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100

40-year-old male unable to ambulate due to foot and back pain. Fell approximately 10 feet off of a ladder, landed on both feet and had immediate foot and back pain. No other signs of trauma or loss of consciousness. The patient appears pale, slightly diaphoretic, and in mild distress pain 6/10. Patient is sitting upright in a wheelchair.

ESI level 2. High risk for lumbar and calcaneus fractures. Again, mechanism of injury is very important to evaluate. Although he is not unresponsive or lethargic, he needs rapid evaluation and treatment.

100

Does an 80-year-old female who is chronically confused need to be triaged as ESI level 2?

No. The criteria for ESI level 2 are new onset of confusion, lethargy, or disorientation.

100

12-year-old female weak and vomiting for three days. The child has been thirsty and complains of a headache. Vomited once today. Denies fever, abdominal pain, or diarrhea. 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 probably diabetic ketoacidosis (DKA). 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 DKA. She needs rapid evaluation and rehydration.

100

A 68-year-old male brought in by his wife for sudden onset of left arm weakness, slurred speech, and difficulty walking. Symptoms began 2 hours prior to arrival. Past medical history: Atrial fibrillation. Meds: Lanoxin. The patient is awake, oriented, 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 for thrombolytic therapy, he may still be in the time window of less than three hours, but every minute counts with this patient. He is a very high-priority ESI level-2 patient.

100

22-month-old, fever, pulling ears, immunizations up to date, history of frequent ear infection, runny nose this week, Calm in mom's arms, cries with exam

Vital signs: Temp 102° F (39° C), HR 128, RR 28, 97%

ESI level 5. A child under 36 months of age requires vital signs. History of frequent ear infections, is up to date on immunizations and presents with signs of another ear infection. This child meets the criteria for ESI level 5 (exam, PO medication administration, and discharge to home). Danger zone vitals not exceeded.

200

A 14-year-old with rash on feet, was exposed to poison ivy 3 days ago. Ambulatory, with stable vital signs.

ESI level 5. This patient has a rash but is able to ambulate and has no abnormalities in appearance, work of breathing or circulation. During his ED visit he will receive an exam and perhaps a prescription, but no ESI resources.

200

A 22-year-old female on college break presents to the triage desk complaining of sudden onset of feeling very sick, severe sore throat, and feeling “feverish.” She is dyspneic and drooling at triage, and her skin is hot to touch.

ESI level 2. This patient is at high risk for epiglottitis. This is a life-threatening condition characterized by edema of the vocal cords. Onset is rapid, with a high temp (usually >101.3° F/38.5° C), lethargy, anorexia, sore throat. Patients do not have a harsh cough associated with croup, often assume the tripod position, and also have mouth drooling, an ominous sign, and may demonstrate an exhausted facial expression. Epiglottitis is more common in children, but may occur in adults; usually age 20 to 40. These patients are at high risk for airway obstruction and need rapid access of an airway (preferably in the operating room).

200

6-year-old cough with fever for two days, chills, short of breath with exertion, green phlegm, sleeping a lot

VS: Temp 104.4° F (40.2° C), HR 140, RR 30, 91%

ESI level 2. The clinical picture indicates high probability of tests that equal two or more resources (ESI level 3). Danger zone vital signs exceeded (SpO2 = 91%, respiratory rate = 30), making the patient an ESI level 2.

200

A 28-year-old male tearing and irritation to the right eye. Was drilling concrete and feels like there is something in his eye. Reports he ”irrigated the eye with no relief.” Patient appears in no severe distress; however, he is continually rubbing his eye. Right eye appears red, 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.

200

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 in moderate discomfort, skin warm and dry, guarding abdomen.

Initially ESI level 3. 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 would indicate a surgical emergency.

300

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, 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.

300

9-year-old male, head trauma.

Collided with another player at lacrosse game, loss of consciousness for “about 5 minutes,” witnessed by coach, now awake with headache and nausea

ESI level 2. This patient is assigned an ESI level 2 due to the high-risk information provided in the scenario. Vital signs are not necessary, and patient should be immediately taken to treatment area for rapid assessment.

300

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: CAD, HTN. The patient is slightly anxious but 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.

300

25-year-old female with the sudden onset of significant vaginal bleeding, with 9/10 abdominal pain. The patient is 7 months pregnant. BP 92/pal, HR 130.

ESI level 1. High risk for abruptio placentae needs immediate cesarean section. Abruption occurs when the placenta separates from its normal site of implantation. Primary causes include hypertension, trauma, illegal drug use, and short umbilical cord. Bleeding may be dark red or absent when hidden behind the placenta. Abruption is usually associated with pain of varying intensity.

300

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.

400

Do I have to upgrade the patient's triage level if the pain rating is 7/10 or greater?

No. Again, this is one factor to consider when assigning the ESI level.

400

A 60-year-old male presents with complaint of dark stools for one month with vague abdominal pain. Pulse is 140 and blood pressure of 80 palpable. His skin is pale and diaphoretic.

ESI level 1. Patient is placed in ESI level 1 after consideration of heart rate, skin condition and blood pressure. Tachycardia and hypotension indicate blood loss. The patient needs immediate hemodynamic support.

400

61-year-old female, referred with asthma and dry cough, steroid dependent, multiple hospitalizations, never intubated

VS: Temp 99.1° F (37.3° C), HR 112, RR 28, BP 157/94, 91%

ESI level 2. The clinical picture mandates ESI level 3 with expected utilization of x-ray, blood work, and specialist consultation resources. Respiratory rate and heart rate danger zone vital signs are exceeded, so patient is up-triaged to ESI level 2. 

400

An 8-month-old presents with fever, cough, and vomiting x2 this am, no diarrhea. Mom states the baby has “not been eating well lately” and report baby is “hot”" and gave acetaminophen two hours ago. The baby is wrapped in a blanket, eyes open, appears listless, skin hot and moist, sunken fontanel. Respirations are regular and not labored.

ESI level 2. High risk for sepsis or severe dehydration. 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.

400

A 3-month-old with petechial and purpuric lesions all over. Vital signs: respiratory rate 60, heart rate 196, oxygen saturation 90%, temperature 39°C rectal.

ESI level 1. The baby has the classic signs of meningococcemia with abnormalities in appearance, work of breathing and circulation. She needs immediate life-saving interventions.

500

A 28-year-old male with a chief complaint of a scalp laceration, headache, neck pain, mild nausea, and emesis x 1. Struck in the head with a baseball bat one hour prior to arrival “passed out for a couple of minutes.” Pale, alert and oriented to person, place, and time.  5-cm laceration to the scalp near his left ear bleeding controlled.

ESI level 2. High risk for epidural hematoma. Mechanism of injury: enough force to cause a witnessed loss of consciousness. Epidural hematomas have a 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.

500

70-year-old female with her right arm in a cast is brought. Daughter states that her mother fell yesterday and fractured her arm and 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. short arm cast; digits appear tense, swollen and ecchymotic. Nail beds are pale; capillary refill delayed.

ESI level 2. High risk for compartment syndrome. Triage nurse should be able to identify some of the signs of threatened compartment syndrome: Pain, pallor, pulselessness, paresthesia, and paralysis. The patient requires immediate life-saving intervention: cutting of the cast and further evaluation for potential compartment syndrome.

500

A 40-year-old male presents to triage with a gradual increase in shortness of breath over the past two days associated with chest pain. Past medical history: colon cancer. He is in moderate respiratory distress, skin warm and dry.

ESI level 2. High risk for a variety of complications associated with cancer, i.e., pleural effusion, congestive heart failure, further malignancy, and pulmonary embolus. A history of cancer can help identify high-risk status.

500

How many ESI resources will this patient need?

40-year-old man presents to triage at 2:00 a.m. with a complaint of a toothache for two days, no fever, and no history of chronic medical conditions.

No resources. This patient will likely have a brief exam (not a resource) and receive a prescription for pain medication (not a resource) by the provider, and therefore is an ESI level-5 patient.

500

Which of the following are considered resources: Eye irrigation, Nebulized medication administration, Blood transfusions

Which of the following are considered resources:

All three are resources. The resources tend to be used for more acute patients, require significant ED staff time, and likely lead to longer length of stay for patients.

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