Neuro
A 63-year-old cachectic male is brought in from the local nursing home because his feeding tube fell out again. The patient is usually unresponsive. He has been in the nursing home since he suffered a massive stroke about 4 years ago.
What level ESI would this patient be?
ESI 4
45 y/o female with c/o a cold for 1 week, hx of asthma. Started wheezing a few days ago then developed a cough and fever of 103. Vitals: T 101.6, HR 92, RR 24, BP 148/86, SP02 97% RA
What ESI Level would you assign this patient?
ESI Level 3; will require 2 or more resources, history sounds more like pneumonia. Pt is not in acute respiratory distress she does not meet ESI level 2 criteria. This patient will require, labs, chest xray, possibly IV antibiotics.
A 52-year-old female requests to see a doctor for a possible urinary tract infection (UTI). She is complaining of dysuria and frequency. She denies abdominal pain or vaginal discharge. No allergies, takes vitamins, and has no significant past medical history. Vital signs: T 97.4°F, HR 78, RR 14, BP 142/70
What ESI level do you assign to this patient?
ESI Level 4
Rationale: She will need one resource—lab, which will include a urinalysis and urine culture. She most likely has a UTI that will be treated with oral medications.
What is the ESI for the following scenario?
"I ran out of my blood pressure medicine, and my doctor is on vacation. Can someone here write me a prescription?" requests a 56-year-old male with a history of HTN. Vital signs: BP 128/84, HR 76, RR 16, T 97°F.
5
A 6yr old boy arrives via EMS actively seizing.
What ESI would you assign? List 3 initial interventions for this patient.
1; ABCDs, IV access, medication administration
“My migraine started early this morning, and I can’t get it under control. I just keep vomiting. Can I lie down somewhere?” asks a 37-year-old female. Past medical history migraines, no allergies. Pain 6/10, T98F, RR 20, HR 102, BP 118/62, SpO2 98%.
What ESI would this patient be?
ESI 3
39 y/o male with c/o cold for a few days and started wheezing today, when this happens "I just need one of those breathing treatments" Pt with hx of asthma, otherwise healthy. Vitals: T 98.0, HR 88, RR 22, BP 130/80, SP02 99% RA
How many resources will this patient require?
One Resource; ESI Level 4; this patient will need a nebulizer treatment for his wheezing. No labs or xrays should be necessary because he does not have a fever.
EMS arrives with a 17-year-old restrained driver involved in a high-speed motor vehicle 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: BP 102/60; HR 86, RR 28, SpO2 96%.
What ESI level do you assign to this patient?
ESI level 2: High-risk situation.
Rationale: The mechanism of injury is significant, and this patient has the potential for serious injuries. He needs to be evaluated for intra-abdominal injuries (FAST exam) and should be considered high risk. If his BP was 70/palp and his HR was 128, he would be an ESI level 1; requires immediate life-saving intervention.
Is this patient one that could be placed in Fast Track/Vertical Care?
"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, SaO2 98
Yes
A 7yr old c/o abd pain and won't play and complains walking increases the pain. Vomits in triage. VS T 100.5, HR 88, RR 22, BP 84/60 SPO2 100%. pain 6/10.
Which ESI level would you assign and how many resources? How about the BP?
Level 3 and 3 or more resources
BP is just at the low end of normal of the age
“I think I am having a stroke,” reports an anxious 40-year-old. “I looked in the mirror this morning and the corner of my mouth is drooping and I Can’t close my left eye. You have to help me please.” No PMH, no meds. VSS.
What ESI would this patient be?
ESI 2
26 y/o female with c/o smoke inhalation. Pt entered her burning apartment building to rescue her cat. Pt is hoarse, c/o sore throat, cough, and you notice she is working hard to breathe. Pt has a history of asthma. Vitals: T 98.0, HR 114, RR 40, BP 108/74
What room would you place this patient in?
Critical Room; ESI Level 1; from 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.
EMS presents with a 54-year-old female with chronic renal failure who did not go to dialysis yesterday because she was feeling too weak. She tells you to look in her medical record for a list of her current medications and past medical history. Her vital signs are HR 54, BP 91/52, RR 30, SaO2 90%.
What ESI level do you assign to this patient?
ESI level 2: High risk
Rationale: A complaint of weakness can be due to a variety of conditions, such as anemia or infection. A dialysis patient who misses a treatment is at high risk for hyperkalemia or other fluid and electrolyte problems. This is a patient who cannot wait to be seen and should be given your last open bed.
"I just don't feel right," reports a 21-year-old female who presented in the ED complaining of a rapid heart rate. "I can barely catch my breath, and I have this funny pressure feeling in my chest." HR is 178, RR 32, BP 82/60. Her skin is cool and diaphoretic.
What is her ESI level?
1 - she is unstable; tachycardic, hypotensive, dyspneic, with poor perfusion
How do you take a pulse on a child age 2 and under?
Apical
An 88-year-old female is brought to the ED by EMS. This morning, she had an episode of slurred speech and weakness of her left arm that lasted about 45 minutes. She has a history of previous stroke and she takes an aspirin every day. She is alert and oriented with clear speech and equal hand grasps.
What would her ESI level be?
ESI 2: Stroke Alert; CT, labs
A 72 y/o female with c/o SOB. Pt has COPD, is wheeled into triage room by her son. Pt is not on home oxygen normally, between breaths she tells you she has had a fever since yesterday and "is having a hard time breathing" The SP02 monitor is reading 79% on RA.
What ESI Level would you assign this patient?
ESI Level 1; this patient requires immediate intervention, immediate aggressive airway management is what this patient requires. Her saturation is very low and she appears to be tiring. The triage nurse does not need other vital signs in order to decide that this patient needs immediate intervention.
"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.
What resources do you anticipate for this patient?
She will need two or more resources—laboratory tests, IV fluid, medication for her nausea, and probably a CT of her abdomen.
Rationale: 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.
Paramedics arrive with a 16-year-old unrestrained driver who hit a tree while traveling at approximately 45 miles per hour. The passenger side of the car had significant damage. The driver was moaning but moving all extremities when help arrived. His initial vital signs were BP 74/50, HR 132, RR 36, SPO2 99%, T 98.6°F.
What ESI would you assign? List 3 immediate interventions.
1 - unrestrained driver, hit a tree, hypotensive and tachycardic. Manage ABCDs, FAST exam, 2 large bore IVs.
Parents bring their 2wk-old infant to ED for a fever at home, child acting appropriately in triage. V/S T 102.0 rectal, HR 154, RR 42, SPO2 100%. Normal vag delivery uncomplicated.
Which ESI level?
Level 2. Child is high risk for bacteremia no matter how good they look
“I just turned my back for a minute,” cried the mother of a 4-year-old. The child was pulled out of the family pool by a neighbor who immediately administered mouth-to-mouth resuscitation. The child is now breathing spontaneously but continues to be unresponsive. On arrival in the ED, VS were HR 126, RR 28, BP 80/64, SpO2 96% on a non-rebreather.
What ESI level is this?
ESI 1
42 y/o female with c/o fluid on lungs. "My sister has metastatic breast cancer, and her doctor suggested that I bring her in today to have more fluid drained off her lungs." The fluid buildup is making it harder for her to breathe. The patient is on multiple medications. Vitals: T 98.6 HR 90, RR 34, BP 114/80, SP02 95%
What ESI level would you assign?
ESI Level 2; Breast cancer can metastasize to the lungs and can cause a pleural effusion . The collection of fluid in the pleural space leads to increasing respiratory distress as evidenced by the increased respiratory rate and work of breathing.
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 HTN, 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, BP 88/68, RR 24, SPO2 94%.
What resources do you anticipate for this patient?
Abdominal CT, IV access, labs, (may require aggressive fluid resuscitation, pressors, and perhaps blood prior to surgery)
Rationale: 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 HTN and is presenting with signs and symptoms that could be attributed to a dissecting aortic abdominal aneurysm.
What ESI would you assign to this patient?
A 58-year-old male collapsed while shoveling snow. Bystander CPR was started immediately; he was defibrillated once by the paramedics with the return of a perfusing rhythm. The hypothermic cardiac arrest protocol was initiated prehospital, and he presents with cold normal saline infusing. Pt is responsive to pain only, on a non-rebreather w/ spontaneous breathing, BP 171/92, HR 104, RR12, Spo2=93% on NRB.
1
“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?”
What ESI is this patient?
ESI 2 High risk for Peripartum Cardiomyopathy