ESI Sample Cases 2
Summary
TLDRThis script discusses various patient scenarios in an emergency department, focusing on triage assessment and prioritization using the Emergency Severity Index (ESI). It highlights the importance of recognizing high-risk patients, such as those with trauma, disorientation, or severe symptoms, and the need for immediate interventions.
Takeaways
- π¨ββοΈ The script discusses the Emergency Severity Index (ESI) triage system, emphasizing the importance of accurately assessing patient conditions to determine the level of care required.
- π It highlights the need for caution with repeat patients or those with substance abuse, as they can be high risk despite appearing stable, and their conditions should not be minimized.
- π The dialogue includes various patient scenarios to illustrate the triage process, showing how different presentations affect the assigned ESI level.
- π€ The script emphasizes that patients with visible signs of trauma, disorientation, or alcohol consumption meet criteria for ESI Level 2, indicating a high-risk situation.
- π§ The importance of not relying solely on vital signs for all patients is stressed, with examples given where specific symptoms necessitate checking blood pressure or other measures.
- πΆ The triage of pediatric patients is highlighted, with different age groups having distinct criteria and considerations for fever and potential serious infections.
- π₯ The script touches on institutional differences in protocols and how they can affect triage decisions, such as the handling of urine samples or eye exams.
- π€ The dialogue suggests that triage nurses must use their judgment, experience, and knowledge of standard care to predict patient resource needs, which may vary based on physician practice.
- πββοΈ The urgency of certain conditions like chest pain and hypotension is underscored, with the need for immediate intervention and physician assessment for such cases.
- π§ The script addresses the unique ways women may present with cardiac disease, often with atypical symptoms like upper GI discomfort, and the importance of recognizing these signs.
- π The importance of patient education is highlighted, especially for cases that do not require extensive medical intervention but can benefit from guidance on self-care and over-the-counter treatments.
Q & A
What is the significance of Glasgow Coma Scale score in the patient scenario involving Joe?
-The Glasgow Coma Scale score is an important indicator of a patient's level of consciousness. In Joe's case, his score of 14 suggests that he is not fully conscious but is not in a state of severe unresponsiveness, which helps in determining the urgency of his condition and the level of care required.
Why is Joe considered a high-risk patient despite not requiring immediate life-saving interventions?
-Joe is considered high-risk due to his disorientation to time, visible signs of trauma to the head, no recollection of events, and obvious alcohol consumption. These factors, combined with his known history with the emergency department, suggest potential for serious underlying issues that need attention.
What is the importance of not minimizing the presentation of well-known patients to the emergency department?
-Well-known patients to the emergency department are often high-risk and may have complex health histories. Minimizing their presentation could lead to overlooking critical symptoms or conditions, potentially resulting in adverse outcomes.
Why is it crucial to maintain a high index of suspicion with patients who present with substance abuse?
-Patients with substance abuse may have altered mental states or may not accurately report their symptoms, making it difficult to assess their condition accurately. A high index of suspicion ensures that the healthcare provider considers all possible complications and does not miss any critical diagnoses.
What are the criteria for assigning a patient to ESI Level 2 in the emergency department?
-ESI Level 2 criteria include patients who are high risk and do not require immediate life-saving interventions. They may present with signs of trauma, altered mental status, or have a history that suggests potential for serious underlying conditions.
What is the potential consequence if a patient like Joe, who is disoriented and has signs of trauma, is not taken seriously?
-If a patient like Joe is not taken seriously, there is a risk of missing a critical diagnosis such as a head injury or internal bleeding, which could lead to severe complications or even death.
How does the triage process differ for a patient with a known history of medical issues like Robert Douglas?
-For patients with a known history of medical issues, the triage process involves a careful assessment of their current symptoms in the context of their medical history. This helps in identifying any changes or potential complications that may require immediate attention.
What is the rationale behind assigning Robert Douglas an ESI Level 2 instead of Level 1?
-Robert Douglas is assigned an ESI Level 2 because he does not require immediate life-saving interventions. However, his significant medical history and current symptoms of weakness and dizziness warrant a high level of attention and timely assessment by the medical team.
Why is it important to consider a patient's medical history during the triage process?
-A patient's medical history provides crucial context for their current symptoms and can help identify potential risks or complications. It allows the triage nurse to prioritize patients more effectively and ensure that high-risk patients receive timely care.
What factors contribute to a patient being classified as high risk in the emergency department?
-Factors contributing to a patient being classified as high risk include known medical history of serious conditions, presenting symptoms that suggest potential complications, signs of trauma, altered mental status, and substance abuse.
How does the emergency department prioritize patients who are assigned to the same ESI level?
-Within the same ESI level, patients are prioritized based on the urgency of their condition, the need for immediate interventions, and the potential risk to their health if not attended to promptly.
Outlines
π Disoriented Patient Encounter
The scenario depicts a disoriented patient, Joe, found by the police on the sidewalk with facial injuries and under the influence of alcohol. Despite not requiring immediate life-saving interventions, his presentation raises concerns due to visible trauma, memory loss, and substance abuse, qualifying him as an Emergency Severity Index (ESI) Level 2 patient. The dialogue emphasizes the importance of maintaining a high index of suspicion for repeat ED visitors, especially with substance abuse or trauma, and not to underestimate their risk.
π€ Dialysis Patient with Weakness
Robert, a 62-year-old with a history of renal failure, hypertension, and heart attacks, presents with weakness and dizziness. Although not requiring immediate intervention, his complex medical history and current symptoms make him an ESI Level 2 patient. The discussion highlights the need for triage nurses to consider the patient's medical background and not to overlook potential cardiac issues or electrolyte imbalances that could escalate the situation to ESI Level 1.
π Pediatric Trauma with Hypotension
An 8-year-old girl is rushed to the ED after being hit by a bus, showing signs of hypotension and tachycardia. She requires immediate life-saving interventions such as fluid resuscitation and possible intubation, marking her as an ESI Level 1 patient. The case underscores the urgency required in pediatric trauma cases and the need for prompt action to stabilize the patient's condition.
π£ Severe Hypertension with Headache
A 33-year-old woman with a severe frontal headache and extremely high blood pressure is referred to the ED by an ophthalmologist. Her symptoms, combined with the alarming blood pressure reading, suggest a potential risk of stroke or other serious complications, categorizing her as an ESI Level 1 patient. The summary stresses the importance of immediate medical attention to address the dangerously high blood pressure.
π¦ 14-Year-Old with Possible Poison Ivy
A 14-year-old boy with symptoms of poison ivy is brought to the ED by his mother. Despite the discomfort, the boy has no significant medical history and stable vital signs, leading to a determination that he does not meet the criteria for ESI Levels 1 or 2. The case illustrates the importance of patient education and appropriate guidance for home care instead of emergency intervention.
π¨ Chest Pressure and Shortness of Breath
A 52-year-old male, Larry, experiences chest pressure and shortness of breath, accompanied by nausea. With risk factors like obesity and high cholesterol, and presenting symptoms that suggest a possible acute myocardial infarction (AMI), he is classified as an ESI Level 1 patient. Immediate interventions such as IV access, fluid administration, and hemodynamic support are required, emphasizing the critical nature of his condition.
π€ Epigastric Pressure with GI Symptoms
A 57-year-old female with a history of high cholesterol and recent heartburn presents with epigastric pressure and a sense of fullness in her stomach. Although her vital signs are stable, her symptoms and risk factors for cardiac disease qualify her as an ESI Level 2 patient. The summary highlights the atypical presentation of cardiac issues in women and the necessity to consider underlying cardiac conditions despite initial gastrointestinal symptoms.
πͺ Suicidal Ideation and Elderly Dizziness
The script presents two cases: a 21-year-old female with recent suicidal ideation after a breakup and a 76-year-old female experiencing dizziness and weakness. The young woman, despite denying suicidal thoughts, is considered high risk and an ESI Level 2 patient due to the potential severity of untreated mental health issues. The elderly woman's symptoms suggest a possible cardiac event, making her an ESI Level 1 patient requiring immediate intervention.
πΆ Pediatric Fever and Asthma Medication
An 11-month-old infant with a high fever and an ear infection is triaged according to the pediatric guidelines, which consider age and appearance as key factors. Meanwhile, a 10-year-old girl with asthma requires a prescription refill, placing her in the ESI Level 5 category. The summary emphasizes the importance of following evidence-based guidelines for pediatric patients and ensuring appropriate care for those with chronic conditions.
π€§ Common Cold and UTI Symptoms
Adult patients presenting with common cold symptoms and a suspected UTI are discussed. The cold patient, without any need for specific interventions, is categorized as an ESI Level 5. The UTI patient, requiring a urine sample and possibly a pregnancy test, is also considered an ESI Level 5 unless the urine requires lab analysis, which would escalate her to Level 4. The discussion clarifies the distinction between bedside testing and lab testing in determining resource allocation.
π Eye Complaints and Triage
The final paragraph addresses eye-related complaints, such as conjunctivitis, foreign body sensation, and trauma. It distinguishes between high-risk situations requiring immediate intervention (ESI Level 2) and common complaints that can be managed with minimal resources (ESI Level 5). The importance of visual acuity assessment at triage for eye complaints is highlighted, emphasizing its significance over traditional vital signs.
Mindmap
Keywords
π‘Triage
π‘Emergency Severity Index (ESI)
π‘Glasgow Coma Scale
π‘Disorientation
π‘Alcohol Consumption
π‘Substance Abuse
π‘Dialysis
π‘Hypertension
π‘Pediatric Trauma
π‘Conjunctivitis
π‘Urinary Tract Infection (UTI)
Highlights
Joe Joe's case demonstrates the importance of not minimizing presentations of well-known ED patients, especially with substance abuse and trauma.
Disoriented patients with visible signs of trauma and alcohol consumption meet criteria for ESI Level 2, indicating high-risk status.
Repeat ED visitors can be prone to triage errors due to over-familiarity, leading to missed diagnoses such as heart attacks.
Robert's case illustrates the triage of a patient with chronic illnesses and new-onset weakness, emphasizing the need for prompt assessment.
Patients with significant medical histories and concerning symptoms should be assigned ESI Level 2 for high-risk prioritization.
The necessity of EKGs in triage for patients with cardiac symptoms is discussed, highlighting the evolution of triage practices.
Triage nurses must prioritize patients effectively, even within the same ESI level, based on the urgency of their conditions.
An 8-year-old female with severe trauma and hypotension meets ESI Level 1 criteria, requiring immediate life-saving interventions.
A 33-year-old with a severe headache and extremely high blood pressure is categorized as ESI Level 1 due to potential stroke risk.
EMS notification of a 78-year-old male post-cardiac arrest requires ESI Level 1 triage for continuous resuscitation efforts.
A 14-year-old male with poison ivy is triaged as ESI Level 5, indicating a low-acuity case suitable for home care and patient education.
Larry's case of chest pressure and multiple cardiac risk factors meets ESI Level 1 criteria, necessitating immediate medical attention.
Louise's case of epigastric pressure and shortness of breath, despite stable vitals, is categorized as ESI Level 2 due to cardiac risk.
The importance of recognizing atypical presentations of cardiac disease in women is emphasized in Louise's case.
A 21-year-old female with expressed suicidal ideation is considered high risk and categorized as ESI Level 2, despite her denial.
A 76-year-old female with symptoms of presyncope, bradycardia, and hypotension meets ESI Level 1 criteria for immediate intervention.
An 11-month-old with a high fever and ear tugging is triaged considering age-specific guidelines and potential serious infections.
A 10-year-old asthmatic needing a prescription refill is triaged as ESI Level 5, highlighting the need for efficient patient flow.
Triage assessment of a patient with UTI symptoms involves determining resource needs, typically a urine sample for analysis.
Eye complaints like conjunctivitis are often triaged as ESI Level 5 unless accompanied by high-risk factors or severe pain.
Visual acuity measurement is recommended at triage for eye complaints, serving as a crucial vital sign for these patients.
Transcripts
but why don't we watch another patient scenario
Joe Joe
the police found you lying on the sidewalk
what happened okay
okay
why can't you just let me alone
you were here yesterday what did you do after you left
I went down to the square
and my buddies
we had a few and the next thing you know I'm here
okay so you were drinking
I noticed
you had this bruise and this little cut on your face
did you fall did you get into a fight
I don't know I can't remember
all right Joe
what's your date of birth
January 22nd, 1951 alright
what month is it right now
September
no Joe
it's April
where are you right now the hospital
um Brigham
in Women's Hospital okay
I need to take your blood pressure and your temperature
and put this on your finger
this patient
appears to be known to the emergency department staff
he was found on the sidewalk
and brought in by the police
he has bruises on his face and a small asseration
his Glasgow coma scores 14
and he is disoriented to time
Joe does not need immediate life saving interventions
so he is not an ESI level 1
but his presentation is concerning
he has visible signs of trauma to the head
and he has no recollection of what happened
and obvious alcohol consumption
he meets a criteria for ESI Level 2
his presentation is high risk
and he is disoriented to time patients
who are well known to an emergency department
are often high risk
and it is important not to minimize their presentation
a triage nurse should always maintain a high index
of suspicion
with well known patients to the emergency department
especially when they present with substance abuse
any signs of trauma or language barrier
this patient meets ESI Level 2 criteria
tell me something do you see patients like Joe
sure sure
do you agree he's high risk definitely
and you know
we need to be very careful with these type of patients
do you have any questions about that case
no but it's interesting
that's where with people who are drunk
are repeat visitors that's where I see mistakes
in my years in the Ed
that's where I've seen the most mistakes
in triageing patients that's really easy to do right
these people every day sometimes several times a day
sure and
it's very hard to keep that high index of suspicion out
but you're right that's when bad things happen
I seen a heart attack
and a couple of other things that were missed
both by the pre hospital personnel and by us
easy for these people that bad head injuries
exactly
and we need to assume at this point
that he had one of those
and that alcohol was just another factor
so he is definitely an ESI level too
what would happen if we couldn't wake him up
like if you shook him and he just
wasn't responding to or it took a painful stimuli
would that change this category at all
depends if he was handling his airway and everything
I don't know right if he's unresponsive your right
he becomes in your way issue
which could bump them up to level one
absolutely
that would definitely bump him up to a level 1 okay
he would need immediate life saving interventions
he would need to be intubated
he cannot protect his own airway
so remember that definition of ESI Level 1 right
okay let's do another case
m I Robert Douglas oh that's me
hi Robert come on in my name is Paul
I'm one of the nurses which have a seat
I'm gonna ask you a couple questions about
what brought you in here today okay
so what what's going on what brought you in here
oh
just feeling weak
have no energy
had trouble getting out of bed this morning okay
when did all this start
last night
I was supposed to go to dialysis this morning
but I just don't have any energy okay
so you're feeling fine yesterday
and today you're feeling really weak
yes
okay I'm gonna go ahead and get your blood pressure
how old are you Robert 62 okay
are you having any pain or problems breathing with this
no just feeling dizzy okay
so you're feeling dizzy
do you have a list of medications that you take oh yes
I think it might be right there yeah
great thanks
okay
so other than the renal failure and the hypertension
do you have any other medical problems
that we should know about
well I've had two heart attacks
okay I had bypass surgery in 2002
okay when was your last dialysis
three days ago I've got one of those catheters
cotton catheter yes
okay yes
another interesting patient
he does not need to be immediately rushed back to
the treatment area
he does not require immediate life saving interventions
he is not an ESI level 1 however
he is a high risk patient
the concern is his significant medical history
that includes chronic Wheeling failure
hypertension and significant cardiac disease
combined with his presenting complaint of feeling weak
there are several questions
the triage nurse cannot answer
a triage is his potassium markedly elevated
is he having another am I
what does his EKG look like
these are major concerns that warrant
assigning this patient ESI level 2
he is high risk and it would
not be safe for him to wait in the waiting room
I would give him my last dad
this patient meets the criteria for ESI Level 2
so do any of you think he looks a little bit too good
to be this dialysis patient
and given him a level 2 what do you mean by too good
does he look pretty okay he looks pretty good to me
really well
except that you have to consider he's chronically ill
so you know a lot of what he's experienced
he's experienced before so you know
it may be usual to him in some ways um
I mean one thing that came to me right away um
I don't think they do it in that yard
that they were showing there
but we do EKGs in our triage area
that would be something
he could get in our triage area
that would right away tell you
there was anything going on
cardiac at that moment
okay but
would you get an
EKG before you assign a triage category
or with the triage category
kind of dictate the fact that you need to get that EKG
well yeah you go ahead and sign him a category however
as an adjunct
along with all the other information you're gathering
and EKG could be part of that
alright that's a good point
cause
a lot of people are doing more and more at triage now
but I think you still
are gonna have to make a decision on
the triage category before you
um have any other interventions or do anything else
and I think he just looks pretty good
but it's important to remember he's high risk
he's due for that dialysis patient
and all those things that we talked about
he's dizzy he's having chest pain
you really don't have any idea right
so if you did is EKG
then that's sort of a process thing afterwards
but you're still not gonna know his potassium level
so I wouldn't I mean
don't you see all these patients with weakness
coming in with that chief complaint
and I think the thing
the triage nurse has to do is sort out
what are the what I will call high risk situations
you know is he a diabetic
is I mean
this particular gentleman told you
he was a renal patient but what is this history
um it could be so many different things
and many of these are high risk patients
because they have chronic medical problems
and many of them don't have the classic symptoms
even if they're having a heart attack
if they've had an incision in their chest
or if they're diabetic sometimes
they won't have classic chest pain
as a presenting complaint
that's an excellent point
and then in a lot of ways
you know I consider it like a puzzle
I mean he starts out with the dizzy weakness part
well then he adds the dialysis part
and he has a hypertension part
then he had two MI's
and you're like adding all these pieces to the puzzle
and they're giving you a picture
because of that history especially
um I would make a room for him
and I you mentioned in the video
that you would give him your last bed
but even if that was not available
I would have to pull somebody that was more stable
and put them in why I do that
because he's weak I
saw him walking with a cane to you
I would go ahead and get a wheelchair
or a stretcher
to push him back into the treatment area
that's what I would do
great excellent points
on this case he was a level 2
he was very very like up there and upwards
a level two that's a good point too
what if you had five level twos now
what if you had we can do it all
a little prioritization of twos
so you have somebody now with
let's put that subarachnoid that we talked about
with a headache
female with severe headache after a bowel movement
that we're thinking is a subarachnoid
and then you have this patient with dialysis
and then you have somebody who has chest pain
and some shortness of breath
so who would you want to put first
certainly want to do the EKGs to see if I slide
don't have that at this
I did the Paul socks on the shortness and bra
and Paul socks on the
I mean that right I mean
I think what you need to look at is who needs
who's requiring intervention immediately
and so that would be one tell tale
in terms of a life saving intervention
is the pulse ox let's say that that we have none
and that's absolutely true
no level 1 criteria for any of these patients to have
three level twos chest pain
short of breath this man who's weak and dizzy
on dialysis and your maybe subarachnoid
I'd have a hard time between the chest pain
short of breath and the subarachnoid
gotta have to see him but say that you know
your distress pain doesn't look very good
yeah that's what I was gonna say the subarachnoid
we'd wanna get her back
but she looked good at that moment right um
but again you know
we don't have the information on the shorter breath
chest pain
but you know things like how he looked physically
is he diaphratic no
it's okay what's his color
like what's his age group
any past history any factors that you know
are making us think part right
I think what Paul is saying
part of it is
you're basing your judgment on your across the room
assessment as well as that information
you gathered during your triosh assessment
and really figuring out who's the circus
who is really needs to go back first
and who can safely wait for a few minutes
until another bed becomes available
you know this era of Ed overcrowding
finding beds is becoming increasingly more difficult
and I really liked your point about pulling somebody
out of her room into the hallway and creating a bed
yes cause you're gonna face the situation all the time
and you still do that
and people ask us that question a lot too
so just because you have five levels
within those levels
you're still gonna have to prioritize your twos
and you're still gonna have to prioritize your threes
so time ordering
your chart according to categories is not a good idea
so you're still gonna have to do a lot of assessment
great
so let's do the next case
you're notified by EMS
that you're receiving an 8 year old female
who was struck by a bus while crossing the street
bystanders report she was thrown across the street
her initial vital signs her heart rate was 1:48
respiratory rate 36 her blood pressure 70 over palpable
and her rumere saturation 91%
so does this patient meet ESI level 1 or 2 criteria
probably probably what
yes I love a 1 or 2
well I want her in the trauma room
she's a bad pediatric trauma
I think she's hypotensive and tachycartic for her age
so level 1 or 2 I think level 1
okay um great
she is hypotensive and
she does require immediate life saving interventions
what specifically do you think she'll need
well lines for fluid resuscitation
a fluid bolus possibly blood
possibly intubation depending upon what they find
perfect you aren't just starting a line to have a line
she needs immediate life saving interventions
she needs hemodynamic resuscitation
now let's talk about this
what if this were an adult with the same vital sign
same scenario I don't think it would change anything
you're right just checking let's move on
okay next case
we have a 33 year old that comes to triage from her
doctor's office um
she complains of a severe frontal headache
10 over 10 for about 4 days
she went to her eye to eye doctor's office
cause she thought she needed glasses
the ophthalmologist performed an eye exam
and sent her directly to the emergency department
for further evaluation she's alert oriented times three
her blood pressure is 260 over 160
her heart rates 82 and her aspirations are 16
s P O 2 and her temperature are fine
so what do you not like the most about this case
well the blood pressure is off the charts
so how does this work
if the blood pressure isn't part of the vital science
criteria for the ESI that's a good question
all patients probably should get vitals
especially adults
who are going to go to the waiting room
this is a perfect case to
demonstrates the need for vitals
well it's true that vitals are usually not helpful
a patient with a headache
or a nosebleed are really two examples
when you need to take the blood pressure
make sure you check it so let's go back to this case
what do you think the ophthalmologist saw
and why do you refer her to the emergency department
well maybe she had papillodema
and then I guess he checked her blood pressure great
so what triage level is this patient
well she's tolerated this pressure for four days
so I would make her a level 2
she is high risk
could she be a level one
well
does she require immediate life saving interventions
I would air on the cautious side with this case
she is going to require immediate access for medication
administration to start lowering that blood pressure
well it is true
she may have had this elevated blood pressure
for 4 days you don't know that for sure
it may have just started today
it's really hard to tell
well
I would make her an ESI level 1 and get her care going
two sixty over one 60 is really high
she is symptomatic and you can bet she has paplodema
she has the potential for stroke
what if she was you know
symptom free and this was a by chance blood pressure
you know she came in for a minor unrelated complaint
I guess you can make her a level 2 or a level 3
I wouldn't make her a level 3 though
she's too high risk
but that high of blood pressure even if she is stable
agree okay time to move on
okay now we have a case
you're notified by EMS
that you're receiving a 78 year old male
who collapsed in the garden
his daughter called 9 1 1 and immediately started CPR
he was defibrillated three times in the field
and he was brought into the emergency department
in Sinus berticcardia
and his pressure was 88 systemic
so what do you wanna do with this gentleman
ESI level 1 he's post arrest
and will require continuation of the resuscitation
he's also gonna be going on event and will need drugs
absolutely he's still hypotensive
he's sprayed a cardiac
and he's gonna need some IV vasopressors
probably dopamine
he may deter back into VFIB for all we know
so he is definitely a level 1
and there is really not much more to say about that
let's do the next case a 14 year old male
is brought to the emergency department
by his mother
who tells you she is concerned her son has poison Ivy
he was doing some yard work for a neighbor
and two days later developed itching
redness and little blisters on his arms
she's concerned that he will
spread it to the whole family
he's healthy takes no medications
has normal vital signs okay
do you think he needs level 1 or level 2 criteria
no way they need to go home
they should have gone to see their doctor
okay so maybe home after some great patient education
so you saying
this patient is not gonna require any resources right
he is an ESI level 5
he's gonna be instructed to go home
to get some over counter medicine
that's right don't forget
this is a really good
opportunity for patient education
why don't we watch another vignette
Larry
why don't you have a seat
my name is Nikki I'm one of the nurses
and I need to ask a few questions about
what brought you to the emergency department today
I also need to take your blood pressure
and put this thing on your finger
my wife brought me to the emergency department
she's all worried she thinks I'm having a heart attack
because I have this pain it's not really pain
more like a pressure like something sitting on my chest
okay do you have this pressure right now yeah
now
do you have any medical problems that you see a doctor
regularly for
just my high cholesterol
but he put me on a medication and anti cholesterol drug
it's much better now
what were you doing when this pressure started
sleeping woke me right up
hasn't gone away all right
what time was that about 6 a m
to feel short of breath at all
kind of right
how about your stomach do you feel sick to your stomach
a little queasy a little queasy all right
I need a wheelchair to triage
and I'm going to be taking that last monitored bed
Larry how old are you 52
52 I have a wheelchair
and then I'm going to have you have a seat in
and your wife
can go ahead and get you
registered into the emergency department
This 52 year old male has multiple respecters
for cardiac disease obesity
smoking anti cholesterol
he presents to the emergency department
with chest pressure that woke him up from sleep
with nausea shortness of breath antiparesis
his heart rate is between 30 and 40 and irregular
his respiratory rate is rapid
and his blood pressure is low
90 over 76 this patient is probably having an acute MI
he needs to be seen immediately
and immediate life saving interventions initiated
he needs IV access fluid pacing
pads in place and other hemodynamic interventions
he meets criteria for ESI Level 1
interesting case what do you think
do you agree ESI level 1 absolutely he may not agree
but you know the denial is along with the diagnosis
oh that's an excellent point
she knows how diphoratic he was
yes my first thing yeah
that across this room assessment
really made you key in on that
he had so many risk factors
now why didn't I just walk him back to trio
you know to treatment wrong
because activity increases his mycardial oxygen demand
so you would want him to rest and get oxygen in
that's an excellent point
we really need to do that
he's also betacartic and I think his
he was also had a hypertense hypotension
his blood pressure was low too
so yes
that's another right flag
great and that's really the thing
that makes him a level 1 versus a 2
cause you really don't wanna make all your chest pains
level 2
if you start making all your chest pains level 2
and people really aren't gonna be attend
paying attention to level 1
this is he was a level 1 because he was bradycardic
most chest pains
the nurse can manage just fine for the first 10
15 minutes you put them on the monitor
you get your access you get your labs
you get your EKG
and you really don't need a physician at the bedside
this patient who's at Breta Cardiac and hypotensive
you want to bring the DOC to the bedside
because you may start doing more than those things
and the things we talked about
the pacer pads all that is really good
still with all that he looks pretty good
and I know
I would have been surprised when I found his hurry was
30 I would not have originally pictured
but I would have been making the level 1
that was
the one thing that would have made me change my mind
especially since he brought in that can of soda
he's pretty active
he had so many arrest factors and you know
it's true ESI level 1 you
my concern
would be getting him back into that resuscitation room
before he arrested so exactly
me too yeah good
why don't we watch another patient scenario
Louise what yes I come on in Louise
okay there to have a seat my name is Paul
I'm gonna ask you a couple questions about
what brought you in here today
and get your blood pressure okay
okay I feel really silly being here
but the girls where I work
insisted that I come over and get checked out
so what's going on
I have this pain
it's like a constant pressure
it's it's not like my heartburn
this makes me sick to my stomach
how long has this been going on
about 3 hours okay
have you taken anything for it
one of my co workers gave me an add acid
I didn't do anything I'm just so tired
okay I'm gonna get your blood pressure
and ask you a couple more questions
how old are you 57
okay and on a scale of 0 to 10
with 10 being the worst pain that you can imagine
how would you rate that pain right now
ah about us 7
okay and Jay Nurse
this isn't gonna take long
is it cause I've got to get back to work
I've got so much work to do
you know
I can't tell you exactly how long it's gonna take
but
it is really important that you see the doctor today
okay okay
do you have any medical problems
I have a high cholesterol
and I've had some heartburn lately
okay
do you take any medicines every day on a regular basis
yes it's here in my purse
okay can I see
great thanks
This 57 year old female
presents to the emergency department
with epigastric area pressure
she has a history of high cholesterol
and seems to be stressed about work
all risk factors for cardiac disease
we know from the research
that women with heart disease
do not present with the classic signs of chest pain
and shortness of breath usually their more
their discomfort is more upper GI
and many will complain of being tired
this patient is currently stable
and does not require immediate
life saving interventions
but she is high risk for cardiac disease
she meets the criteria for ESI Level 2
if her blood pressure was low
or her heart rate was high
low or irregular and her skin was cool and diaphratic
she would then be an ESI Level 1
this patient is currently ESI Level 2
interesting woman what do you think
do you agree with that yes
that really makes sense
women are different aren't they
yes one of the first things I noticed about her
is that she was very short of breath
and that kind of alarmed me
said the whole time that she was talking to you
um
it just that was what I was thinking about
okay that she showed her breath
you know I need to try to help
you need to do yes
intervene soon even if she was just being dramatic
right you know
which you know
obviously in the emergency department
we have patients who present that way
would that change your priority rating at all
would you still make her too
I would and
I was considering the question of
whether she was hysterical
and nervous
or whether she was actually short of breath
the other thing is that she did take an Anacid
and it didn't help at all
which is leans me still in the direction
further
in the direction of a possible cardiac condition
that's an excellent point
now women with heart disease
they tend to deny their pain
we know that so
a lot of things were learning in the last 10 years
about women
and how they present to the emergency department
you know we need to make sure that they get seen
simply
have any other questions about this particular patient
any anything they wanna say
no she was her vital signs were normal
they were
they were still pressure heart rate everything
she just as you said was a little to get neck and I
I didn't see her pulse socks
what was that um
I believe it was 100% it was normal cause I again
I thought the yeah
shortness of breath was was quite evident
I wanted to give her an nemesis basin
that's a good point
so had so much up against or disrupts
just watching the video
I was concerned and that bothered me a lot too
but we really tend to blow off women
and even in some of the teaching that we do
we still find a lot of nurses that
don't want to take females um
seriously with this kind of cheap complaint
and it's kind of surprising that still
there are people that wanna minimize women with um
up a gastric distress
and it's not something that you want to do
they're so vague and right
they are big
we're so big and how we speak about our complaints
we tell too much what would you have to look like
to make her a level one
well some instability in the vital signs
what if I said her heart rate was one eighty oh
then she knew yeah definitely
definitely if her color looked worse as well
if she had diaphoresis
as well as the epigastric distress
and the shortness of breath
either hypertension or hypertension
either one good
interesting case I think we Learned a lot from that one
okay let's do a suicidal scenario okay
we have a 21 year old female
who comes in with her parents
who said that her daughter express suicidal ideation
after the boyfriend broke up with her
the patient denies being suicidal
she's alert she's oriented times 3
and she's a little bit non cooperative
her vitals are 97 nine 82
20 and one 15 over 70 she is requesting to leave
after all she says she is 21 years old
so with everything you know about this scenario
what triage level is she
I know she's considered high risk and an ESI level 2
but I just don't get it
why is she given such a high priority
well that's a concern that many Ed nurses have
so let's just go ahead and talk about it
because we have a lot of these patients
this patient cannot be trusted
we must assume she's suicidal
therefore she is high risk
if she were to leave and kill herself
you and the hospital would be liable
you know she may not get to your next bed
but this case really illustrates process and trash
categorization subtle days
some institutions will have a place for these patients
others have protocols
that require the triage nurse to immediately call for
standby or for somebody to observe her
and possibly notify a crisis worker
or a psychiatric liaison
and other institutions
may draw labs for medical clearance
so
we are actually doing quite a bit for these patients
on arrival but the bottom line is she is high risk
and take credit for it don't sweat it
suicidal
homicidal and psychotic patients are very high risk
we now have a 76 year old female
that tells you
that she feels like she's gonna pass out
she says you know
I've been feeling weak and dizzy
ever since I got up this morning
and I don't usually feel like that
I usually feel fine
I'm really healthy and I don't even complain at all
her SPR2 is 96 her heart rate is 32
so what do you think about her a little weak and dizzy
do you got something that we never see
I think she's a level 1
how come what kind of interventions does she need
oh first off
she's beta cardiac um
and I don't know what her blood pressure is
but she is dizzy and weak
so most likely she could be hypertensive
so she needs an IV line
um possibly some atropine
and at least external pacer pads applied
right if her VP is okay
I just leave the pads on and go for IB access
but if she's hypotensive
she may need immediate external pacing
perfect she definitely is a level 1 patient
she needs immediate hemodynamic interventions
I think it's time for a pediatric case
all right here we go
parents rush into the emergency department
with your 11 month old child
he has a temperature of 103
8 reports the mom
he woke up from his nap
cranky and he keeps pulling on his left ear
the baby is sitting quietly on the mother's lap
sucking on a bottle of juice
he cries when you try to listen to his heart
his temperature is 1 0
2 6
his respiratory rate is 30
his heart rate is 1:28 his Romeo saturation is 100%
so what do you think is he high risk
I hate trashing the kids I just don't feel comfortable
oh we see kids all the time
this gets fine well
how do you know that well
look at him he's sitting there sucking down juice
he looks great
but he's got a fever of 102 secs
but an antipartic will take care of that
let's look at the algorithm under Decision Point d
this is section under Vital Signs that discusses PEDs
fever criteria
there's actually a lot of very good literature
on this topic
if we go through the guidelines that are evidence based
we'll see that
if this child was less than 28 days of age
no matter how good he looked
he'd be at risk for serious infection
and therefore would be at least an ESI level 2
if he looked flacid or lethargic
he'd be an ESI level one
so moving up in the age group
there is some controversy over how to manage a fever
in the 28 day to three month old
so depending on your institutional practice
you could make a child in this age group
a level 2 or three
finally the 3 to 36 month old child
the child in our scenario
will probably be triage as ESI level 5
in this age group the triage nurse
first considers fevers greater than 102.2
so you may uptriage for this high of a fever
you know you should also consider
if there's an obvious source of infection
this child is tugging on his ear
so there's a probable source of infection
the triagenurist must also
ensure
that the child is up to date on his immunizations
so this child could actually be an ESI Level 5
again it's the nurse's judgment
but all babies less than 28 days of age must be
at a minimum ESI Level 2
okay let's go back to the tape
and see what other kind of cases we've got on here
Kristen Kristen McKenzie
come on in have a seat
my name is Nikki I'm one of the nurses
I need to ask you a few questions about
what brought you here
to the emergency department today
I also need to put this on your finger
and we'll take your temperature
and your blood pressure okay
all right so what brought you here today
we're here in Boston on vacation
my daughter has a history of asthma
it's not bad
but she needs to use an inhaler when she plays sports
we're heading up north to go skiing
and she forgot her inhaler
I told her to pack it
even put it on the bed next to her suitcase
but she forgot okay
so you're here for prescription refill
yes all right
Kristen how are you feeling
any shortness of breath
you feel like you're wheezing at all
no okay good
a healthy 10 year old with a history of asthma
presents to the emergency department with her mother
requesting a prescription for an inhaler
this child meets ESI Level 5 criteria
she needs to be seen by a physician
have a prescription written
and be discharged by the nurse
if she had been wheezing a little
she would need a handheld nebulizer
treatment with a pre and post peak flow 1 resource
making her an ESI Level 4
a level 3
asthmatic would be one who required a chest X ray
or labs additional resources
if this patient was wheezing significantly
and in severe distress with a good oxygen saturation
she would be ESI level 2 however
if she was decompensating
tiring and had an SPO 2 less than 90%
and the triage nurse was concerned
she would require immediate intervention
she would meet ESI Level 1 criteria
so what do you think about that case
pretty straightforward what do you think
sure
okay I think the patient looks good
I know we get a lot of patients in the Ed um
that come in because either they ran out of medication
um or they didn't have it a lot of times um
we do see that and I do agree that she would
this case would be a level 5
you know I bet there's probably some nurses out there
and some of us
that wanna kind of read more into the case um
but she doesn't have any soreness of breath
she has absolutely no complaints
another kind of example of the same thing
as patients that come in with a different complaint
and have a blood pressure that's up
totally unrelated
so don't make things more than they are
she just wants a prescription refill that's a 5
well if I was triaging her
she told me she felt fine still
but I would still grab my stethoscope
and still listen to her just
you know in case
because of her history for asthma
and because she's in a new area
where the altitude or the weather is different
so I'd still be you know a little cautious about that
that's another great point
you know
can you think of any other patients who would be ESI
Level 5 what about suture
what about suture removal
that seems very simple
is that a procedure removing sutures
no we don't count that as a resource oh okay
that would be an ESA Level 5 definitely
and you were saying
I was gonna say a ration as an example
yes many of those patients come in
they just want to know what it is
they got a medical exam and they're perhaps given P O
medication and then discharged
many of the time you know
often it's discharge instructions
that's really what they need
what else couple more
what about like
adult that comes in with like a common cold
because they couldn't sleep in the middle of the night
they're tossing and turning
they have no place else to you know
they're not gonna sleep so they're gonna come in
yeah sure
as long as you don't think they're gonna need a lamp
if they're gonna send a culture or throw culture
and then they'd be one resource
and level 4
it's a couple more fives that are pretty common else
earrings and children
that's a good one okay
a wound check wound check is a great one
they come in all the time
doesn't require any resources to set physical exam
abrasion to the skin
that's a very good example
or minor cut that turns out not to need suturing
another good one you know
as I watch the scenario I felt bad for the mother
you know here she is on vacation
and has to bring her child to the emergency department
for a prescription refill
you know sometimes nurses need a really
you know why are you here
they question that and you know Paula
I think we both agreed that
you know there's nothing we can do about it
these patients we want to see them
and we want to try and streamline them
through the department
and I think it's nice to see a patient
where we can offer preventative care
for a change and also um
like you said
someone from from out of town that's stressed
you know any patient that comes in
we should look at
as an opportunity for customer service
good point and I felt kind of sorry for the little girl
because I think she's gonna hear about this a lot haha
even though it was her fault
good point
okay here's a new scenario
here's a patient with a UTI
so patient comes in and says
I think I have a UTI it burns when I go to the bathroom
and I'm going all the time and I only go a little bit
this is a 19 year old patient
who's had these symptoms for 24 hours
she denies abdominal pain
fever chills or any kind of vaginal discharge
she's healthy no medications
no allergies her vital signs are good 97
8 80
16 and 110 over 76
so do we need a life saving intervention here
I don't think so okay
how about high risk criteria
severe pain or distress
not hardly how about just a urine sample
uh sounds like a good plan
does anybody think she's gonna need anything else
well it depends on which physician is working wow
I'm so glad you brought that up
you know
ESI is based only on the triage nurses judgment
of how many resources
she thinks the patient will require
to get the patient to a final disposition
whether that's home admission or transfer
this judgment is based on her experience
and knowledge of emergency medicine
standard to care and institutional protocols
physician practice will bury
but ESI
has shown that triage nurses do really well
at predicting what patients will need
and remember
the purpose of predicting resources is only to help
assign a triage category to the lower acuity patients
the threes the fours
the fives so
if the story changes
and the patient requires more resources
that's okay
you shouldn't triage differently based on how
you know who's working
how busy the department is okay
so let's go back to the case
sounds like a urine is all we need
one resource level 4 patient
but wait she's gonna need a pregnancy test too
and we don't usually send our urines to the lab
we just dip it and then treat when necessary
let's talk about the pregnancy test first
bedside testing if that's what your institution does
doesn't count as a resource
adding a pregnancy test
doesn't change the number of resources
lab counts as one resource
regardless of the number of tests you send
or the type of specimen for example
blood or urine or stool
so this is another
great example of some institutional differences
that are handled without a problem
using the assign
if the case you just discussed
if the urine is never sent to the lab
it is considered a bedside test
does not count as a resource
and the patient is a level 5
if at any point that urine goes to the lab
then we're back to ESI level 4 one resource
let's do an eye case
do you have a patient who comes in and says
you know my eyes are just all red and crusty
she's a 19 year old female
she said she's had red itchy eyes for two days
she has no medical problems
she takes birth control pills
has no allergies her vitals are 98 six 72
16 and 1 22 over 76
her visual cuties are 20 20 in both eyes
so what do you think is going on with this patient
she probably has conjunctivitis
the red itchy
goopy eyes absolutely
now is that a higher situation
oh no it's a very common complaint
okay so now we have to move on to resources
how many research
do you think it's gonna take to get this patient
out of the emergency department
just one an eye exam
okay and does that count as a resource
well
I looked no
I guess not
why not it's pretty important
that's a great question when ESI was developed
the researchers made some
really thoughtful decisions about
what does and does not count as a resource
if everything that we did count as a resource
we wouldn't have any level 4 or 5 patients
every patient gets a physical exam
so it's decided that physical exam doesn't count
let me talk a little bit more about physical exam
the patient who comes in with an eye complaint
is going to need a slight lamp exam
that is part of their physical
it would be just like a woman with abdominal pain
she would require a pelvic exam
and again
that's part of the physical exam of that patient
so does this patient require any resources
I guess not so what level is she
well if no resources
then I guess she's an ESI level 5 great
so let's talk a little bit more about eye complaints
this patient most likely has conjunctivitis
which is a common complaint
in which patients often seek treatment
in the emergency department
most I complaints often end up being treated as
it's either yes I
level 5 or 2 because they represent a high risk
to the loss of eyesight
well in this particular case is
and this one's triage is an ESI level 5
conjunctivitis is not an acute eye problem
that is considered high risk
what's another example of an eye complaint
that might be an ESI
level 5 what about someone that comes in
complaining of something in their eye
but has severe pain that's an excellent question
so you have to actually ask two questions first
is this a higher situation
and second do they have severe pain
well it's certainly not high risk
people come in the Ed all the time
thinking they have something in their eye
but they have 10 out of 10 pain
so that makes them meet the ESI Level 2 criteria true
but you could put up pain in her eye
the protocol states that
in order to be level 2 criteria
you have to have pain of 7 out of 10 or greater
that you can't do anything about in triage
so in this case
we could put some topical anaesthetic in her eye
to make her feel much better
and then therefore we can make her a level 5
but if your hospital doesn't have such protocols
then I would make her a level 2 based on severe pain
okay good
let's talk about some examples of high risk
high situations can you guys think of any
how about a sudden loss of vision in one eye
absolutely
that could be central retinal artery occlusion
or retinal detachment
can you think of some other examples
chemical splash definitely
it's safe to
assume that most patients with a chemical splash
are going to require rapid irrigation
an eye problem that requires irrigation
but not necessarily high risk
would require one resource
and that would be an ESI level for a patient
so those are both great examples
but there's one more I'm thinking of
can you think of something else
how about trauma to the eye or foreign body like a nail
absolutely patients have obvious trauma
are at risk for a lot of injuries
and obviously foreign bodies are really bad as well
a high FEMA is another good example
that should be considered ESI level 2
another example of a patient with an eye complaint
that's considered ESI Level 5
would be someone with a foreign body
sensation and pain to the eye
often patients present
either with something that blew in their eye
or pain from contact lenses
these patients usually have a corneal abrasion
and again only require an eye exam
these patients also complain of severe pain
however
if the triage nurse can instill a few drops of topical
anaesthetica triage
and decrease the pain
then they meet ESI Level 5 criteria
and finally this is an aside
if possible
it is recommended to obtain visual acuities at triage
this is a really important
vital sign for patients with eye complaints
even more so than a temperature
a pulse and respirations
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