Ankle Biters
A 22-month-old, fever, pulling ears, immunizations up to date, history of frequent ear infections Vital signs: Temperature: 39° C (102.2° F) Heart rate: 128 beats/minute Respiratory rate: 28 breaths/minute Oxygen saturation: 97% Narrative: Awoke screaming Pulling at ears Runny nose this week Alert, tired, flushed, falling asleep now Calm in mom's arms, cries with exam
What is an ESI level 5?
A child under 36 months of age requires the obtaining of vital signs. This child has a 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, oral medication administration, and discharge to home). Danger zone vitals are not exceeded. If the child were underimmunized or there were no obvious source of infection, the child would be assigned to ESI level 3.
A 60-year-old male presents with complaint of dark stools for one month with vague abdominal pain. Past medical history: None. Pulse is tachycardic at a rate of 140 and he has a blood pressure of 80 by palpation. His skin is pale and diaphoretic.
What is an ESI level 1?
Patient is rated 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.
“This morning, I stepped on a rusty nail, and it went right through my shoe into my foot. I washed it really well. I read on the internet that I need a tetanus shot.” No previous medical history, and vital signs are within normal limits.
What is an ESI level 5?
No resources. This patient will require a physical exam and then a tetanus booster, which is not considered a resource.
“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 36.6°C (98˚F), RR 40 breaths/minute, HR 114 beats/minute, BP 108/74 mm Hg.
What is an 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 breaths/minute, and she is in respiratory distress
A 26-year-old female presents to the ED because she cannot get an appointment with her therapist. She went home for the holidays, and the visit brought back many issues from her childhood. She is unable to sleep and has been drinking more than usual. She admits to thinking about hurting herself but has no plan. She has a history of previous suicide attempts. Vital signs are within normal limits.
What is an ESI level 2?
High-risk situation. This patient is a danger to herself and needs to be placed in a safe environment with a constant observer.
A 3-week-old male Vital signs: Temperature: 38.2° C (100.8° F) Heart rate: 160 beats/minute Respiratory rate: 48 breaths/minute Oxygen saturation: 96% Narrative: Poor feeding Less active than usual Sleeping most of the day
What is an ESI level 2?
An infant less than 28 days with a temperature greater than 38°C (100.4° F) is considered high risk regardless of how good they look. For a child between 3 and 36 months with a fever greater than 39°C (102.2° F), the triage nurse should consider assigning ESI level 3 if there is no obvious source for a fever or the child has incomplete immunizations.
A 72-year-old female is brought in by ambulance from the nearby nursing home. The ambulance personnel 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 37.6°C (99.6°F), HR 86 beats/minute, RR 28 breaths/minute, BP 136/72 mm Hg, SpO2 94% on room air.
What is ESI level 2?
High risk. An elderly patient with increasing confusion and a fever needs to be evaluated for an infection. Urinary tract infection and pneumonia need to be ruled out. This patient may be septic and requires rapid evaluation and treatment.
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.
What is 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.
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.
What is an 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.
An ambulance arrives with a 52-year-old female overdose. The patient took eight 75 mg tabs of bupropion 2 hours ago because her husband left her for another woman, and now she wants to die. She is awake, alert, and oriented.
What is ESI level 2?
High-risk situation. An overdose is a high risk situation, and bupropion overdoses are prone to seizures, hallucinations, and irregular heart rhythms. This patient is suicidal and also needs to be monitored closely for safety.
A 10-year-old presents with facial swelling after eating a cookie at school. Fine red rash all over. Has a history of peanut allergies. Wheezing heard upon auscultation. Vital signs: respiratory rate 16 breaths/minute, heart rate 76 beats/ minute, oxygen saturation 97%, temperature 36.7°C (98.1°F).
What is an ESI level 2?
Though this patient has stable vital signs, she is at high risk of respiratory compromise given her history and wheezing. She is a high-risk patient and should be promptly taken to the treatment area for monitoring and treatment.
A 16-year-old high school hockey player collapsed on the ice after being hit in the anterior chest by the puck. The coaching staff began cardiopulmonary resuscitation almost immediately, and he was defibrillated three times with a return of spontaneous circulation. He arrives in the emergency department intubated.
What is an ESI level 1?
Requires immediate lifesaving interventions. From the history, it sounds like the hockey player experienced a disruption in the electrical activity in his heart due to the blow to the chest from the hockey puck. He will require immediate lifesaving interventions to address airway, breathing, and circulation. This patient is intubated, which meets criteria for lifesaving interventions
The local police arrive with a 48-year-old male who was arrested last night for public intoxication. He spent the night in jail, and this morning he is restless and has tremors. The patient usually drinks a case of beer a day and has not had a drink since 7 p.m. Vital signs: BP 172/124 mm Hg, HR 122 beats/minute, RR 18 breaths/minute, T 37°C (98.6°F), SpO2 97% Pain 0/10.
What is an ESI level 2?
High-risk situation. This 48-year-old male is probably showing signs of alcohol withdrawal, a highrisk situation. He is restless, tremulous, and tachycardic. In addition, he is hypertensive. He is not safe to wait in the waiting room and should be given your last open bed.
“I was at a family reunion, and we were playing baseball. One of my nephews hit the ball so hard, and I tried to catch it, missed, and it hit me right in the eye. My vision is fine. It just hurts,” reports a 34-year-old healthy female. Vital signs are within normal limits. There are no obvious signs of trauma to the globe, only redness and swelling in the periorbital area. The patient denies loss of consciousness.
What is ESI level 4?
One resource. The history is suggestive of an orbital fracture. The patient will require one resource – a radiograph. She will need a visual acuity check and eye evaluation, but these are not ESI resources.
“Why the hell don’t you just leave me alone?” yells a 73- year-old disheveled male who was brought to the ED by ambulance. 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.
What is an 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 the presence of alcohol, he is at risk for a number of complications.
An 8-year-old healthy child with a fever of 38.7°C (101.6°F) at home arrives at triage with complaints of a sore throat and a fine red sandpaper rash across chest. Sibling at home had a positive strep culture at the pediatrician a few days ago. Respirations are unlabored. Vital signs are stable.
What is ESI level 4?
This is a healthy patient with stable vital signs and a family member with a positive strep culture. The only resource likely needed is a strep culture.
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.
What is an 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 interventions such as immediate intravenous access, aggressive fluid resuscitation, and perhaps blood prior to surgery.
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.
What is an ESI level 1?
Requires immediate lifesaving intervention. 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 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.
What is an 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.
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.
What is an 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 3-month-old with petechial and purpuric lesions all over. Vital signs: respiratory rate 60 breaths/minute, heart rate 196 beats/minute, oxygen saturation 90%, temperature 39°C rectal.
What is an ESI level 1?
The baby has the classic signs of meningococcemia with abnormalities in appearance, work of breathing and circulation. She needs immediate lifesaving interventions.
Paramedics arrive with a 62-year- old male with a history of a myocardial infarction (four years ago) who is complaining of chest pressure that started an hour ago. The field electrocardiogram shows ST-segment elevation in the anterior and lateral leads. Currently, the patient’s HR is 106 beats/minute, RR 28 breaths/minute, BP 72/53 mm Hg, SpO2 is 95% on a non-rebreather mask. His skin is cool and clammy.
What is an ESI level 1?
Requires immediate lifesaving intervention. This patient is experiencing another cardiac event that requires immediate treatment. His vital signs and skin perfusion are suggestive of cardiogenic shock, and the patient may require fluid resuscitation or vasopressors to treat hypotension.
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.
What is an 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 27-year-old female wants to be checked by a doctor. She has been experiencing low abdominal pain (6/10) for about 4 days. This morning, she began spotting. She denies nausea, vomiting, diarrhea, or urinary symptoms. Her last menstrual period was 7 weeks ago. Past medical history includes previous ectopic pregnancy. Vital signs: T 36.6°C (98˚F), HR 66 beats/minute, RR 14 breaths/ minute, BP 106/68 mm Hg
What is an ESI level 3?
Two or more resources. Based on her history, this patient will require two or more resources – labs and an ultrasound. She may in fact be pregnant. Ectopic pregnancy is a possibility, but this patient is currently hemodynamically stable, and her pain is generalized across her lower abdomen.
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 has been sent from Mars as the savior of the world. He refuses to answer questions or allow you to take vital signs.
What is an ESI level 2?
High-risk situation. 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.