Respiratory
A 32-year-old female presents to the emergency department complaining of shortness of breath for several hours. No past medical history, +smoker. Vital signs: RR 32, HR 96, BP 126/80, SpO2 93% on room air, T 98.6˚F. No allergies, current medications include vitamins and birth control pills.
ESI level 2: High risk. This 32-year-old female with new-onset shortness of breath is on birth control pills. She is a smoker and is exhibiting signs and symptoms of respiratory distress (SpO2 and respiratory rate.) Based on history and signs and symptoms, a pulmonary embolus, as well as other potential causes for her respiratory distress, must be ruled out.
EMS arrives with a 76-year-old male found on the bathroom floor. The family called 911 when they heard a loud crash in the bathroom. The patient was found in his underwear, and the toilet bowl was filled with maroon-colored stool. Vital signs on arrival: BP 70/palp, HR 128, RR 40. His family tells you he has a history of atrial fibrillation and takes a “little blue pill to thin his blood.”
ESI level 1: Requires immediate lifesaving intervention. This 76-year-old patient is in hemorrhagic shock from his GI bleed. His blood pressure is 70, his heart rate is 128, and his respiratory rate is 40, all indicating an attempt to compensate for his blood loss. This patient needs immediate IV access and the administration of fluid, blood, and medications.
A 4-year-old female is transported to the ED following a fall off the jungle gym at a preschool. A fall of 4 feet. A witness reports that the child hit her head and was unconscious for a couple of minutes. On arrival you notice that the child is crying and asking for her mother. Her left arm is splinted. Vital signs: HR 162, RR 38.
ESI level 2: High-risk situation. This 4- year-old had a witnessed fall with loss of consciousness and presents to the ED with a change in level of consciousness. She needs to be rapidly evaluated and closely monitored.
EMS presents to the ED with an 18-year-old female with a suspected medication overdose. Her college roommates found her lethargic and “not acting right,” so they called 911. The patient has a history of depression. On exam, you notice multiple superficial lacerations to both wrists. Her respiratory rate is 10, and her SpO2 on room air is 86 percent.
ESI level 1: Requires immediate lifesaving intervention. The patient’s respiratory rate, oxygen saturation, and inability to protect her own airway indicate the need for immediate endotracheal intubation.
“I was taking my contacts out last night, and I think I scratched my cornea,” reports a 27-yearold- female. “I’m wearing these sunglasses because the light really bothers my eyes.” Her right eye is red and tearing. She rates her pain as 6/10. Vital signs are within normal limits.
ESI level 5: No resources. This patient will need an eye exam and will be discharged to home with prescriptions and an appointment to follow up with an ophthalmologist.
“The smoke was so bad; I just couldn’t breathe.” reports a 26-year-old female who entered her burning apartment building to try to rescue her cat. She is hoarse and complaining of a sore throat and a cough. You notice that she is working hard at breathing. History of asthma; uses inhalers when needed. No known drug allergies. Vital signs: T 98˚F, RR 40, HR 114, BP 108/74.
ESI level 1: Requires immediate lifesaving intervention. From the history and presentation, this patient appears to have a significant airway injury and will require immediate intubation. Her respiratory rate is 40, and she is in respiratory distress.
“I have this aching pain in my left leg,” reports an obese 52-year-old female. “The whole ride home, it just ached and ached.” The patient tells you that she has been sitting in a car for the last 2 days. “We drove my daughter to college, and I thought it was the heat getting to me.” She denies any other complaints. Vital signs: BP 148/90, HR 86, RR 16, T 98˚F
ESI level 3: Two or more resources. At a minimum, she will require labs and noninvasive vascular studies of her lower leg. She should be placed in a wheelchair with her leg elevated and instructed not to walk until the doctor has seen her
A normal healthy 7-year-old walks into the emergency department accompanied by his father, who reports that his son woke up complaining of a stomach ache. “He refused to walk downstairs and is not interested in eating or playing.” The child vomits at triage. Vital signs: T 100.4˚F, RR 22, HR 88, BP 84/60, SpO2100%. Pain 6/10
Initially 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-tosevere 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 26-year-old female walks into the triage room and tells you she needs to go into detox again. She has been clean for 18 months but started using heroin again 2 weeks ago when her boyfriend broke up with her. She had called several detox centers but was having no luck finding a bed. She denies suicidal or homicidal ideation. She is calm and cooperative.
ESI level 4: One resource. This patient is seeking help finding a detoxification program that will help her. She is not a danger to herself or others. The social worker or psychiatric counselor should be consulted to assist her. Once a placement has been found, she can be discharged from the emergency department and can get herself to the outpatient program. If your social worker or psychiatric counselor requires a urine toxicology or other lab work, the patient will require two or more resources and then meet ESI level-3 criteria.
A 60-year-old man requests to see a doctor because his right foot hurts. On exam the great toe and foot skin is red, warm, swollen, and tender to touch. He denies injury. past medical history includes type 2 diabetes, and psoriasis. Vital signs: T 99.4˚F, RR 18, HR 82, BP 146/70, SpO2 99%.
ESI level 3: Two or more resources. This patient has a significant medical history, and based on his presentation, he will require two or more resources, which could include labs and IV antibiotics.
“I have had a cold for a few days, and today I started wheezing. When this happens, I just need one of those breathing treatments,” reports a 39-year-old female with a history of asthma. T 98˚F, RR 22, HR 88, BP 130/80, SpO2 99%, No meds, no allergies.
ESI level 4: One resource. This patient will need a hand-held nebulizer treatment for her wheezing. No labs or x ray should be necessary because the patient does not have a fever
A 46-year-old female with a history of sickle cell disease presents to the emergency department because of a crisis. She has pain in her lower legs that began 8 hours ago, and the pain medication she is taking is not working. Currently, she rates her pain as 8/10. She has no other medical problems, and her current medications include folate and vicodin. Vital signs are all within normal limits.
ESI level 2: High risk. Sickle cell disease requires immediate medical attention because of the severity of the patient’s pain, which is caused by the sickle cells occluding small and sometimes large blood vessels. Rapid analgesic management will help prevent the crisis from progressing to the point where hospitalization will be unavoidable.
Concerned parents arrive in the ED with their 4-day-old baby girl who is sleeping peacefully in the mother’s arms. “I went to change her diaper,” reports the father, “and I noticed a little blood on it. Is something wrong with our daughter?” The mother tells you that the baby is nursing well and weighed 7 lbs., 2 oz. at birth.
ESI level 5: No resources. The parents of this 4-day-old need to be reassured that a spot of blood on their baby girl’s diaper is not uncommon. The baby is nursing and looks healthy.
Police escort a disheveled 23-year-old handcuffed male into the triage area. The police report that the patient had been standing in the middle of traffic on the local highway screaming about the end of the world. The patient claims that he had been sent from Mars as the savior of the world. He refuses to answer questions or allow you to take vital signs.
ESI level 2: High risk. This patient is experiencing delusions and may have a past medical history of schizophrenia or other mental illness, or he may be under the influence of drugs. Regardless, the major concern is patient and staff safety. He needs to be taken to a safe, secure area and monitored closely.
“My right breast is so sore, my nipples are cracked, and now I have a fever. Do you think I will have to stop nursing my baby?” asks a tearful 34-year-old female. She is 3 months post partum and has recently returned to work parttime. Vital signs: T 102.8˚F, HR 90, RR 18, BP 108/60, pain 5/10. No past medical history, taking multivitamins, and is allergic to penicillin.
ESI level 3: Two or more resources. At a minimum, she will require labs and IV antibiotics
A 46-year-old asthmatic in significant respiratory distress presents via ambulance. The paramedics report that the patient began wheezing earlier in the day and had been using her inhaler with no relief. On her last admission for asthma, she was intubated. Vital signs: RR 44, SpO2 93% on room air, HR 98, BP 154/60. The patient is able to answer your questions about allergies and medications.
ESI level 2: High-risk. An asthmatic with a prior history of intubation is a high-risk situation. This patient is in respiratory distress as evidenced, by her respiratory rate, oxygen saturation, and work of breathing. She does not meet the criteria for ESI level 1, requires immediate lifesaving intervention.
“I am here on business for a week, and I forgot to pack my blood pressure medication. I haven’t taken it for 2 days. Do you think one of the doctors will write me a prescription?” asks a 58-year-old male. BP 154/88, HR 64, RR 18, T 98°F, SpO2 99%.
ESI level 5: No resources. The patient will need a history and physical exam and then will be discharged to home with a prescription. An oral dose of his blood pressure medication does not count as a resource.
“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 101˚F, HR 154, RR 42, SpO2 100%. Uncomplicated, vaginal delivery. The baby is acting appropriately.
ESI level 2: High risk. A temperature higher than 100.4˚F (38.0˚C) in an infant less than 28 days old is considered high risk no matter how good the infant looks. Infants in this age range are at a high risk for bacteremia.
A 72-year-old female is brought in by ambulance from the nearby nursing home. They report that she has become increasingly confused over the last 24 hours. She is usually awake, alert, and oriented and takes care of her own activities of daily living. At triage she has a temperature of 99.6°F, HR 86, RR 28, BP 136/72, SpO2 94% on room air
ESI level 2: High risk. An elderly patient with increasing confusion and a fever needs to be evaluated for an infection. UTIs and pneumonia need to be ruled out. This patient may be septic and requires rapid evaluation and treatment.
“My doctor told me to come to the ED. I had a gastric bypass 3 weeks ago and have been doing fine, but today I started vomiting and having this belly pain.” The patient, an obese 33-yearold female, rates her pain as 6/10. Vital signs: BP 126/70, HR 76, RR 14, T 98˚F.
ESI level 3: Two or more resources. She will need two or more resources – laboratory tests, IV fluid, medication for her nausea, and probably a CT of her abdomen. This patient will be in your emergency department an extended period of time being evaluated. If her pain was 10/10 and she was tachycardic, the patient would meet the ESI level-2 criteria.
A 56-year-old male with a recent diagnosis of late-stage non-Hodgkin’s lymphoma was brought to the ED from the oncology clinic. He told his oncologist that he had facial and bilateral arm swelling and increasing shortness of breath. The patient also reports that his symptoms are worse if he lies down. Vital signs: BP 146/92, HR 122, RR 38, SpO2 98% on room air, temperature normal.
ESI level 2: High risk. This patient is demonstrating respiratory distress with his increased respiratory rate and decreased oxygen saturation. Symptoms are caused by compression of the superior vena cava from the tumor. It is difficult for blood to return to the heart, causing edema of the face and arms
“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: High risk. This patient is describing more than just the fatigue or anemia. This patient could be describing the classic symptoms of a low-volume but high-risk situation – peripartum cardiomyopathy, a form of cardiomyopathy that occurs in the last month of pregnancy and up to 5 months postpartum. There is a decrease in the left ventricular ejection fraction which causes congestive heart failure.
“Our pediatrician told us to bring the baby to the emergency department to see a surgeon and have some tests. Every time I feed him, he vomits and it just comes flying out,” reports the mother of a healthy appearing 3–week-old. “None of my other kids did this.” Normal vaginal delivery. Vital signs are within normal limits.
ESI level 3: Two or more resources. A 3- week-old with projectile vomiting is highly suspicious for pyloric stenosis. The infant will need, at minimum, labs to rule out electrolyte abnormalities, an ultrasound, and a surgery consult
“Why the hell don’t you just leave me alone?” yells a 73-year-old disheveled male who was brought to the ED by EMS. He was found sitting on the curb drinking a bottle of vodka with blood oozing from a 4-centimeter forehead laceration. He is oriented to person, place, and time and has a Glasgow Coma Scale score of 14
ESI level 2: High-risk situation. The history of events is unclear. How did the 73- year-old gentleman get the laceration on his forehead? Did he fall? Get hit? Because of his age, presentation, and presence of alcohol, he is at risk for a number of complications
“How long am I going to have to wait before I see a doctor?” asks a 27-year-old female with a migraine. The patient is well known to you and your department. She rates her pain as 20/10 and tells you that she has been like this for 2 days. She vomited twice this morning. past medical history: migraines, no allergies, medications include Fioricet.
ESI level 3: Two or more resources. At a minimum, this patient will require an IV with fluid, IV pain medication, and an antiemetic. Although she rates her pain as 20/10, she should not be assigned to ESI level 2. She has had the pain for 2 days, and the triage nurse can’t justify giving the last open bed to this patient. The triage nurse will need to address this patient’s concerns about wait time.