Emergency Severity Index (ESI) Scoring
The Pediatric Assessment Triangle
Pediatric
Vital Signs
Vital Signs
Pediatric
Red Flags
Red Flags
Resource or Not a Resource?
200
A 12-year-old patient who is visiting family forgot to bring their epinephrine pen. They are looking for a prescription because they have been unable to contact their pediatrician’s office while they have been out of town. What ESI score would you assign this patient?
ESI Level 5
200
Name the 3 components of the Pediatric Assessment Triangle.
Appearance, Work of Breathing, Circulation
200
True or False: According to BWMC Policy, you must obtain a blood pressure on a 5 year old patient.
FALSE!
Per BWMC Policy: For pediatric patients under 6 years of age a blood pressure should be attempted but is not required. However, you should still attempt to obtain a BP when possible and document if you are unable to obtain.
200
Name the ABCDE of Initial Assessment.
Alertness/Airway
Breathing
Circulation
Disability
Exposure
200
True or False: A tetanus immunization is considered a resource.
FALSE! A tetanus immunization is NOT considered a resource according to the ENA.
400
A 15-year-old was hit by a pitch during baseball practice. Trauma is noted to the right periorbital area. The patient states he is currently unable to see out of that eye and rates his pain 10/10. Vital signs are BP 110/72, HR 96, RR 18, T 36.9°C (98.5°F), and SpO2 99%. What ESI score would you assign this patient?
ESI Level 2 - this patient is experiencing a high-risk potential threat to sight.
400
What kind of cues are used when utilizing the Pediatric Assessment Triangle?
Auditory and Visual
400
Name the 3 pain scales used to assess pediatric pain.
FLACC
FACES
Numeric
400
True or False: You should be concerned if you are in triage and the PCT documents the patient's temperature as 96.7°F.
TRUE! Any patient with T 36°C (96.8°F) or below = hypothermic, think sepsis!
400
A 10-year-old is brought in by their caregiver. The patient presents with abdominal pain and vomiting for the past two hours. Vital signs are BP 102/72, HR 110, RR 20, T 37.1°C (98.8°F), and SpO2 98% on RA. You give this patient an ESI score of 3 because...
2 or more resources will most likely be used (labs, IV fluids, x-ray, etc)
600
A 9-year-old is brought in by their caregiver for evaluation of fever for the past two days. They currently are receiving chemotherapy treatment for leukemia. Vital signs include BP 92/62 mm Hg, HR 116, RR 22, T 38.9°C (102°F), and SpO2 97%. What ESI score would you assign this patient?
ESI Level 2 - this patient is immunocompromised with a fever and should automatically be assigned ESI 2.
600
A 7-year-old presents with shortness of breath. You notice the child is alert, is using their accessory muscles, and their skin color is pale. Which components of the Pediatric Assessment Triangle are altered?
Work of Breathing and Circulation
Work of Breathing: SOB, accessory muscles
Circulation: pallor
600
A 21-day-old is brought in by her mother who states "I can't get her to stop crying." The baby is alert, respirations are unlabored, and skin color is normal. Vital signs are BP 68/40 mm Hg, HR 196 beats/minute, RR 60 breaths/minute, T 38.2°C, and SpO2 97% on RA. Which vital sign are you most concerned about?
Temperature - 38.2°C (100.8°F)
A fever in the 21-day old neonate who cannot stop crying is highly concerning and this patient should be scored as ESI 2.
600
A patient presents via Emergency Petition to the Pediatric Emergency Department for suicidal ideation. The patient refuses to answer when the nurse asks if the patient is having thoughts of harming themselves. The nurse knows that this patient will require what type of monitoring?
1:1 continuous monitoring until an in-person evaluation can be completed by a physician or other qualified healthcare professional.
1:1 observation is the continuous monitoring of a patient by a staff member who has no other assignment and is able to provide direct observation of the patient and must remain within 3-4 feet (6 feet COVID+ patients) at all times.
600
A 4-year-old child presents to the emergency department with a fever, cough, and nasal congestion for the past two days. The child is alert, breathing comfortably, has normal vital signs, and is playing with toys in the waiting room. The parent requests evaluation because the fever has not improved. You expect that the provider will order how many resources?
One resource. The child is stable, alert, and well-appearing. The provider may order a chest X-ray due to the fever and cough (one resource) and a rapid viral panel (not a resource).
800
A 6-year-old with a known nut allergy presents with vomiting, facial swelling, hives, and labored breathing after eating a cookie at her friend's birthday party. Vital signs are BP 78/42 mm Hg, HR 132, RR 24, T 37.1°C (98.7°F), and SpO2 98% on RA. What ESI score would you assign this patient?
ESI Level 1 - the patient is experiencing an anaphylactic reaction and will need IM epinephrine which is a lifesaving intervention.
800
What mnemonic can you utilize when assessing Appearance on the Pediatric Assessment Triangle?
TICLS
Tone - Interactiveness - Consolability - Look/Gaze - Speech/Cry
800
Which age group has a normal HR range from 80-130 bpm and a normal RR range from 20-30 breaths per minute? Hint: This age group is also more likely to develop a fever due to common viral infections.
Toddlers (1-3 years old)
800
Name a physical ingestion that you would raise as an immediate red flag because it is time sensitive.
Button battery ingestion is extremely time-sensitive due to the potential for rapid and severe complications that can occur within hours of ingestion.
800
A 10-month-old infant is brought to the ED by their parents for vomiting and diarrhea for the past 24 hours. The infant has had 4 wet diapers in the last 12 hours, is alert but fussy, with dry mucous membranes and slightly decreased skin turgor. Vital signs are WNL. The triage nurse anticipates that the provider will order lab tests and IV fluids and scores this patient as an ESI Level __.
ESI Level 3. The infant is stable but showing signs of mild to moderate dehydration. The labs and IV fluids count as two resources, so this patient is already at ESI 3.
There’s no immediate life threat, and the situation is not high-risk enough to warrant ESI Level 2.
1000
A 19-month-old presents with a 2.5 cm laceration to their left forehead after walking into a table corner about an hour ago. The child is alert, respirations unlabored, and skin color is normal for the patient. Vital signs include BP 104/72, HR 100, RR 20, T 36.7°C (98.0°F), and SpO2 99%. What ESI score would you assign this patient?
ESI Level 3. The patient will most likely require procedural sedation (2 resources) for the laceration repair.
1000
You are precepting a new graduate nurse about the Pediatric Assessment Triangle. Name at least 3 abnormal symptoms you should teach the nurse to identify when assessing Work of Breathing.
Retractions, head bobbing, grunting, abnormal sounds such as wheezing or stridor, belly breathing, gasping
1000
A 2-year-old child is brought into the Peds ED with a history of vomiting and diarrhea for the last 24 hours. The child is lethargic, pale, and has dry mucous membranes. His vital signs are T 98.6°F (37°C), HR: 170 bpm, RR: 50 breaths/min, O2 96% on room air, BP: 70/50. Which vital sign is the most concerning and should be addressed immediately?
BP 70/50: This child is in hypovolemic shock due to dehydration from the vomiting and diarrhea. A normal systolic blood pressure for a 2-year-old would be 74 (70 + 2 x age in years). The 170 bpm HR is elevated but may be compensatory for the low BP. The respiratory rate of 50 breaths/min is elevated but not critical.
1000
A pediatric patient presents with multiple bruises at various stages of healing. The caregiver states the patient fell. How should the triage nurse document if NAT (non-accidental trauma) is suspected?
The triage nurse should document objective facts and quote verbatim statements made by the caregiver or child. Avoid interpretations or assumptions. When faced with injury patterns inconsistent with developmental ability or caregiver explanation, the nurse should elicit a thorough and specific account of the injury circumstances to assess for consistency with clinical findings.
1000
A 23-month-old is brought in by their caregiver who states the child has not been using their right wrist since playing with their older sibling. Mild swelling is present, but neurovascular status is normal. The patient is alert with unlabored respirations, and skin color is normal. The provider orders a right wrist x-ray and oral Ibuprofen. The x-ray comes back normal, and the patient started using their wrist once the Ibuprofen kicked in. The patient is then discharged. What ESI score did this patient have?
ESI Level 4 - the x-ray = 1 resource and the Ibuprofen which is an oral medication = NOT a resource.