ESI resources
Healthy 19-year-old with sore throat and fever (how many resources)
none
An 11-year-old presents to triage with his mother, who reports that her son has had a cough and runny nose for a week. The child is running around the waiting room and asking his mother for a snack. Vital signs are within normal limits.
ESI level 5: No resources. This healthy-sounding 11- year-old will be examined by a physician and then discharged home with appropriate instructions and a prescription if indicated.
22-year-old male with suicidal thoughts
Yes. High risk for patient injury if left alone.
Give three examples of a high risk situation in relation to ESI triage
Active chest pain, suspicious for acute coronary syndrome but
does not require an immediate lifesaving intervention.
• Signs of a stroke but does not meet level-1 criteria.
• A possible ectopic pregnancy, hemodynamically stable.
• A patient on chemotherapy, and therefore
immunocompromised, with a fever.
• Transplant recipient presenting with a fever or other
indication of infection.
• Actively suicidal or homicidal patient
• A needle stick in a health care worker (time sensitive to
postexposure prophylaxis treatment)
• Sexual assault survivor
• Increasing respiratory effort
• Postpartum hemorrhage
What is Shannon's favorite dog
all dogs
Are crutch walking instructions considered an ESI resource (yes or no)
No
Pt presents with brisk nasal bleeding that appears to be a posterior bleed.
ESI 2
9-month-old baby with vomiting and diarrhea. She is able to drink, has a wet diaper, and is fussy and crying tears during triage.
No. While the baby may be dehydrated, this does not appear to be a high-risk situation.
Give three examples of a patient that would be triaged as an ESI 1
Ineffective airway clearance
• Ineffective respiratory pattern
• Impaired gas exchange
• Ineffective tissue perfusion
• Obtunded/unresponsive patient
• SpO2 < 90% that is not the patient’s norm, with other signs of
respiratory compromise
• Anaphylaxis
• Hypotension with signs of hypoperfusion
(e.g., Chest pain with signs of hypoperfusion and systolic blood
pressure of 80 mm Hg)
• Hypoglycemia
• Severe bradycardia or tachycardia
• Flaccid infant
• Cardiac and/or pulmonary arrest (or appears to be imminent)
• Penetrating trauma of head, neck, abdomen, chest requiring
a lifesaving intervention
A 14-year-old female is brought in by ambulance after diving into the pool and hitting her head. She is awake, alert, and moving all extremities. She is currently on a back board with cervical collar in place. VS: BP 118/72 mm Hg, HR 76 beats/minute, RR 14 breaths/minute.
ESI 2- High risk injury due to the mechanism
List three interventions that are not considered ESI resources
H&P, POCT, Saline or Hep lock, Oral meds, tetanus immunization, prescription refills, simple wound care, crutches, splints, slings
“I called my pediatrician, and she told me to bring him in because of his fever,” reports the mother of a 2-week-old. Vital signs: T 38.3°C (101˚F), HR 154 beats/minute, RR 42 breaths/minute, SpO2 100%. Uncomplicated, vaginal delivery. The baby is acting appropriately.
ESI level 2: High-risk situation. A temperature higher than 38˚C (100.4˚F ) in an infant less than 28 days old is considered a high-risk situation no matter how good the infant looks. Infants in this age range are at a high risk for bacteremia.
52-year-old male with sudden onset of pain to left foot, a history of diabetes requiring insulin therapy. Left foot is cold to touch, and the nurse is unable to palpate a pulse in the foot
Yes. High risk for acute arterial occlusion.
BVM, intubation, CPAP/BiPAP, defib, cardioversion, pacing, nalaxone, atropine, dopamine
If a person in P or U on the AVPU scale what is their ESI score
ESI 1
Which of the following are considered resources (Select all that apply):
Eye irrigation
nebulized medications administration
blood transfusion
All
A 34-year-old patient assigned female at birth presents with generalized
abdominal pain, vomiting, and constipation. She has a history of
laminectomy and currently takes no medications. She states her
LMP was within the last 28 days. Vital signs are as follows: T 36.5°C
(97.8°F), HR 102 beats/minute, RR 16 breaths/minute, BP 132/80
mm Hg, and SpO2 99%
This patient will need a minimum of two or more resources: labs,
intravenous fluids, perhaps intravenous medication for nausea, and a
CT scan. The triage nurse would review the patient’s vital signs and
consider the heart rate. The heart rate falls just outside the accepted
parameter for the age of the patient, but other vital signs are within
expected limits. In this case, the decision should be to assign the patient
to ESI level 3
65-year-old female with sudden onset of loss of vision
Yes. All complaints with sudden loss of vision are high risk.
What does AVPU stand for
Alert, Verbal, Painful, Unresponsive
A 76-year-old male is brought to the ED because of severe abdominal pain. He tells you, “It feels like someone is ripping me apart.” The pain began about 30 minutes prior to admission, and he rates the intensity as 20/10. He has hypertension, for which he takes a diuretic. No allergies. The patient is sitting in a wheelchair moaning in pain. His skin is cool and diaphoretic. Vital signs: HR 122 beats/minute, BP 88/68 mm Hg, RR 24 breaths/minute, SpO2 94%.
ESI level 1: Requires immediate lifesaving intervention. The patient is presenting with signs of shock: hypotensive, tachycardic, with decreased peripheral perfusion. He has a history of hyper-tension and presenting with signs and symptoms that could be attributed to a dissecting abdominal aortic aneurysm. He needs immediate intra-venous access, aggressive fluid resuscitation, and, perhaps, blood prior to surgery
Define "simple wound care"
dressing, dressing change, recheck
A 28-year-old patient presents with generalized abdominal pain. Her last menstrual period is reported as 8 weeks ago. Vital signs are
as follows: T 36.7°C (98°F), HR 120 beats/minute, RR 22 breaths/minute, and BP 92/50mm Hg.
ESI level 2 based on her vital signs. Her increased heart rate, respiratory rate, and decreased blood pressure make her high risk. This presentation could indicate internal bleeding from a ruptured ectopic pregnancy.
88-year-old female with severe right lower quadrant abdominal pain, vital signs stable
Yes. High risk for acute abdominal emergency, which is associated with high mortality in the elderly.
What is considered a "Danger zone" temperature for a < 3 month old patient
38C (100.4)
Pediatric Fever Considerations
1-28 days of age: Assign at least ESI 2 if T > 38° C (100.4 ° F)
1-3 months: Consider assigning ESI 2 if T > 38 ° C (100.4 ° F)
3 months and older: Consider assigning ESI 2 or 3 if:
1. T > 39°C (102.2°F) or < 36°C (96.8°F), or
2. Incomplete immunizations,
OR
3. No obvious source of fever
list three "high risk" situations in a pediatric patient
Seizures • Severe sepsis, severe dehydration • Diabetic ketoacidosis • Suspected child abuse • Burns • Head trauma • Ingestions and overdoses including vitamins • Infant less than 30 days of age with a fever of 38°C (100.4°F) or greater • Sickle cell crisis