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Tanggal Masuk IGD:
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Pukul: .
WITATRIASE GAWAT DARURAT
Keterangan: Beri tanda √ pada pernyataan yang dipilih
CARA MASUK
:JALAN BRANCARD KURSI RODA GENDONG
ALASAN KEDATANGAN : SENDIRI POLISI RUJUKAN DI JEMPUT
IDENTITAS PENGANTAR : NAMA: _____________________________________ NO. TELP: ___________________
KASUS : TRAUMA NON TRAUMA
MEKANISME TRAUMA : ________________________________________________________________________________
TEMPAT KEJADIAN : TGL. KEJADIAN:
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PUKUL: .
WITA KELUHAN UTAMA: ________________________________________________________________________________
AUSTRALIAN TRIAGE SCALE (ATS)
A (Alert) V (Voice Responsive) P (Pain Responsive) U (Unresponsie)
PEMERIKSAAN
(EXANINATION) RESUSITASI EMERGENCY URGENT NON URGENT FALSE
EMERGENCY
AIRWAY
SUMBATAN : CAIRAN BENDA ASING
BEBAS BEBAS
(PATENT) BEBAS BEBAS
BREATHING
HENTI NAFAS (BREATHING ARREST)
FREK NAFAS (RR
>32x/mnt)
FREK NAFAS (24-32x/mnt)
FREK NAFAS (21-23x/mnt)
FREK NAFAS (16-20x/mnt) FREK NAFAS
(RR < 10x/mnt) WHEEZING WHEEZING
SIANOSIS RONKHI RHONKI
CIRCULATION
HENTI JANTUNG (CARDIAC ARRES)
NADI TIDAK TERABA
PUCAT
AKRAL DINGIN (CLAMMY)
CRT<2dtk
NADI TERABA LEMAH
FREK NADI
<50x/mnt
FREK NADI
>150x/mnt (DWS)
AKRAL DINGIN CRT<2dtk
FREK NADI 120-150x/mnt
TD SISTOL
>160mmHg
TD DIASTOL
>100mmHg CRT<2dtk
FREK NADI (100- 120x/mnt)
TD SISTOL
<160mmHg
TD DIASTOL
<100mmHg
FREK NADI 80-100x/mnt
TD SISTOL 100-120 mmHg
TD DIASTOL 60-80xmmHg
DISABILITY GCS < 9 GCS 9 - 12 GCS > 12 GCS 15 GCS 15
TANDA VITAL TEKANAN DARAH : / mmHg PERNAFASAN : x /
menit
SATURASI O2 :
%
NADI : x / menit TEMPERATUR : ºC SKALA NYERI : ANTROPOMETRI
BERAT BADAN : Kg TINGGI BADAN : cm
