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MALAYSIAN TRIAGE SCALE

INTRODUCTION

TO TRIAGE

SERVICES

MTS

MALAYSIAN TRIAGE SCALE

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

AHMAD ZAKI BIN AB.HALIM

PENOLONG PEGAWAI PERUBATAN U41

JABATAN KECEMASAN DAN TRAUMA

HOSPITAL DUNGUN

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https://sites.google.com/moh.gov.my/jkteknikaltriageemts

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Papan pemuka pada device masing-masing
Pilih tiga titik bertindih

3

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Pilih tiga titik bertindih
Pilih “Add to home screen”

4

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Pilih “Add to home screen”
Ikon pada “home screen” masing-masing

5

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MALAYSIAN TRIAGE SCALE

LEARNING

OBJECTIVE

Understand Triage System: Learn the system to reduce wait times and ensure effective care for patients.

Use Malaysia Triage Scales: Master tools like the Critical First Look and Rapid Assessment for quick evaluation of serious conditions.

Implement Effective Triage Practices: Train healthcare professionals in assessment to prioritize and expedite care for at-risk patients following Malaysia Triage Scale.

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MALAYSIAN TRIAGE SCALE

LEARNING

OUTCOMES

Understand the importance of a triage system in emergency and trauma departments.

Identify the historical context and evolution of triage systems.

Comprehend the classification and components of triage.

Recognize the processes involved in primary and secondary triage.

Get familiarized with the new revisions in the Malaysian Triage Scale 2022.

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MALAYSIAN TRIAGE SCALE

OUTLINES

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Introduction
History of Triage
Classification of Triage
Component of Triage
Primary Triage
Secondary Triage
Introduction of Malaysian Triage Scale
Overview of Malaysian Triage Scale

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MALAYSIAN TRIAGE SCALE

INTRODUCTION

Definition Of Triage :

the process of quickly examining patients who are taken to a hospital in order to decide which ones are the most seriously ill and must be treated first -

SOURCE: cambridge.dictionary

RIGHT PATIENT

RIGHT PLACE

RIGHT TIME

RIGHT CARE PROVIDER

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MALAYSIAN TRIAGE SCALE

INTRODUCTION

“PETALING JAYA: Sistem triage untuk menentukan pesakit mana yang perlu diberi rawatan terlebih dahulu adalah penting bagi memastikan jabatan kecemasan dan trauma hospital dapat berfungsi dengan berkesan.

"Proses triage dijalankan dengan pantas dalam beberapa minit untuk menentukan keutamaan, sumber dan zon rawatan. Ini penting untuk melancarkan aliran pesakit di jabatan kecemasan dan mengelakkan kesesakan yang tidak perlu," kata Datuk Dr Muhammad Radzi Abu Hassan.

SOURCE: Triage system vital for any hospital to function effectively, The Star (Friday, 15 Dec 2023)

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Datuk Dr Muhammad Radzi bin Abu Hassan. Ketua Pengarah Kesihatan (KPK)

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MALAYSIAN TRIAGE SCALE

HISTORY OF TRIAGE

Triage word originally come from French word “ Trier” which means sort/to sieve/to select choice.

“To prioritize and to serve objectives best with available resources”

Prior to 1792, soldiers who fell in combat were left on the battlefield until the battle was over.

First described by Surgeon Marshall Dominique Jean Larrey (Napoleon’s chief medical officer).

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CLASSIFICATION OF TRIAGE

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

HOSPITAL TRIAGE

Primary Triage
Secondary Triage
Surveillance Triage

FIELD TRIAGE

performed outside hospital usually at the incident site

START
JumpSTART
SALT

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COMPONENT IN TRIAGE

PRIMARY TRIAGE

PROACTIVE TRIAGE - Outside Department
STATIC TRIAGE - At The Counter

SECONDARY TRIAGE

Vital Signs Assessment
First Aid And Initial Treatment

DEFINITVE TRIAGE

Triage and rapid sequence examination done at the various zone of patient management

SURVEILLANCE TRIAGE

Surveillance triage in the Green waiting area ensures continuity of care and reassesses pain management. Trained staff should regularly reassess and chart pain based on drug onset intervals.

MALAYSIAN TRIAGE SCALE

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INTRODUCTION

RED (critical)

GREEN (non-critical)

YELLOW (semi-critical)

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JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

Triage In EMTS POLICY 2012 :

The triage counter is the first point of contact for all patients in the Emergency and Trauma Department.
All patients arriving at the Emergency and Trauma Department are triaged by trained staff.
Triage ensures prompt care, early intervention, efficient resource use, and effective time management.
Patients are assigned a triage category based on urgency, following Malaysian Triage Category guidelines.

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MALAYSIAN TRIAGE SCALE

EMTS POLICY 2012

RED (critical)

GREEN (non-critical)

YELLOW (semi-critical)

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MALAYSIAN TRIAGE SCALE

PRIMARY TRIAGE

Rapidly identify and prioritize patients with life-threatening conditions, severe injuries, or high-risk profiles, assigning them a high acuity triage category immediately.

To assess patient severity and infectivity.
To manage patients accordingly and direct them to appropriate treatment areas.

Sources: Standard Practice Guidelines For AMO In EMTS, (November 2023)

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MALAYSIAN TRIAGE SCALE

PRIMARY TRIAGE

FLOWCHART

STANDARD PRACTICE GUIDLINES FOR AMO IN EMTS, (NOVEMBER 2023)

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MALAYSIAN TRIAGE SCALE

SECONDARY TRIAGE

The Secondary Triage Officer performs additional assessment of patients who did not initially identify as life threatening condition. Patients may still be assigned these severity if warranted by abnormalities of vital signs, initial tests or if they have high risk complaints.

To assess patient severity.
To reassess for infectivity.
To manage patient accordingly and direct to appropriate treatment area.

Sources: Standard Practice Guidelines For AMO In EMTS, (November 2023)

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MALAYSIAN TRIAGE SCALE

SECONDARY TRIAGE FLOWCHART

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MALAYSIAN TRIAGE SCALE

EMTS POLICY 2012

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EMTS POLICY 2012

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EMTS POLICY 2012

MALAYSIAN TRIAGE SCALE

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EMTS POLICY 2012

MALAYSIAN TRIAGE SCALE

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EMTS POLICY 2012

MALAYSIAN TRIAGE SCALE

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MALAYSIAN TRIAE SCALE

INTRODUCTION OF

MALAYSIAN TRIAGE SCALE 2022

The Ministry of Health Malaysia has updated the Emergency and Trauma Services triage protocol to the Malaysian Triage Scale 2022, replacing the Malaysian Triage Category 2011 protocol detailed in the "Emergency and Trauma Services Policy, Appendix 8" published in 2012.

MALAYSIAN TRIAGE SCALE

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Malaysian Triage Category 2011

MALAYSIAN TRIAGE SCALE (Revised 2022)

MALAYSIAN TRIAGE SCALE

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OVERVIEW

OF MALAYSIAN TRIAGE SCALE

PRIMARY

TRIAGE

SECONDARY

TRIAGE

LEVEL 1- RESUSCITATION

LEVEL 3 - URGENT

LEVEL 5 - ROUTINE

LEVEL 2- EMERGENCY

LEVEL 4 - EARLY CARE

Critical First Look
Pead Assessment Triangle
Safety

Pead Vital Signs
Pead Complaints List
Initial Tests

OVERALL TRIAGE PROCESS IN PAEDIATRICS

PRIMARY

TRIAGE

SECONDARY

TRIAGE

LEVEL 1- RESUSCITATION

LEVEL 3 - URGENT

LEVEL 5 - ROUTINE

LEVEL 2- EMERGENCY

LEVEL 4 - EARLY CARE

Critical First Look
Rapid Assessment
Safety

Vital Signs
Complaints List
Initial Tests

OVERALL TRIAGE PROCESS IN ADULTS

MALAYSIAN TRIAGE SCALE FOR EMERGENCY AND TRAUMA DEPARTMENTS

(NEW REVISED VERSION 2022)

OVERVIEW OF TRIAGE PROCESS IN EMERGENCY AND TRAUMA DEPARTMENTS

MALAYSIAN TRIAGE SCALE

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OVERVIEW

OF MALAYSIAN TRIAGE SCALE

MALAYSIAN TRIAGE SCALE

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

The number of treatment zones in Emergency and Trauma Departments (ETD) depends on : hospital size, ETD attendances, available Emergency Physicians, and intervention levels.
Each ETD decides on zone management based on its zones and staffing.
While treatment zones vary, triage levels remain consistent.

Time to Treatment Standards
LEVEL 1	Resuscitation�( requires rapid team activation mechanism)	0 minute
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

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PRIMARY TRIAGE IN MALAYSIA TRIAGE SCALE

The Primary Triage Officer, identifies critically ill or injured patients and diverts them immediately to treatment areas.

Specifically, the Primary Triage Officer performs the following roles:

Critical First Look

Rapid Assessment

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PRIMARY TRIAGE

IN MALAYSIA TRIAGE SCALE

Critical First Look

determines rapidly if the patient requires resuscitation or immediate emergency care.

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APPEARANCE

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CRITICAL FIRST LOOK

IN PRIMARY TRIAGE

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 respiratory distress	Not responding to call Severe chest pain Severe pain Ongoing seizure	Altered mental status Cannot communicate Cannot sit / stand unsupported	Walking Talking Not distressed Not aggressive

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PRIMARY TRIAGE

IN MALAYSIA TRIAGE SCALE

Rapid Assessment:

looking for Respiratory Distress, Shock State, Decreased Conscious Levels and / or Active Bleeding that requires resuscitation, immediate emergency care or urgent attention.

RESPIRATORY DISTRESS

SHOCK STATE

CONSCIOUS LEVELS

BLEEDING

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RAPID ASSESSMENT
LOOK FOR	LEVEL 1 RESUSCITATION	LEVEL 2 EMERGENCY	LEVEL 3 URGENT	SECONDARY TRIAGE
RESPIRATORY DISTRESS	Abnormal sounds Excessive work of breathing, sweating Cannot speak, one word reply Confused, lethargic Require assisted breathing SpO₂ < 90% on RA	Difficulty to breathe Short phrases only Agitation, anxious SpO₂ 90 – 92% RA	Wheeze, expiratory rhonchi, airway intact SpO₂ 92 – 94% RA Need O₂ supplement	No breathlessness SpO₂ > 94% No need O₂
SHOCK STATE	Pale, cyanosed, cold peripheries Severe tachycardia / bradycardia Absent radial pulse	Tachycardia, weak pulse Confused Septic / Toxic CRT < 2 seconds	Peripheries warm, CRT normal Cannot stand / walk unsupported	Warm, pink Pulses normal Alert, walking

RAPID ASSESSMENT

IN PRIMARY TRIAGE

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RAPID ASSESSMENT
LOOK FOR	LEVEL 1 RESUSCITATION	LEVEL 2 EMERGENCY	LEVEL 3 URGENT	SECONDARY TRIAGE
CONSCIOUS LEVELS	Unresponsive Airway unprotected	Confused Agitated Disorientated Obvious neurological deficits Ongoing seizure Abnormal posturing	Not fully conscious Cannot sit without supported	Alert Sit upright
BLEEDING Seen external Suspect internal Bleeding disorders Anticoagulant therapy	Arterial limb bleeding Active uncontrolled bleeding Massive PV bleeding Severe facial injury Severe pelvic injury	Active vomit / cough blood Suspected vascular injury Suspected intra-abdominal bleeding / ectopic / AAA Compartment syndrome	Bleeding from fractures / joints / dislocations / wounds Menorrhagia ENT bleeding Expanding hematoma Bleeding disorders	Minimal / no active bleeding

RAPID ASSESSMENT

IN PRIMARY TRIAGE

MALAYSIAN TRIAGE SCALE

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SAFETY

IN PRIMARY TRIAGE

MALAYSIAN TRIAGE SCALE

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

Ensures safety of the patient, healthcare providers and other persons in the ETD.
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.
To ensure isolation and other infection control measures, or decontamination can be carried out.
All staff must wear appropriate PPE.
All movement of patients should be restricted to reduce risk to others

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SAFETY

IN PRIMARY TRIAGE

MALAYSIAN TRIAGE SCALE

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

DISEASES / EXPOSURE	INITIAL ACTIONS
COVID / Pandemic Influenza and other emerging respiratory viruses	Patient/ Relatives wear surgical mask �Wash hand with alcohol
Meningococcemia
Active Tuberculosis, untreated	Patient/ Relatives wear surgical mask
HAZMAT- inhaled	Identify potential exposure�Early airway support�Consider early Antidote

Isolation ( Negative Pressure)

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SAFETY

IN PRIMARY TRIAGE

MALAYSIAN TRIAGE SCALE

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

DISEASES / EXPOSURE	INITIAL ACTIONS
CRE, MRSA, other multi-drug resistant infections	Patient wear surgical mask �Wash hand with alcohol
EBOLA and other re-emerging viruses	Patient wear surgical mask �Wash hand with alcohol

Isolation room

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SAFETY

IN PRIMARY TRIAGE

MALAYSIAN TRIAGE SCALE

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

DISEASES / EXPOSURE	INITIAL ACTIONS
Organophosphates and similar compounds	Removal of clothes�External shower decontamination
HAZMAT - chemical, dry or liquid	Removal of clothes�Removal of any dry decontaminant�External shower decontamination for liquid and radioactive decontaminants�Radiation survey performed urgently*
HAZMAT - radioactive*

Decontamination

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SAFETY

IN PRIMARY TRIAGE

MALAYSIAN TRIAGE SCALE

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

DISEASES / EXPOSURE	INITIAL ACTIONS
Chemical exposure to eyes, ENT	Immediate and continuing wash-off.

Any external area

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SAFETY

IN PRIMARY TRIAGE

MALAYSIAN TRIAGE SCALE

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

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 ETD.

Aggressive Persons
Potentially Violent
Violent Persons / Weapons

Activation of trained teams are essential ( protocols and drill are needed)

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SECONDARY TRIAGE

IN MALAYSIAN TRIAGE SCALE

The Secondary Triage Officer reassesses patients who did not qualify for Levels 1-3 at Primary Triage.

The officer can assign triage levels from 2-5, considering Primary Triage, vital signs, complaints, and test results.

SECONDARY

TRIAGE

LEVEL 3 - URGENT

LEVEL 5 - ROUTINE

LEVEL 2- EMERGENCY

LEVEL 4 - EARLY CARE

Vital Signs
Complaints List
Initial Tests

MALAYSIAN TRIAGE SCALE

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

Measures vital signs (BP, HR, RR, SpO2, Temp, GCS, Pain Score)
Performs initial : ECG and glucose tests
Assesses complaints and identifies modifiers to describe symptoms, selecting the higher level if modifiers are unclearTime to Treatment Standards:

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If patient is stable

NO critical issues

NO problem during rapid assessment

YES Safety

Then patient can go to Secondary Triage

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SECONDARY TRIAGE

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SECONDARY TRIAGE

IN MALAYSIAN TRIAGE SCALE

SECONDARY

TRIAGE

LEVEL 3 - URGENT

LEVEL 5 - ROUTINE

LEVEL 2- EMERGENCY

LEVEL 4 - EARLY CARE

Vital Signs
Complaints List
Initial Tests

MALAYSIAN TRIAGE SCALE

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SECONDARY TRIAGE

IN MALAYSIAN TRIAGE SCALE

Complaint List (Adult )
Abdominal pain	8. Dengue Suspected	15. Fever	22. Low back Pain	29. Scrotal pain/ Penile trauma
2. Allergy / Anaphylaxis	9. Diarrhoea / Vomiting	16. Follow up / Return	23.Palpitation	30. Seizures
3. Altered Mental State	10. Dizziness/ Giddiness/ Vertigo	17. Genitourinary	24. Pregnancy Rested ( Early 20 weeks)	31. SOB
4. Burn/ Scald	11. Ear /ENT	18. Gynaecology	25. Pregnancy Related ( Late >20 weeks to 6 weeks postpartum )	32. Syncope
5. Chest / Abdotrauma	12. Environmental	19. Headache	26. Psychiatric	33. Trauma, Head Neck
6. Chest pain	13. Eye /Vission	20. Lethargy weakness	27. Referrals	34. Trauma, Limb
7.Dehydration	14. Fall	21. Limb pain / Swelling	28. Respiratory	35. Wound/ Skin

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COMPLAINT LIST (ADULTS)
LOOK FOR	LEVEL 2 - EMERGENCY	LEVEL 3 - URGENT	LEVEL 4 - EARLY CARE	LEVEL 5 - ROUTINE
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 / ANAPHYLAXIS	• Face / Tongue oedema • Unable to swallow • Speaking difficulty • Near-fainting	• Skin Rash / Blisters • Abdominal pain • Vomit / Diarrhoea • Chemical / Toxin	• Pain main symptom	• Comfortable • Local Swelling • Itchiness

EXAMPLE OF COMPLAINTS LIST

IIN MALAYSIAN TRIAGE SCALE

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COMPLAINT LIST (ADULTS)
LOOK FOR	LEVEL 2 - EMERGENCY	LEVEL 3 - URGENT	LEVEL 4 - EARLY CARE	LEVEL 5 - ROUTINE
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	• None	• Comfortable • Local Swelling • Itchiness

EXAMPLE OF COMPLAINTS LIST

IIN MALAYSIAN TRIAGE SCALE

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SECONDARY TRIAGE

IN MALAYSIAN TRIAGE SCALE

Vital Sign
Blood Pressure
2. Heart Rate
3. Respiration Rate
4. SpO2
5. Temperature
6. GCS
7. Pain Score

Initial Test
ECG
2. Glucometer

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VITAL SIGNS (ADULTS)
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 • Temperature • GCS • Pain Score	• Temp > 39 or < 36C • 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

MALAYSIAN TRIAGE SCALE

VITAL SIGNS

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MALAYSIAN TRIAGE SCALE

VITAL SIGNS:

BLOOD PRESSURE

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

S

D

SBP	< 90	90 - 129	130 - 179	> 180	> 220
DBP		60 - 89	≥ 90	> 110	> 130

Narrow PP = SBP – DBP < 30

Shock index = ≥ 0.7 ( HR / SBP )

SBP < HR

JETS MTC

Normal range

LEVEL 4

LEVEL 5

LEVEL 2

Hypotension

Hypertension

Hypertensive Crisis

LEVEL 3

With Symptoms

LEVEL 3

LEVEL 4 & LEVEL 5

LEVEL 2

LEVEL 3

With Symptoms

Pregnant

No Symptoms

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MALAYSIAN TRIAGE SCALE

VITAL SIGNS:

HEART RATE (ADULT)

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

< 60

60

-

100

-

120

> 120

< 40

Tachycardia

Bradycardia

LEVEL 3

LEVEL 4

LEVEL 2

LEVEL 5

Normal range

LEVEL 3

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VITAL SIGNS:

RESPIRATORY RATE

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

Bradypnea

Apnea

Normal range

Tachypnea

LEVEL 1

LEVEL 3

LEVEL 4

< 12

12

-

20

-

30

> 30

LEVEL 2

LEVEL 1

LEVEL 2

LEVEL 5

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VITAL SIGNS:

OXYGEN SATURATION

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> 95

< 90

Normal range

LEVEL 4

LEVEL 5

LEVEL 1

92

-

94

90

-

92

LEVEL 3

LEVEL 2

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MALAYSIAN TRIAGE SCALE

VITAL SIGNS:

BODY TEMPERATURE

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

< 36^oC

37.5^oC

-

38.9^oC

> 39^oC

Hypothermia

36^oC

-

37.4^oC

Normal range

LEVEL 4

LEVEL 5

LEVEL 2

Hyperthermia

LEVEL 3

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MALAYSIAN TRIAGE SCALE

VITAL SIGNS:

PAIN SCORE

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Mild

Moderate

Severe

LEVEL 2

LEVEL 3

4

7

LEVEL 4

LEVEL 5

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INITIAL TEST (ADULTS)
LOOK FOR	LEVEL 2 - EMERGENCY	LEVEL 3 - URGENT	LEVEL 4 - EARLY CARE	LEVEL 5 - ROUTINE
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

MALAYSIAN TRIAGE SCALE

INITIAL TEST

IN MALAYSIAN TRIAGE SCALE

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MALAYSIAN TRIAGE SCALE

INITIAL TEST:

ELECTROCARDOGRAM (ECG)

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

LEVEL 2	LEVEL 3	LEVEL 4	LEVEL 5
Wide complex tachycardia Narrow complex tachycardia > 150 Bradycardia < 40 ST elevation or depression	AF rate > 100 Frequent ectopic Blocks / Sinus pause Tall tented T wave	Normal ECG changes Ongoing mild chest pain	Normal ECG changes

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INITIAL TEST (ADULTS)
LOOK FOR	LEVEL 2 - EMERGENCY	LEVEL 3 - URGENT	LEVEL 4 - EARLY CARE	LEVEL 5 - ROUTINE
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

MALAYSIAN TRIAGE SCALE

INITIAL TEST

IN MALAYSIAN TRIAGE SCALE

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MALAYSIAN TRIAGE SCALE

INITIAL TEST

BLOOD GLUCOSE

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With symptoms

LEVEL 2

No symptoms

LEVEL 3

With symptoms

LEVEL 2

No symptoms

LEVEL 3

LEVEL 4 - 5

2.5

18

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MALAYSIAN TRIAGE SCALE

SECONDARY TRIAGE IN MALAYSIAN TRIAGE SCALE

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

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MALAYSIAN TRIAGE SCALE

REFERENCES

Protocol Malaysian Triage Scale 2022 Ke Arah Penyeragaman Kaedah Saringan Pesakit Di Kaunter Triage Jabatan Kecemasan Dan Trauma, Hospital-Hospital Kementerian Kesihatan Malaysia KM.600-27/12/1

Emergency Medicine and Trauma Services Policy EMTS MOH/P/PAK/228.12(BP) 2012

Standard Practice Guidelines for Assistant Medical Officer In Emergency Medicine and Trauma Services (NOVEMBER 2023)

World Health Organization

Malaysian Triage Scale For Emergency And Trauma Departments (New Revised Version 2022)

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

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THANK YOU

MALAYSIAN TRIAGE SCALE

JAWATANKUASA TEKNIKAL PERKHIDMATAN TRIAGE EMTS KEBANGSAAN

We extend our heartfelt thanks to everyone who contributed ideas and modules to the development of the Malaysian Triage Scale 2022 course slides. Your efforts have been invaluable in making this project a success.

Thank you for your dedication.

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PRACTICAL SESSION

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SOALAN 1

55 tahun lelaki, datang ke kaunter triage mengadu sakit dada yang teruk dengan pain score 9, merebak ke lengan kiri dan disertai peluh sejuk dan mual. kesakitan bermula 1 jam yang lalu ketika dia sedang berehat di rumah.

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SOALAN 2

Seorang lelaki berusia 30 tahun tiba di Jabatan Kecemasan dan Trauma selepas jatuh daripada motorsikal. Dia mengalami luka terbuka sepanjang 10 cm di betis kanan dengan perdarahan aktif sederhana. Pesakit mengadu kesakitan dengan skala 7. Apakah triage level pesakit ini?

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SOALAN 3

70 tahun lelaki datang ke Jabatan Kecemasan dan Trauma dengan kelemahan mendadak pada anggota sebelah kanan dan kesukaran untuk bercakap. Dia juga mengadu sakit kepala yang teruk dengan skala 8. Gejala bermula 1 jam sebelum tiba di hospital.

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SOALAN 4

Seorang remaja lelaki berusia 16 tahun, tiba selepas jatuh ketika bermain bola sepak. Dia mengadu sakit di pergelangan kaki kiri dengan pain score 6 dan kesukaran berjalan. Tiada luka terbuka tetapi terdapat bengkak yang ketara.

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SOALAN 5

Seorang remaja lelaki 17 tahun tiba di Jabatan Kecemasan dan Trauma selepas jatuh semasa bermain bola keranjang. Dia mengadu sakit ringan hingga sederhana di pergelangan tangan kanan dengan pain score 5. Tidak ada laku terbuka atau kecacatan jelas namun dia merasa ketidakselesaan yang meningkat ketika cuba menggerakkan tangan tersebut. Pesakit tidak mengalami bengkak yang teruk, tetapi terdapat sedikit kesukaran dalam melakukan pergerakan penuh pada tangan tersebut.

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SOALAN 6

Seorang wanita berusia 50 tahun datang dengan rasa tidak selesa di dada kiri dan pain score 4 yang berlangsung selama 2 jam. Dia tidak mengalami sesak nafas tetapi kelihatan cemas.

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