1. นพ . เพชรพงษ์ กำจรกิจการ ภาควิชาเวชศาสตร์ฉุกเฉิน วิทยาลัยแพทยศาสตร์กรุงเทพมหานครและวชิรพยาบาล TRIAGE

4. No. of Patients INCLUSIVE SYSTEM FIELD TRIAGE EXCLUSIVE SYSTEM MINOR MODERATE SEVERE Injury Severity Risk *

8. Prehospital Care Process มีเหตุฉุกเฉิน เกิดขึ้น แจ้งเหตุ ( วิธีการแจ้ง ?) รับแจ้งเหตุ ประเมิน / ตัดสินใจ ในการออกปฏิบัติการ แจ้งหน่วยปฏิบัติการฉุกเฉิน ( รถ / เรือ / ฯลฯ ) ออกปฏิบัติการ เดินทางถึงที่เกิดเหตุ ประเมินสถานการณ์ และตัดสินใจเพื่อให้การรักษาพยาบาล เบื้องต้นในที่เกิดเหตุ ตัดสินใจ ส่งสถานพยาบาล ที่เหมาะสม ถึงสถานพยาบาล รายงานเหตุการณ์ แก่ผู้เกี่ยวข้อง ให้การรักษาพยาบาล ณ ที่เกิดเหตุ พบเหตุ จบการ ปฏิบัติการ

10. ถูกทำร้าย / บาดเจ็บ

11. ถูกทำร้าย / บาดเจ็บ

12. ถูกทำร้าย / บาดเจ็บ

13. ถูกทำร้าย / บาดเจ็บ

14. BURN

15. BURN

16. พลัดตกหกล้ม / อุบัติเหตุ / เจ็บปวด

17. พลัดตกหกล้ม / อุบัติเหตุ / เจ็บปวด

18. พลัดตกหกล้ม / อุบัติเหตุ / เจ็บปวด

19. อุบัติเหตุจราจร

20. อุบัติเหตุจราจร

21. อุบัติเหตุจราจร

22. Field Triage

27. Triage Decision Scheme Measure vital signs and level of consciousness Glasgow Coma Scale < 14 or Systolic blood pressure < 90 or Respiratory rate < 10 or > 29 or Revised Trauma Score < 11 Pediatric Trauma Score < 9 YES NO Take to trauma center; alert trauma team Assess anatomy of injury Step 2 Step 1

31. Multiple- or mass-casualty triage

32. Hot zone Warm zone Cold zone Decontamination area Wind direction Command Center / supporting unit

37. Multiple- or mass-casualty triage INCIDENT SITE TRIAGE SIEVE TRIAGE SORT ALP RECEIVING HOSPITAL RECEIVING HOSPITAL RECEIVING HOSPITAL 1 - Immediate 1 - Immediate 2 - Urgent 2 - Urgent 3 - Delayed 4 - Expectant Dead 4 - Expectant Body Holding Area TEMPORARY MORTUARY CCS

42. WALKING BREATHING RESPIRATORY RATE CAPILLARY REFILL PRIORITY 3 (delayed) DEAD PRIORITY 1 (immediate) PRIORITY 2 (urgent) Yes Yes No No When airway opened 10 - 29 Over 2 sec 2 seconds or under Triage Sieve Diagram 9 or less 30 or more

44. Revised trauma score GCS SBP RR Coded Value 13 – 15 > 89 10 – 29 4 9 – 12 76 – 89 > 29 3 6 – 8 50 – 75 6 – 9 2 4 – 5 1 – 49 1 – 5 1 3 0 0 0 TRTS = GCS + SBP + RR

46. Multiple- or mass-casualty triage INCIDENT SITE TRIAGE SIEVE TRIAGE SORT ALP RECEIVING HOSPITAL RECEIVING HOSPITAL RECEIVING HOSPITAL 1 - Immediate 1 - Immediate 2 - Urgent 2 - Urgent 3 - Delayed 4 - Expectant Dead 4 - Expectant Body Holding Area TEMPORARY MORTUARY CCS

48. Multiple- or mass-casualty triage Single card system

49. Multiple- or mass-casualty triage Folding/ Cruciform Card System

50. Multiple- or mass-casualty triage

51. Emergency Department Triage

52. The Canadain E.D. Triage and Acuity Scale Level I resuscitation Nurse – immediate Physician - immediate Usual Presentation Arrest Major trauma Shock status Near death asthma Severe respiratory distress Altered mental state (unconscious, delerious) seizures Sentinel Diagnosis Traumatic shock Pneumothorax - traumatic / tension Facial burns with airway compromise Severe burn > 30% TBS Overdose with hypotension/unconscious AAA AMI with complications / CHF / low BP Status asthmaticus Head injury – major / unconsciuos Status epilepticus

53. The Canadain E.D. Triage and Acuity Scale Level II emergency Nurse – immediate Physician – 15 min Usual Presentation Head injury (risk features – altered mental state) Severe trauma Sentinel Diagnosis Head injury Trauma:- multiple sites, multiple rib fracture, neck injury / spinal cord

54. The Canadain E.D. Triage and Acuity Scale Level II emergency (con’t) Nurse – immediate Physician – 15 min Usual Presentation Altered mental state (lethargic, drawsy, agitated) Chemical exposure – eyes Allergic reaction (severe) Chest pain : visceral, non-traumatic : + associated symptoms Overdose (conscious), Drug withdrawal Sentinel Diagnosis Alkaline / caustic occular burns Anaphylaxis AMI, unstable angina, CHF, chest pain NOS Gastrointestinal reflux Unspecified drug / medicinal overdose

55. The Canadain E.D. Triage and Acuity Scale Level II emergency (con’t) Nurse – immediate Physician – 15 min Usual Presentation Abd pain (age > 50) with visceral symptom Back pain (nontrauma, not musculoskeletal) GI bleed with abnormal vital signs CVA with major deficit Asthma severe (PEFR < 40%) Moderate/severe dyspnea/ difficulty breathing Sentinel Diagnosis AAA, appendicitis, cholecystitis Gastrointestinal bleed, hypotension CVA Severe asthma COPD, Croup

56. The Canadain E.D. Triage and Acuity Scale Level II emergency (con’t) Nurse – immediate Physician – 15 min Usual Presentation Vaginal bleeding: acute, pain scale > 5 + abnormal vital signs Vomiting and/or diarrhea (with suspicious of dehydration) Signs of serious infection (purpuric rash, toxic) Chemotherapy or immunocompromised Fever (age < 3 mo.) temp > 38.0 (rectal) Sentinel Diagnosis Spontaneous abortion Ectopic pregnancy/Rupture Epiglottitis, meningitis, sepsis

57. The Canadain E.D. Triage and Acuity Scale Level II emergency (con’t) Nurse – immediate Physician – 15 min Usual Presentation Acute psychotic episode/ extreme agitation Diabetes: hypoglycemia, hyperglycemia Headache (pain scale 8 – 10/10) Pain scale 8 – 10 (CVA, back, eye) Sexual assault Neonate ( < 7 days old) Sentinel Diagnosis Acute phychotic episode / agitation Hypoglycemia, DKA, hyperglycemia Migraine Renal colic, LBP / stain (disc), keratitis, Iriitis

58. The Canadain E.D. Triage and Acuity Scale Level III urgent Nurse – 30 min Physician – 30 min Usual Presentation Head injury, alert, vomiting Moderate trauma Abuse / neglect / assualt Vomiting and/or diarrhea ( < 2 yrs) Dialysis problem Signs of infection Mild / moderate asthma Sentinel Diagnosis Head injury Anterior dislocated shoulder, tibia/fibular fracture, bimalleolar or trimalleolar ankle fracture Pyelonephritis Asthma without status / COPD

59. The Canadain E.D. Triage and Acuity Scale Level III urgent (con’t) Nurse – 30 min Physician – 30 min Usual Presentation Mild / moderate dyspnea Chest pain no viscal symptom (sharp) no previous heart disease GI bleed with normal vital signs Seizue, alert on arrival Acute psychosis + suicidal idea Pain scale 8-10/10 with minor injury Pain scale 4-7/10 (headache, CVA, back) Sentinel Diagnosis Bronchiolitis / croup, pneumonis Chest pain NOS (musculoskeletal, GI, respitatory) GI bleed, no complication Seizure Acute psychosis + suicidal idea Migraine, renal colic, LBP/strain (disc)

60. The Canadain E.D. Triage and Acuity Scale Level IV Less urgent Nurse – 60 min Physician – 60 min Usual Presentation Head injury, alert, no vomiting Minor trauma Abd pain (acute) Earache Chest pain, minor trauma or musculoskeleton, no distress Vomiting and diarrhea (> 2 yrs./no dehydration) Suicidal ideation / depression Sentinel Diagnosis Head injury, alert, no vomiting Colles fracture, ankle sprain Appendicitis, chelecystitis Otitis media / otitis externa Chest pain NOS (musculoskeletal, GI, respitatory) gastroesophageal reflux Suicidal ideation / depression

61. The Canadain E.D. Triage and Acuity Scale Level IV Less urgent (con’t) Nurse – 60 min Physician – 60 min Usual Presentation Allergic reaction (minor) Corneal foreign body Back pain (chronic) URI symptoms Pain scale 4-7 Headache (non-migraine / not sudden) Sentinel Diagnosis Urticaria Corneal foreign body LBP pain URI

62. The Canadain E.D. Triage and Acuity Scale Level V non urgent Nurse – 120 min Physician – 120 min Usual Presentation Minor trauma, not necessarity acute Sore throat, no respiratory symptoms Diarrhea alone (no dehydration) Vomiting alone, normal mental status (no dehydration) Menses Minor symptoms Sentinel Diagnosis LBP / strain URI Gastroenteritis Vomiting Disorder of menstruation Dressing changes, cast changes

63. The Canadain E.D. Triage and Acuity Scale Level V non urgent (con’t) Nurse – 120 min Physician – 120 min Usual Presentation Abd pain (chronic) Psychiatric complaints Pain scale < 4 Sentinel Diagnosis Constipation Symptoms / neurotic, personality and nonpsychotic mental disorders Unspecified superficial laceration Patient should have an initial triage assessment within 10 minutes of arrival

65. Retriage In 15 min. ATLS

66. Trauma victim ED Triage Evaluate in ED and Discharge Evaluate in ED and observe Resuscitate in ED and admit Resuscitate in ED and transport to OR Transport directly to OR for resuscitation Pronounce DOA

67. Mass casualty in ED ?

68. Thank you