Cardiac/Respiratory
A 40-year-old male presents to triage with vague, midsternal chest discomfort, occurring intermittently for one month. This morning, he reports a similar episode, which has now resolved. Currently complains of mild nausea but feels pretty good. Medical history: smoker. He is alert, with skin warm and dry, and does not appear to be in any distress.
ESI level 2. This patient is high-risk, due to history of angina for 1 month. The patient complained of symptoms of acute coronary syndrome earlier in the morning. Smoking is a significant risk factor; however, the patient presentation is concerning enough to be considered high risk. These are symptoms significant for a potential cardiac ischemic event. Acute myocardial infarction is frequently accompanied or preceded by waxing and waning symptoms. An immediate electrocardiogram is necessary.
A 34-year-old male presents to triage with right lower quadrant pain, 5/10, all day. Pain is associated with loss of appetite, nausea, and vomiting. Past medical history: None. The patient appears to be in moderate discomfort, guarding his abdomen. Skin is warm and dry.
ESI level 3. However, the patient could be upgraded to ESI level 2 if vital signs were abnormal, i.e., heart rate greater than 100. Signs of acute appendicitis include mild to severe right lower quadrant pain with loss of appetite, nausea, vomiting, low-grade fever, muscle rigidity, and left lower quadrant pressure that intensifies the right lower quadrant pain. The presence of all these symptoms and tachycardia would indicate a high risk for a surgical emergency.
A 60-year-old male complains of sudden loss of vision in the left eye that morning. Patient denies pain or discomfort. Past medical history: Coronary artery disease, high blood pressure. The patient is slightly anxious but in no distress.
ESI level 2. High risk for central retinal artery occlusion caused by an embolus. This is one of the few true ocular emergencies and can occur in patients with risk factors of coronary artery disease, hypertension, or embolus. Without rapid intervention, irreversible loss of vision can occur in 60 to 90 minutes.
A 12-year-old female is brought to triage by her mother who states her daughter has been weak and vomiting for three days. The child states she "feels thirsty all the time and her head hurts." Vomited once today. Denies fever, abdominal pain, or diarrhea. No significant past medical history. The child is awake, lethargic, and slumped in the chair. Color is pale, skin warm and dry.
ESI level 2. Lethargy and high risk for severe dehydration from probable diabetic ketoacidosis. It is not normal for a 12-year-old to be slumped over in a chair. Her history of being thirsty and lethargic suggest a strong suspicion for diabetic ketoacidosis. She needs rapid evaluation and rehydration.
A 70-year-old female with her right arm in a cast is brought to triage by her daughter. The daughter states that her mother fell yesterday and fractured her arm. The patient is complaining of pain. Daughter states, “They put this cast on yesterday, but I think it's too tight.” Daughter reports her mother has been very restless at home and thinks her mother is in pain. Patient has a history of Alzheimer's disease. The patient is confused and mumbling (at baseline per daughter); her face is flushed. She is unable to provide verbal description of her complaints. Her right upper extremity is in a short arm cast and digits appear tense, swollen and ecchymotic. Nail beds are pale; capillary refill is delayed. Patient is not wearing a sling.
ESI level 2. High risk for compartment syndrome. Despite the patient being a poor historian, the triage nurse should be able to identify some of the signs of possible compartment syndrome: pain, pallor, pulselessness, paresthesia, and paralysis. The patient requires immediate lifesaving intervention: cutting off the cast and further evaluation for potential compartment syndrome.
The family of a 74-year-old male called for an ambulance when he developed severe mid-abdominal pain. “My husband is not a complainer,” reports his wife.“ The only medication he takes is for high blood pressure.” On arrival at the ED, the patient’s HR is 140 beats/minute, RR 28 breaths/minute, SpO2 94%, BP 72/56 mm Hg.
ESI level 1: The patient is presenting with signs of shock, hypotension, tachycardia, and tachypnea. He has a history of hypertension and is presenting with signs and symptoms that could be suggestive of a dissecting abdominal aortic aneurysm. On arrival at the emergency department, he will require immediate lifesaving inter-ventions such as immediate intravenous access, aggressive fluid resuscitation, and perhaps blood prior to surgery.
A 22-year-old female with 10/10 abdominal pain for two days. Denies nausea, vomiting, diarrhea, or urinary frequency. Her heart rate is 84, and she is eating ice cream.
ESI level 3. Since she is able to eat ice cream, you would not give your last open bed for this patient. She will probably require at least two resources.
Melissa, a 4-year-old with a ventriculoperitoneal shunt (to treat hydrocephalus), is brought to the ED by her parents. The mother tells you that she is concerned that the shunt may be blocked because Melissa is not acting right. The child is sleepy but responds to verbal stimuli. When asked what was wrong, she tells you that her head hurts and she is going to throw up. Vital signs: T 37°C (98.6°F), RR 22 breaths/ minute, HR 120 beats/minute, SpO2 99% on room air, BP 94/76 mm Hg.
ESI level 2: New-onset confusion, lethargy, or dis-orientation. The mother of this 4-year-old knows her child and has probably been through this situation before. A child with a ventriculoperitoneal shunt with a change in level of consciousness and a headache is thought to have a blocked shunt until proven otherwise and may be experiencing increased intracranial pressure.
An 8-month-old presents with fever, cough, and vomiting. The baby has vomited twice this morning. No diarrhea. Mother states the baby is usually healthy but has “not been eating well lately.” Does not own a thermometer but states the baby is “hot” to the touch and gave acetaminophen two hours prior to arrival. The baby is wrapped in a blanket, eyes open, and appears listless, with skin hot and moist. Fontanel is sunken. Respirations are regular and not labored.
ESI level 2. High risk for sepsis or severe dehydration. If the baby were alert and active with good eye contact, similar complaints, and had a fever of 38°C (100.4°F) or greater, the ESI category would be 3. The temperature is not needed to make the assessment that the baby is high risk. The presence of lethargy and a sunken fontanel are indications of severe dehydration.
A 28-year-old male presents with a chief complaint of tearing and irritation to the right eye. He is a construction worker and was drilling concrete. He states, “I feel like there is something in my eye” and reports he ”irrigated the eye several times, but it doesn't feel any better.” Patient appears in no severe distress; however, he is continually rubbing his eye. Right eye appears red and irritated with excessive tearing.
ESI level 2. High risk for severe alkaline burn. Concrete is an alkaline substance and continues to burn and penetrate the cornea causing severe burns. Alkaline burns are more severe than burns with acid substances and require irrigation with very large amounts of fluids.
An ambulance arrives with a 22-year-old woman with asthma who began wheezing earlier this morning. She is sitting upright on the ambulance stretcher leaning forward with an albuterol nebulizer underway. The patient is diaphoretic, working hard at breathing and unable to answer your questions. Ambulance personnel tell you that they think she is tiring out. Her respiratory rate is 48, SpO2 is 94%, and she has a prior history of intubations.
ESI level 1: Requires immediate lifesaving inter-vention. This young asthmatic is tiring out and will need immediate lifesaving intervention that will require at a minimum a nurse and physician at the bedside immediately. The decision may be to continue the respiratory treatments and try intravenous steroids, intravenous magnesium, and heliox immediately. She may also require rapid sequence intubation.
A 65-year-old female is brought in by ambulance from the local nursing home for replacement of her percutaneous endoscopic gastrostomy tube. The information from the nursing home states that she had a massive stroke three years ago and is now aphasic. Her mental status is unchanged, and she has “do not resuscitate/do not intubate” orders. Vital signs are within normal limits.
ESI level 3: Two or more resources. This patient will need to be seen by surgery or gastroenterology and her percutaneous endoscopic gastrostomy tube reinserted – two resources.
A 51-year-old presents to triage with redness and swelling of his right hand. He reports being scratched by his cat yesterday. Past medical history of gastroesophageal reflux disease. Vital signs: BP 121/71 mm Hg, HR 118 beats/ minute, RR 18 breaths/minute, T 38.8°C (101.8°F), SpO2 98%. Pain 5/10.
ESI level 3: Two or more resources. This patient probably has cellulitis of the hand and will require labs and intravenous antibiotics. Starting a saline lock is not a resource, but intravenous antibiotics are a resource.
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.
A 28-year-old male arrives with friends with a scalp laceration. Patient states he was struck in the head with a baseball bat one hour prior to arrival. Friends state he “passed out for a couple of minutes.” Patient complains of headache, neck pain, mild nausea, and emesis x 1. Patient looks pale, but is otherwise alert and oriented to person, place, and time. There is a 5-cm laceration to the scalp near his left ear with bleeding controlled.
ESI level 2. High risk for epidural hematoma. This is a great example of the importance of understanding mechanism of injury. This man was struck with a baseball bat to the head with enough force to cause a witnessed loss of consciousness. Patients with epidural hematomas have a classic transient loss of consciousness before they rapidly deteriorate. Even though this patient looks good now and is alert and oriented at present, he must be immediately placed for further evaluation.
A 58-year-old male collapsed while shoveling snow. Bystander CPR was started immediately. He was defibrillated once by the paramedics, resulting in the return of a perfusing rhythm. The hypothermic cardiac arrest protocol was initiated prehospital, and he presents with cold normal saline infusing.
ESI level 1: Requires immediate lifesaving intervention. Studies have shown that lowering brain temperature post cardiac arrest decreases ischemic damage. This patient requires immediate lifesaving interventions to airway, breathing, circulation, and neurologic outcome. Even though the patient converted to a stable rhythm, the nurse should anticipate that additional lifesaving interventions might be necessary.
“He has had diarrhea for two days, and he just started throwing up this morning. This has been going around the family, and he seems to have it the worst. He has been drinking before today, but now he doesn’t want anything to drink,” reports the mother of a 19-month-old. The toddler is awake and alert but quiet in the mother’s arms, and you notice his lips are dry and cracked. Vital signs: T 36.2°C (99°F), RR 30 breaths/minute, HR 130 beats/minute, SpO2 100%.
ESI level 3: Two or more resources. This 19-month-old is dehydrated and will require a minimum of two resources: labs and intravenous fluids. In addition the physician may order an intravenous antiemetic.
A 68-year-old male is brought in by his wife for sudden onset of left arm weakness, slurred speech, and difficulty walking. Symptoms began two hours prior to arrival. Past medical history: atrial fibrillation. Medications: digoxin. The patient is awake, oriented, and mildly short of breath. Speech is slurred; right-sided facial droop is present. Left upper-extremity weakness noted with 2/5 muscle strength.
ESI level 2. This patient is presenting with signs of an acute stroke and requires immediate evaluation. If he meets criteria, he may still be in the time window for fibrinolytic or percutaneous vascular intervention. He is a very high-priority ESI level-2 patient.
"I had a baby 5 weeks ago, and I am just exhausted. I have seen my doctor twice, and he told me I wasn't anemic. I climb the stairs, and I am so short of breath when I get to the top that I have to sit down, and now my ankles are swollen. What do you think is wrong with me?" asks a 23-year-old obese female
ESI Level 2
The patient is describing more than just fatigue and anemia. The patient is describing classic symptoms of a low-volume but high risk situation- Peripartum cardiomyopathy. There is a decrease in the left ventricular ejection fraction with causes CHF.
“I was walking down the street and twisted my ankle as I stepped off the curb. I don’t think it’s broken, but it hurts so much,” reports a 43-year- old female with a history of colitis. Vital signs: T 36.7°C (98°F), HR 72 beats/minute, RR 18 breaths/minute, BP 134/80 mm Hg, SpO2 100%. Pain 8/10.
ESI level 4: One resource. To rule out a fracture, this patient will require a radiograph, one resource. The application of a splint and crutch walking instructions are not counted as resources. This patient does not meet the criteria for ESI level 2 for pain because nursing can immediately initiate interventions to address her pain.
"I was smoking a cigarette and had this coughing fit, and now I feel short of breath", reports a tall, thin 19 year old man. No past medical history. No meds or allergies. Vitals: T 98.0 F, HR 102, RR 36, BP 128/76 SP02 92%
ESI Level 2 - High Risk
This young healthy male has an elevated reparatory rate and a low oxygen saturation. The patient's history and signs and symptoms are suggestive of a spontaneous pneumothorax. He needs to be rapidly evaluated and monitored
An ambulance presents to the ED with a 54 year old female with chronic renal failure who did not go to dialysis yesterday because she was feeling too weak. Her vital signs are all within normal limits.
ESI Level 2
A complains of weakness can be due to a variety of conditions such ad anemia and infection. A dialysis patient who misses a treatment is at high risk for hyperkalemia and other fluid and electrolyte problems.
"My mother is just not acting herself," reports the daughter of a 72 year old female. She is sleeping more than usual and complains that it hurts to pee." Vital signs: T 100.8 F, HR 98, RR 22, BP 122/80. The patient responds to verbal stimuli but is disoriented to time and place.
ESI Level 2
New onset confusion, lethargy or disorientation. The reason for her change in mental status may be a urinary tract infection that has advanced to bacteremia. She has an acute change in mental status and is therefore a high risk.
"I'm 7 weeks pregnant, and every time I try to eat something, I throw it up," reports a 27 year old female. " My doctor sent me to the emergency department because he thinks I am getting dehydrated. T 97.0 F, RR18, HR, 104, BP 104/68, SP02 99%. Pain 0/10. Lips are dry and cracked.
ESI Level 3
Lab studies, IV fluid and IV antiemetics are the resources this patient will require. She is showing signs of dehydration.
An ambulance arrives with a 17 year old restrained driver involved in a high-speed motor crash. The patient is immobilized on a backboard and is complaining of abdominal pain. he has multiple lacerations on his left arm. Vital signs prior to arrival: B/P 102/60, HR 86, RR 28, SP02 96%.
ESI Level 2
The mechanism of injury is significant, and the patient has the potential or serious injuries. He needs to be evaluated by the trauma team and should be considered high risk.