain main
symptom
• Comfortable
• Local Swelling
• Itchiness
ALTERED
MENTAL
STATE
• Associated Seizures
• Neuro Deficits
• Agitated
• Confused
• Glucose < 2.5
• Improved
• Psychiatric history
• Drug Use history
• Comfortable
• No current
symptoms
BURNS
SCALDS
• Inhalational
• Lightning related
• Electrical
• Chemical
• Facial Thermal Burns
• Major Burn Area >
15%
• Major Burn area <
15%
• Involving hands, feet,
joints, perineum
• Circumferential burns
• Pain main
symptom
• None
CHEST /
ABDO
TRAUMA
• Penetrating type
• High velocity
• SpO2 < 95%
• Respiratory distress
• Increased work of
breathing
• Likely rib fractures
• Possible Pelvic Injury
• Significant external
bruising
• Child < 5 years
• High risk
mechanisms
• Elderly
• Anticoagulant use
• Pregnancy
• Mild symptoms
CHEST PAIN • New Onset < 6 H
• Arrhythmias on ECG
• On-going chest pain
• Profuse sweating
• STEMI / NSTEMI / UA
(referral)
• Onset > 6 H
• Reduced chest pain
• ECG non-conclusive
• Risk assessment high /
moderate
• Persisting mild
pain
• ECG normal
• Risk assessment
low
• No further pain
• Cause unlikely
cardiac
• ECG normal
DEHYDRA-
TION
• Severe with signs of
shock and altered
mental state
• Child< 5 years, not
taking orally
• Severe with dry
mucous membranes
and tachycardia
• Child 5 - 12 years, not
taking orally
• Fully conscious
• Cannot take orally
• Able to take
orally
DENGUE,
SUSPECTED
• Fever onset 3 - 6 days
• Lethargy / Near-
fainting
• SBP < HR
• SBP - DBP < 30
• Fever onset 3 - 6 days
• Abdominal pain
• Persistent vomiting
• FBC - HCT > 45 (M);
HCT > 40 (F)
• No Warning Signs
• Elderly
• Pregnant
• CCF / CKD / CLD
• Obese
• Immunocompromi
sed
• No Warning
Signs
DIARRHOEA
VOMITING
• Fresh blood PR
• Fresh blood
haematemesis
• Altered
consciousness
• Bloody diarrhoea
• Black stools
• Coffee ground vomitus
• Anticoagulant use
• Persisting
vomiting
• Unable to tolerate
orally
• Single episode
• Small qty
• Stable
• Mild Symptoms
• Tolerating orally
Appendix 8 - Malaysian Triage Scale (New Revised Version 2019)
8. COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
DIZZINESS /
GIDDINESS /
VERTIGO
• altered conscious
level
• Neurological Deficit
• Visual / Speech
difficulty
• Ataxia / Gait difficulty
• behavioral
change
• symptoms only
EAR / ENT • Possibly airway
obstruction
• Active Nose Bleeding
• Difficulty Swallowing
• Tracheostomy
• Child < 5 years
• Foreign Body ENT
• All other
presentations
ENVIRON-
MENTAL
• Inhalation of Chemical
Fumes
• High Voltage
Electrical
• Near-drowning post-
resuscitation
• Heat Stroke Temp >
39
• Heat related injuries
• Household electrical
injury
• HAZMAT Skin
exposure post-
decontamination
• Persisting
symptoms
• Child < 5 years
• Mild or recovered
EYE / VISION • Penetrating Eye Injury
• Chemical Exposure
Eye
• Direct Trauma Eye
• Sudden Vision Loss
• Painful Red Eye
• Foreign body Eye
• Post-op < 1 week
• Associated Severe
Headache
• Child < 12 years • All other
presentations
FALL • Altered conscious
level
• Neurological Deficit
• Limb injury / deformity
• Neuro deficit
• Vascular injury
• > 6 m height
• > 3 m height or more
than 2x height of child
• Pain main
symptom
• Mobilizing well
• Mild symptoms
FEVER • Skin Rash / Blisters
• Altered Mental State
• Associated Seizures
• Immunocompromised
• QSOFA / SIRS
• Child < 3 months
• Fever > 5 days (child)
• Limb / Joint Swelling
• Headache
• Toxin / Drug reactions
• Poor oral intake
• Elderly > 65
• Child < 8
• Not currently
febrile
• Tolerating orally
• Mobilizing
independently
FOLLOW-
UP /
RETURN
VISIT
• Tight Cast
• Immunocompromised
• Post-chemotherapy
• Post-daycare surgery
• Return visit > 2 times
• Recurring /
worsening
symptoms
GENITO-
URINARY
• Severe scrotal pain,
non traumatic
• Frank haematuria
• Acute Urinary
Retention
• Mobilizing well
• Mild symptoms
GYNAE-
COLOGY
• Massive Vaginal
Bleeding
• Pain Score > 7
• Known Gyn pathology
with worsening
symptoms
• Pain Score > 4
• Mobilizing well
• Mild symptoms
HEADACHE • Altered mental state
• Neuro deficits
• Pain Score > 7
• Sudden onset
• Assoc neck pain
• Visual / Speech
difficulty
• Ataxia / Gait difficulty
• Pain Score > 4
• Behavioral
change
• Aura / Unilateral
• Vomiting
• Associated Fever
• symptoms only
Appendix 8 - Malaysian Triage Scale (New Revised Version 2019)
9. COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
LETHARGY
WEAKNESS
• Airway reflexes lost
• Unable to swallow,
speak
• Post exposure to
drugs, bites, stings,
toxins, environment
• Acute Stroke < 3 H
• Associated Syncope,
Breathless, Fever
• Acute Stroke > 3 H
• Immunocompromised
• Skin rashes / blisters
• CKD / CLD
• Dehydration
• Elderly
• Delirium /
Abnormal
behaviour
• Chronic or
repeated
episodes
• Obeying
commands
LIMB PAIN /
SWELLING
• Cold, painful, dusky
limb
• CRT > 2 sec, pulse
not felt
• Generalized oedema
• Not able to bear
weight
• Bilateral LL
oedema
• Mobilizing well
• Mild symptoms
LOW BACK
PAIN
• Associated Abdo Pain
• Neuro Deficits
• Loss of Urinary / Bowel
control
• Colicky Pain
• Blunt Trauma
• Fall
• Elderly
• Chronic
symptoms
• No associated
symptoms
PALPITATIONS • Associated ECG
abnormalities
• Associated vital sign
abnormalities
• Ongoing chest pain,
breathlessness,
altered mental state.
• Associated syncope,
chest pain
• Elderly > 65 • Mild symptoms
PREGNANCY
RELATED
(EARLY < 20
WEEKS)
• Active PV Bleeding
• BP > 140 / 90
• Likely Abortion
• Persistent
Vomiting
• Urinary Symptoms
• Not pregnancy
related
symptoms
PREGNANCY
RELATED
(LATE > 20
WEEKS TO 6
WEEKS POST
PARTUM)
• Seizures
• Active Labour
• Massive PV Bleeding
• Septic appearance
• Head / Neck / Torso
Trauma
• Limb Trauma
• Active PV Bleeding
• Lower Abdo Pain /
Cramping
• BP > 140 / 90
• Diagnosed Pregnancy
Complications
• Persistent
Vomiting
• Urinary Symptoms
• None
PSYCHIATRIC • Airway threatened
• Associated overdose
• Risk of Self-Harm
• Need for Sedation
• Need for Restraint
• Paeds Disruptive
Behaviour
• Currently calm
• Non-suicidal
• None
REFERRALS • Ischaemic Limb
• Vascular Injuries
• Aortic Aneurysms
• Febrile Neutropenia
RESPIRATORY • Abnormal sounds
• Slow breaths, poor
respiratory effort
• Respiratory distress
• Airway Foreign Body
• Breathless, Change of
Voice
• Wheezing, known
asthmatic
• Hyperventilation,
SpO2 < 98%
• Difficulty in swallowing
• Hyperventilation,
SpO2 > 98%
• Mild URTI
symptoms
Appendix 8 - Malaysian Triage Scale (New Revised Version 2019)
10. COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
RESPIRATORY • Abnormal Sounds
• Incessant Cough
• Cyanotic spells
• Unable to swallow
• Foreign body (Airway)
• Tripod position
• Previous Intubation /
ICU care
• Swallowed foreign
body
• Overdose, Drugs,
Allergy, Injury-linked
• Poor feeding
• Mild URTI
symptoms
• Tolerating orally
• None
SCROTAL
PAIN /
PENILE
TRAUMA
• Severe Pain (8 - 10)
• Sudden Onset
• Moderate Pain (5 - 7)
• Persistent Vomiting
• Colicky Pain
• LIkely trauma • Mild Symptoms
SEIZURES • Ongoing seizures
• Overdose / Poisoning*
• Skin Rashes*
• Trauma associated
• Neck Stiffness
• First episode seizure
• Persistent Post-Ictal
Drowsiness
• Na / Glucose
abnormalities
• Neuro deficits
• Headache / Fever
• Anticoagulant use
• Epilepsy history
• Full recovery
• Mobilizing well
• Mild symptoms
• Medication
review
SOB • Stridor
• Altered conscious
level
• Increased work of
breathing, tired
• Agitation, anxious
• On-going chest pain
• Rapid breaths
• Wheeze, expiratory
rhonchi; airway intact
• PEFR > 250 L/min
• Child < 12
• Mild / minimal
• RR normal
• Associated other
symptoms
• Comfortable
• RR Normal
• SpO2 > 98%
• No other
symptoms
SYNCOPE • Altered conscious
level
• Neurological Deficit
• Noted arrhythmias
• Skin purpura or
rashes
• Abnormal limb
movements
• Improved conscious
levels
• Neuro Deficit > 12 H
• Full recovery
• No deficits
• Full recovery
• No deficits
• History of
syncope
TRAUMA,
HEAD NECK
• Penetrating type
• High velocity
• Active Bleeding
• Visual / Hearing
Impact
• Altered Mental State
• Scalp wounds only
• Retrograde amnesia
• Neck pain
• Distracting pain
• Fully conscious
• Brief LOC
• Elderly > 65
• Mild symptoms
TRAUMA,
LIMB
• Mangled Limb
• Amputation proximal
to wrist
• Ongoing
haemorrhage
• Proximal long bone
fractures
• Possible vascular
injury
• Distal amputation
• Dislocations
• Open fractures
• Possible nerve /
tendon injury
• Complications of
immobilization
• Hand injuries
• Small bone
fractures likely
• Pulses felt
• Moving fingers /
toes
• Mild symptoms
• Unlikely fractures
Appendix 8 - Malaysian Triage Scale (New Revised Version 2019)
11. COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
COMPLAINTS LIST (ADULT)
WOUNDS /
SKIN
• arterial bleeding
• degloving
• multiple penetrating
• burns / chemical
• associated nerve,
tendon, open fractures
• continuing venous
bleeding
• wound
complications
• surgical
complications
• new symptoms
• Mild symptoms
Appendix 8 - Malaysian Triage Scale (New Revised Version 2019)
12. PAEDIATRIC TRIAGE
• Paediatric Triage is performed similarly; but with different parameters relevant to paediatric
patients. Generally, paediatric patients are triaged higher to reduce potential wait times and to
facilitate their care processes.
• Specific Paediatric Treatment areas or zones are recommended; with medical devices and
materials specific for paediatric patients made readily available.
• Rapid Assessment of Paediatric patients is performed using Critical First Look and the
Paediatric Assessment Triangle in younger children. Children identified with danger signs must
be moved to Resuscitation, immediate Emergency Care or Urgent attention.
Triage Level 1
Resuscitation
Level 2
Emergency
Level 3
Urgent
APPEARANCE
APPEARANCE
Tone • Limp or Flaccid • Limited movement
• Movement or Vigorously
resisting examination
• Good Muscle Tone
Interactivenes
s
• Not alert
• Unresponsive
• Uninterested to surrounding
or play
• Alert
• Attentiveness to
surroundings
• Interest to play or reach
for item
Consolability
• No cry
• Very weak cry
• Crying or agitated that is
unrelieved by reassurance
• Ability to be consoled or
comforted by parent or
caregiver
Look / Gaze • Blank stare • Gaze fixed to a face • Looking around
Speech / Cry
• No speech
• No cry
• Weak crying • Limited speech
OVERALL TRIAGE PROCESS IN PAEDIATRICS
PRIMARY
TRIAGE
• Critical First Look
• Paed Assessment Triangle
• Safety
SECONDARY
TRIAGE
• Paeds Vital Signs
• Paeds Complaints List
• Initial Tests
LEVEL 1 - RESUSCITATION
LEVEL 2 - EMERGENCY
LEVEL 3 - URGENT
LEVEL 4 - EARLY CARE
LEVEL 5 - ROUTINE
Appendix 8 - Malaysian Triage Scale (New Revised Version 2019)
13. Triage Level 1
Resuscitation
Level 2
Emergency
Level 3
Urgent
WORK OF BREATHING
WORK OF BREATHING
Abnormal
Airway Sounds
• Snoring, muffled or
hoarseness in
speech
• Stridor, grunting or
wheezing
• Difficulty in swallowing
• Wheezing
• Drooling
Abnormal
Positioning
• Sniffing position,
tripod position
• Unable to walk
• Refusal to lie down
Retractions
• Head bobbing for
infants
• Supraclavicular, intercostal
or substernal retractions
• Increased work of breathing
• Tachypnoea alone
Flaring
• Nasal flaring on inspiration
• Accessory muscles
CIRCULATION
CIRCULATION
Pallor
• Pale mucous membranes /
sole / palm
Mottling,
Cyanosis
• Patchy or bluish skin
discolouration
Capillary Refill
Time
• Cold Peripheries
• CRT > 5 secs
• CRT > 2 secs
• Children without danger signs identified by the Paediatric Assessment Triangle at Primary
Triage should proceed to Registration and Secondary Triage. Children should not be routinely
triaged-away.
• At Secondary Triage, children may be given priority to early assessment. They may be triaged
to Levels 1 - 4 as needed. Generally, children, especially those below 8 years old should not
be triaged at Level 5 - Routine.
• At Secondary Triage, assessment of children is performed by measurement of vital signs, some
initial tests and biometric measurements, and considerations for their presenting symptoms (as
listed in Complaints List (Paediatrics).
Appendix 8 - Malaysian Triage Scale (New Revised Version 2019)