Chapter 9. Practice Cases | Agency for Healthcare Research & Quality

Emergency Severity Index (ESI): A Triage Tool for Emergency Department

Chapter 9. Practice Cases

The cases in this chapter are provided to give a nurse the opportunity to practice categorizing patients using the Emergency Severity Index (ESI). Please read each case and, based on the information provided, assign a triage acuity rating using ESI. Answers to and discussions of these cases are presented at the end of the chapter.

Practice Cases

"I was taking my contacts out last night, and I think I scratched my cornea," reports a 27-year-old 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.
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.
EMS arrived with an unresponsive 19-year-old male with a single self-inflicted gunshot wound to the head. Prior to intubation, his Glasgow Coma Scale score was 3.
"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.
A 41-year-old male involved in a bicycle accident walks into the emergency department with his right arm in a sling. He tells you that he fell off his bike and landed on his right arm. His is complaining of pain in the wrist area and has a 2-centimeter laceration on his left elbow. "My helmet saved me," he tells you.
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.
"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, vital signs were: HR 126, RR 28, BP 80/64, SpO2 96% on a non-rebreather.
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.
A 6-year-old male tells you that he was running across the playground and fell. He presents with a 3-centimeter laceration over his right knee. Healthy, no medications and no allergies, immunizations are up to date.
"I slipped on the ice, and I hurt my wrist," reports a 58-year-old female with a history of migraines. There is no obvious deformity. Vital signs are within normal limits, and she rates her pain as 5/10.
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.
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%.
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.
"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.
"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.
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.
EMS arrives with a 45-year-old woman with asthma who has had a cold for week. She started wheezing a few days ago and then developed a cough and a fever of 103. Vital signs: T 101.6°F, HR 92, RR 24, BP 148/86, SpO2 97%.
"I have an awful toothache right here," a 38-year-old male tells you as he points to his right lower jaw. "I lost my dental insurance, so I haven't seen a dentist for a couple of years." No obvious swelling is noted. Vital signs are within normal limits. Pain 9/10.
"I think I have food poisoning," reports an otherwise healthy 33-year-old female. "I have been vomiting all night, and now I have diarrhea." The patient admits to abdominal cramping that she rates as 5/10. She denies fever or chills. Vital signs: T 96.8°F, HR 96, RR 16, BP 116/74.
"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, T 98°F, RR 20, HR 102, BP 118/62, SpO2 98%.
"I cut my finger trying to slice a bagel," reports a 28-year-old healthy male. A 2-centimeter laceration is noted on the left first finger. Bleeding is controlled. Vital signs are within normal limits. His last tetanus immunization was 10 years ago.
"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.
"I'm 7 weeks pregnant, and every time I try to eat something, I throw up," reports a 27-year-old female. "My doctor sent me to the emergency department because he thinks I am getting dehydrated. T 97°F, RR 18, HR 104, BP 104/68, SpO2 99%. Pain 0/10. Lips are dry and cracked.
"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.
EMS arrives with an 87-year-old male who fell and hit his head. He is awake, alert, and oriented and remembers the fall. He has a past medical history of atrial fibrillation and is on multiple medications, including warfarin. His vital signs are within normal limits.
"I have this rash in my groin area," reports a 20-year-old healthy male. "I think it's jock rot, but I can't get rid of it." Using over the counter spray. No known drug allergies. Vital Signs: T 98°F, HR 58, RR 16, BP 112/70.
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%.
"I just need another prescription for pain medication. I was here 10 days ago and ran out," a 27-year-old male tells you. "I hurt my back at work, and it's still bothering me." Denies numbness, tingling, or bladder or bowel issues. Vital signs are within normal limits. Pain 10+/10.
EMS arrives with a 32-year-old female who fell off a stepladder while cleaning her first-floor gutters. She has an obvious open fracture of her right lower leg. She has +2 pedal pulse. Her toes are warm, and she is able to wiggle them. Denies past medical history medications, or allergies. Vital signs are within normal limits for her age.
The medical helicopter is en route to your facility with a 16-year-old male who was downhill skiing and hit a tree. Bystanders report that he lost control and hit his head. He was intubated at the scene and remains unresponsive.
A healthy middle-aged man presents to the emergency department with his left hand wrapped in a bloody cloth. "I was using my table saw, and my hand slipped. I think I lost of couple of fingertips." No past medical history, no med or allergies. Vital signs are within normal limits. Pain 6/10.
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: previous ectopic pregnancy. Vital signs: T.98°F, HR 66, RR 14, BP 106/68.
"My right leg is swollen, and my calf hurts," reports a 47-year-old morbidly obese female sitting in a motorized scooter. The patient denies chest pain or shortness of breath, but admits to a history of type 2 diabetes and HTN. Vital signs: T 98°F, RR 24, HR 78, BP 158/82, SpO2 98%. Pain 6/10.
"I think my son has swimmer's ear. He spends half the day in the pool with his friends, so I am not surprised," the mother of a 10-year-old boy tells you. The child has no complaints except painful, itchy ears. Vital signs: T 97°F, HR 88, RR 18, BP 100/68.
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 all within normal limits.
A 68-year-old female presents to the ED with her right arm in a sling. She was walking out to the mailbox and slipped on the ice. "I put my arm out to break my fall. I was lucky I didn't hit my head." Right arm with good circulation, sensation, and movement, obvious deformity noted. past medical history: arthritis, medications, ibuprofen, No known drug allergies. Vital signs within normal limits. She rates her pain as 6/10.
"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 and regular, RR 32, BP 82/60. Her skin is cool and diaphoretic.
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.
"I was using my chainsaw without safety goggles, and I think I got some sawdust in my left eye. It hurts and it just won't stop tearing," reports a healthy 36-year-old male. Vital signs are within normal limits.
"It hurts so much when I urinate," reports an otherwise healthy 25-year-old. She denies fever, chills, abdominal pain, or vaginal discharge. Vital signs: T 98.2°F, HR 66, RR 14, BP 114/60.
"I was smoking a cigarette and had this coughing fit, and now I feel short of breath," reports a tall, thin 19-year-old man. No past medical history, No meds or allergies, Vital signs: T 98°F, HR 102, RR 36, BP 128/76, SpO2 92%. Pain 0/10.
A 26-year-old female is transported by EMS to the ED because she experienced the sudden onset of a severe headache that began after she moved her bowels. She is 28 weeks pregnant. Her husband tells you that she is healthy, takes only prenatal vitamins, and has no allergies. On arrival in the ED, the patient is moaning and does not respond to voice. Emergency medical technicians (EMTs) tell you that she vomited about 5 minutes ago.
"I think I'm having a stroke," reports an anxious 40-year-old female. "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 past medical history, no meds. Vital signs all within normal limits.
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 a previous stroke, and she takes an aspirin every day. She is alert and oriented with clear speech and equal hand grasps.
"It is like I have my period. I went to the bathroom, and I am bleeding. This is my first pregnancy, and I am scared. Do you think everything is OK?" asks a 26-year-old healthy female. Vital signs: BP 110/80, HR 72, RR 18, SpO2 99%, T 98.6°F. She describes the pain as crampy, but rates it as "1" out of 10.
A 42-year-old male presents to triage with a chief complaint of "something in his right eye." He was cutting tree limbs and thinks something went into his eye. No past medical history, no allergies, no medications. On exam, his right eye is reddened and tearing. Pain is 4/10.
"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.
"I suddenly started bleeding and passing clots the size of oranges," reports a pale 34-year-old who is 10 days post partum. "I never did this with my other two pregnancies. Can I lie down before I pass out?" Vital signs: BP 86/40, HR 132, RR 22, SpO2 98%.
"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.
"I was seen in the ED last night for my fractured wrist. The bone doctor put this cast on and told me to come back if I had any problems. As you can see, my hand is really swollen and the cast is cutting into my fingers. The pain is just unbearable." Circulation, sensation, and movement are decreased.
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.
"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.
"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.
"I am so embarrassed!" An 18-year-old tells you that she had unprotected sex last night. "My friend told me to come to the hospital because there is a pill I can take to prevent pregnancy." The patient is healthy, takes no medications, and has no allergies. Vital signs: T 97°F, HR 78, RR 16, BP 118/80.
A 76-year-old male requests to see a doctor because his toenails are hard. Upon further questioning, the triage nurse ascertains that the patient is unable to cut his own toenails. He denies any breaks in the skin or signs of infection. He has a history of chronic obstructive pulmonary disease and uses several metered-dose inhalers. His vital signs are normal for his age.
EMS arrives with a 42-year-old male who called 911 because of dizziness and nausea every time he tries to move. The patient states, "I feel okay when I lie perfectly still, but if I start to sit up, turn over, or move my head, the room starts to spin and I have to throw up." No past medical history. Vital signs: T 97.2°F, RR 16, HR 90, BP 130/82, SpO2 99%. Pain 0/10.
This patient is the restrained driver of an SUV involved in a high-speed, multicar accident. Her only complaint is right thigh pain. She has a laceration on her left hand and an abrasion on her left knee. Vital signs: BP 110/74, HR 72, RR 16, no medications, no allergies, no past medical history.
"My wife called 911 because my internal defibrillator gave me a shock this morning when I was eating breakfast. Really scared me! I saw my doctor a few days ago, and he changed some of my medications. Could that be why that happened?" The patient has a significant cardiac history and reports taking multiple medications, including amiodarone. Vital signs: T 98.5°F, RR 20, HR 90, BP 120/80.
"Nurse, I have this pressure in my chest that started about an hour ago. I was shoveling that wet snow, and I may have overdone it," reports an obese 52-year-old male. He tells you his pain is 10 out of 10 and that he is nauseous and short of breath. His skin is cool and clammy. Vital signs: BP 86/50, HR 52 and irregular.
"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 a cachectic 42-year-old female on multiple medications. Vital signs: T 98.6°F, RR 34, SpO2 95%, HR 92, BP 114/80.
A 58-year-old male presents to the emergency department complaining of left lower-quadrant abdominal pain for 3 days. He denies nausea, vomiting, or diarrhea. No change in appetite. past medical history HTN. Vital signs: T 100°F, RR 18, HR 80, BP 140/72, SpO2 98%. Pain 5/10.
"I think he has another ear infection," the mother of an otherwise healthy 2-year-old tells you. "He's pulling on his right ear." The child has a tympanic temperature of 100.2°F and is trying to grab your stethoscope. He has a history of frequent ear infections and is currently taking no medication. He has a normal appetite and urine output, according to the mother.
"My son needs a physical for camp," an anxious mother tells you. "I called the clinic, but they can't see him for 2 weeks and camp starts on Monday." Her son, a healthy 9-yearold, will be attending a summer day camp.
"Last night I had sex, and we used a condom but it broke. I just don't want to get pregnant," a teary 18-year-old female tells you. Vital signs are within normal limits.
"I have a fever and a sore throat. I have finals this week, and I am scared this is strep," reports a 19-year-old college student. She is sitting at triage drinking bottled water. No past medical history, medications: birth control pills, no allergies to medications. Vital signs: T 100.6°F, HR 88, RR 18, BP 112/76.
"This 84-year-old male passed out in the bathroom," reports the local paramedics. "When we arrived he was in a third-degree heart block with a rate in the 20s and a blood pressure in the 60s. We began externally pacing him at a rate of 60 with an MA in the 50s. He is now alert, oriented, and asking to see his wife."
A 16-year-old male wearing a swimsuit walks into the ED. He explains that he dove into a pool, and his face struck the bottom. You notice an abrasion on his forehead and nose as he tells you that he needs to see a doctor because of tingling in both hands.
A-25-year-old female presented to the emergency department because of moderate lower abdominal pain with a fever and chills. Two days ago, the patient had a therapeutic abortion at a local clinic. The patient reports minimal vaginal bleeding, Vital signs: T 100.8°F, RR 20, HR 92, BP 118/80, SpO2 99%. Pain 5/10.
EMS radios in that they are in route with a 17- year-old with a single gunshot wound to the left chest. On scene the patient was alert, oriented and had a BP of 82/palp. Two large-bore IVs were immediately inserted. Two minutes prior to arrival in the ED, the patient's HR was 130 and BP was 78/palp.
"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.
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%.
The patient states that she is 6 weeks post laparoscopic gastric bypass. Two days ago, she began to have abdominal pain with nausea and vomiting of pureed food. She reports a decrease in her fluid intake and not being able to take her supplements because of vomiting. Vital signs: T 97.8°F, RR 20, HR 90, BP 110/70, SpO2 99%. Pain 4/10.
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.
"My throat is on fire," reports a 19-year-old female. It started a couple of days ago, and it just keeps getting worse. Now I can barely swallow, and my friends say my voice is different. I looked in the mirror, and I have this big swelling on one side of my throat." No past medical history , no meds, no allergies. Vital signs: T 101.6°F, RR24, HR 92, BP 122/80, SpO2 100% on room air.
"My doctor told me to come to the ED. He thinks my hand is infected," a 76-year-old female with arthritis, chronic renal failure, and diabetes tells you. She has an open area on the palm of her hand that is red, tender, and swollen. She hands you a list of her medications and reports that she has no allergies. She is afebrile. Vital signs: HR 72, RR 16, BP 102/60.
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.
"My dentist can't see me until Monday, and my tooth is killing me. Can't you give me something for the pain?" a healthy 38-year-old male asks the triage nurse. He tells you the pain started yesterday, and he rates his pain as 10/10. No obvious facial swelling is noted. Allergic to penicillin. Vital signs: T 99.8°F, HR 78, RR 16, BP 128/74.
"I have been on antibiotics for 5 days for mastitis. I am continuing to nurse my baby, but I still have pain and tenderness in my right breast. Now there is this new reddened area," a 34-year-old new mother tells you. The patient reports having a fever, chills, and just feeling run down. T 102.2°F, RR 20, HR 990, BP 122/80, SpO2 98%. Pain 6/10.
A young male walks into triage and tells you that he has been shot. As he rolls up the left leg of his shorts, you notice two wounds. He tells you that he heard three shots. He is alert and responding appropriately to questions. Initial Vital signs: T 98.2°F, HR 78, RR 16, BP 118/80.
An 82-year-old resident of a local assisted living facility called 911 because of excruciating generalized abdominal pain and vomiting that started a few hours ago. The woman is moaning in pain but is still able to tell you that she had a heart attack 6 years ago. Vital signs: T 98°F, RR 28, HR 102, BP 146/80, SpO2 98%. Pain 10/10.
"I should have paid more attention to what I was doing," states a 37-year-old carpenter who presents to the ED with a 3-centimeter laceration to his right thumb. The thumb is wrapped in a clean rag. "I know I need a tetanus shot," he tells you. BP 142/76, RR 16, T 98.6°F.
"My son woke me up about 3 hours ago complaining of a right earache. I gave him some acetaminophen but it didn't help," the 4-year-old's mother tells you. No fever, other vital signs within normal limits for age.
"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.
EMS arrives with a 75-year-old male with a self-inflicted 6-centimeter laceration to his neck. Bleeding is currently controlled. With tears in his eyes, the patient tells you that his wife of 56 years died last week. Health, No known drug allergies, baby ASA per day, BP 136/82, HR 74, RR 18, SpO2, 98% RA.
"My mother is just not acting herself," reports the daughter of a 72-year-old female. She is sleeping more than usual and complains that it hurts to pee." Vital signs: T 100.8°F, HR 98, RR 22, BP 122/80. The patient responds to verbal stimuli but is disoriented to time and place.
EMS arrives in the ED with a 57-year-old female with multiple sclerosis. She is bedridden, and her family provides care in the home. The family called 911 because her Foley catheter came out this morning. No other complaints. Vital signs are within normal range, currently on antibiotics for a UTI.
"I got my belly button pierced a month ago and now it hurts so bad," reports a 19-year-old healthy college student who is accompanied by her roommate. They are chatting about plans for the evening. The area is red, tender, and swollen, and pus is oozing from around the site. Vital signs: T 100°F, HR 74, RR 18, BP 102/70, SpO2 100%. Pain 8/10.
"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.
"This is so embarrassing," reports a 42-year-old male. "We were having incredible sex, and I heard a crack. Next thing you know, my penis was flaccid, and I noticed some bruising." The pain is "unbelievable," 20/10. No meds, No known drug allergies.
"I have this infection in my cuticle," reports a healthy 26-year-old female. "It started hurting 2 days ago, and today I noticed the pus." The patient has a small paronychia on her right second finger. No known drug allergies. T 98.8°F, RR 14, HR 62, BP 108/70.
A 20-year-old male presents to the ED after being tackled while playing football. He has an obvious dislocation of his left shoulder and complains of 10/10, severe pain. Neurovascular status is intact, and vital signs are within normal limits.
A 72-year-old female with obvious chronic obstructive pulmonary disease and increased work of breathing is wheeled into triage. Between breaths, she tells you that she "is having a hard time breathing and has had a fever since yesterday." The SpO2 monitor is alarming and displaying a saturation of 79 percent.
A 17-year-old handcuffed male walks into the ED accompanied by the police. The parents called 911 because their son was out of control: verbally and physically acting out and threatening to kill the family. He is cooperative at triage and answers your questions appropriately. He has no past medical history or allergies and is currently taking no medications. Vital signs are within normal limits.
"I think I need a tetanus shot," a 29-year-old female tells you. "I stepped on a rusty nail this morning, and I know I haven't had one for years." No past medical history, No known drug allergies, no medications.
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.
A 28-year-old male presents to the ED requesting to be checked. He has a severe shellfish allergy and mistakenly ate a dip that contained shrimp. He immediately felt his throat start to close, so he used his EpiPen. He tells you that he feels okay. No wheezes or rash noted. Vital signs: BP 136/84, HR 108, RR 20, SpO2 97%, T 97°F.
You are trying to triage an 18-month-old whose mother brought him in for vomiting. The toddler is very active and trying to get off his mother's lap. To distract him, the mother hands him a bottle of juice, which he immediately begins sucking on. The child looks well hydrated and is afebrile.
"He was running after his brother, fell, and cut his lip on the corner of the coffee table. There was blood everywhere," recalls the mother of a healthy 19-month-old. "He'll never stay still for the doctor." You notice that the baby has a 2- centimeter lip laceration that extends through the vermilion border. Vital signs are within normal limits for age.
A 44-year-old female is retching continuously into a large basin as her son wheels her into the triage area. Her son tells you that his diabetic mother has been vomiting for the past 5 hours, and now it is "just this yellow stuff." "She hasn't eaten or taken her insulin," he tells you. No known drug allergies. Vital signs: BP 148/70, P 126, RR 24.
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."

Practice Cases Answers and Discussion

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.
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.
ESI level 1: Requires immediate lifesaving intervention. The patient is unresponsive and will require immediate lifesaving interventions to maintain airway, breathing, circulation, and neuro status; specifically, the patient will require immediate confirmation of endotracheal tube placement.
ESI level 5: No resources. The patient needs a prescription refill and has no other medical complaints. His blood pressure is controlled with his current medication. If at triage his blood pressure was 188/124 and he complained of a headache, then he would meet the criteria for a high-risk situation and be assigned to ESI level 2. If this patient's BP was elevated and the patient had no complaints, he or she would remain an ESI level 5. The blood pressure would be repeated and would most likely not be treated in the ED or treated with PO medications.
ESI level 3: Two or more resources. At a minimum, this patient will require an x-ray of his right arm and suturing of his left elbow laceration.
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.
ESI level 1: Unresponsive. This 4-year-old continues to be unresponsive. The patient will require immediate lifesaving interventions to address airway, breathing, and circulation.
ESI level 3: Two or more resources. At a minimum, this child will need a workup for his abdominal pain, which will include labs and a CT or ultrasound—two resources.
ESI level 4: One resource. The laceration will need to be sutured—one resource.
ESI level 4: One resource. This patient needs an x-ray to rule out a fracture. A splint is not a resource.
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.
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.
ESI level 4: One resource. 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.
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.
ESI level 3: Two or more resources. At a minimum, she will require labs and IV antibiotics.
ESI level 1: Requires immediate lifesaving intervention. The patient is presenting with signs of shock—hypotension, tachycardia, and tachypnea. Based on the mechanism of injury and presenting vital signs, this patient requires immediate lifesaving interventions, including aggressive fluid resuscitation.
ESI level 3: Two or more resources. This history sounds more like pneumonia. Because the patient is not in acute respiratory distress, he or she doesn't meet ESI level-2 criteria. This patient will require labs, a chest x-ray, and perhaps IV antibiotics.
ESI level 5: No resources. This patient will require a physical exam. He has no signs and symptoms of an abscess or cellulitis, so he will be referred to a dentist for treatment. In the emergency department, he may be given medications by mouth. On arrival he rates his pain as 9/10, but because he does not meet the criteria for ESI level 2, he would not be given the last open bed.
ESI level 3: Two or more resources. Lab studies, IV fluid, and an IV antiemetic are three of the resources this patient will require. The patient is not high risk or in severe pain or distress.
ESI level 3: Two or more resources. A patient with a known history of migraines with vomiting will require pain medication, an antiemetic, and fluid replacement. The pain is not severe, 6/10. This patient is not high risk.
ESI level 4: One resource. This patient will require a laceration repair. A tetanus booster is not a resource.
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.
ESI level 3: Two or more resources. Lab studies, IV fluid, and an IV antiemetic are three of the resources this patient will require. She is showing signs of dehydration.
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.
ESI level 2: High risk. Patients taking warfarin who fall are at high risk of internal bleeding. Although the patients' vital signs are within normal limits and he shows no signs of a head injury, he needs a prompt evaluation and a head CT.
ESI level 5: No resources. Following a physical exam, this patient will be sent home with prescriptions and appropriate discharge instructions.
ESI level 2: High-risk situation. The mechanism of injury is significant, and this patient has the potential for serious injuries. He needs to be evaluated by the trauma team 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.
ESI level 5: No resources. No resources are required. Following a physical exam, this patient will be sent home with appropriate discharge instructions and a prescription if indicated.
ESI level 3: Two or more resources. An obvious open fracture will necessitate this patient going to the operating room. At a minimum, she will need the following resources: x-ray, lab, IV antibiotics, and IV pain medication.
ESI level 1: Requires immediate lifesaving interventions. Prehospital intubation is one of the criteria for ESI level 1. This patient has sustained a major head injury and will require an immediate trauma team evaluation.
ESI level 3: Two or more resources. Based on the patient's presentation, he will require a minimum IV pain medication and laceration repairs. In addition he may need an x-ray and IV antibiotics.
ESI level 3: Two or more resources. Based on her history, this patient will require two or more resources—lab and an ultrasound. She may in fact be pregnant. Ectopic pregnancy is on the differential diagnosis list, but this patient is currently hemodynamically stable, and her pain is generalized across her lower abdomen.
ESI level 3: Two or more resources. This patient is at high risk for a deep vein thrombosis. For diagnostic purposes, she will require two resources: labs and a Doppler ultrasound. If a deep vein thrombosis is confirmed, she will require additional resources—remember, ESI level 3 is two or more resources. If this patient were short of breath or had chest pain, they would meet ESI level-2 criteria.
ESI level 5: No resources. This child needs a physical exam. Even if eardrops are administered in the emergency department, this does not count as a resource. The family will be sent home with instructions and a prescription.
ESI level 2: High risk. 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.
ESI level 3: Two or more resources. It looks like this patient has a displaced fracture and will need to have a closed reduction prior to casting or splinting. At a minimum, she needs x-rays and an orthopedic consult. Her vital signs are stable, so there is no need to uptriage her to an ESI level 2. Her pain is currently 6/10. If she rated her pain as 9/10 and she is tearful, would you up-triage her to an lESI level 2? Probably not, given the many nursing interventions you could initiate to decrease her pain, such as ice, elevation, and appropriate immobilization.
ESI level 1: Requires immediate lifesaving interventions. The patient is hypotensive with a heart rate of 178. She is showing signs of being unstable—shortness of breath and chest pressure. This patient requires immediate lifesaving interventions, which may include medications and cardioversion.
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.
ESI level 4: One resource. This patient will require eye irrigation. Eye drops are not a resource. A slit lamp exam is part of the physical exam of this patient.
ESI level 4: One resource. This patient will require one resource—lab. A urinalysis and urine culture will be sent, and depending on your institution, a urine pregnancy test. One or all of these tests count as one resource.
ESI level 2: High risk. This young, healthy male has an elevated respiratory rate and a low oxygen saturation. The patient's history and signs and symptoms are suggestive of a spontaneous pneumothorax. He needs to be rapidly evaluated and closely monitored.
ESI level 1: Requires immediate lifesaving intervention. From the history, it sounds like this patient has suffered some type of head bleed. She is currently unresponsive to voice and could be showing signs of increased intracranial pressure. She may not be able to protect her own airway and may need to be emergently intubated.
ESI level 2: High risk. Facial droop is one of the classic signs of a stroke. This patient needs to be evaluated by the stroke team and have a head CT within minutes of arrival in the ED. Many nurses want to make all stroke alerts an ESI level 1. This patient does not meet level 1 criteria as she does not require immediate lifesaving interventions. The triage nurse needs to facilitate moving this patient into the treatment area and initiate the stroke alert process.
ESI level 2: High-risk situation. The patient's history indicates that she may have had a transient ischemic attack this morning. The patient is high risk, and it would not be safe for her to sit in the waiting room for an extended period of time.
ESI level 3: Two or more resources. Based on her history, this patient will require two or more resources—labs, an ultrasound. On the differential diagnosis list is a spontaneous abortion. Currently, she is hemodynamically stable and has minimal cramping or pain.
ESI level 4: One resource. The only resource this patient will require is irrigation of his eyes. A slit lamp exam is not considered a resource but is part of the physical exam.
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.
ESI level 1: Requires immediate lifesaving intervention. This patient is presenting with signs and symptoms of a post partum hemorrhage. She tells you she is going to pass out, and her vital signs reflect her fluid volume deficit. The patient needs immediate IV access and aggressive fluid resuscitation.
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.
ESI level 2: High-risk situation. The recent application of a cast along with swelling of the hand and unbearable pain justifies an ESI level-2 acuity level. He may have compartment syndrome.
ESI level 1: Requires immediate lifesaving intervention. Studies have shown that lowering brain temperature post cardiac arrest decreases ischemic damage. This patient requires immediate lifesaving interventions to airway, breathing, circulation, and neurologic outcome. Even though the patient converted to a stable rhythm, the nurse should anticipate that additional lifesaving interventions might be necessary.
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.
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.
ESI level 5: No resources. This patient will need a bedside pregnancy test before receiving medication. She may be an ESI level 4, if your institution routinely sends pregnancy tests to the lab.
ESI level 5: No resources. This elderly gentleman has such brittle toenails that he is no longer able to clip them himself. He requires a brief exam and an outpatient referral to a podiatrist.
ESI level 3: Two or more resources. Based on the history, this patient may have acute labyrinthitis and will require two or more resources—IV fluids and an IV antiemetic.
ESI level 2: High-risk situation. Based on mechanism of injury, this patient will need rapid evaluation by the trauma team.
ESI level 2: High risk. This patient is not someone who should sit in your waiting room. He does not meet the criteria for ESI level 1, but he meets the criteria for ESI level 2. The patient's internal defibrillator fired for some reason and needs to be evaluated.
ESI level 1: Requires immediate lifesaving intervention. The history combined with the signs and symptoms indicate that this patient is probably having an MI. The "pressure" started after shoveling wet snow, and now he is nauseous and short of breath, and his skin is cool and clammy. He needs immediate IV access, the administration of medications, and external pacing pads in place.
ESI level 2: High risk. 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.
ESI level 3: Two or more resources. Abdominal pain in a 58-year-old male will require two or more resources. At a minimum, he will need labs and an abdominal CT.
ESI level 5: No resources. This child has had previous ear infections and is presenting today with the same type of symptoms. He is not ill appearing, and his vital signs are within normal limits. The child requires a physical exam and should be discharged with a prescription.
ESI level 5: No resources. Because the mother could not get an appointment with a primary care physician, she brought her son to the emergency department for a routine physical exam. He will be examined and discharged.
ESI level 5: No resources. This patient will need a bedside pregnancy test prior to receiving medication. She may be an ESI level 4 if your institution routinely sends pregnancy tests to the lab.
ESI level 4: One resource. In most EDs, this patient will have a rapid strep screen sent to the lab; one resource. She is able to drink fluids and will be able to swallow pills if indicated.
ESI level 1: Requires immediate lifesaving intervention. The patient is in third-degree heart block and requires external pacing to preserve airway, breathing, and circulation.
ESI level 2: High risk. Because of the mechanism of injury and his complaints of tingling in both hands, this patient should be assigned ESI level 2. He has a cervical spine injury until proven otherwise. He is not an ESI level 1 in that he does not require immediate lifesaving interventions to prevent death. At triage, he needs to be appropriately immobilized.
ESI level 3: Two or more resources. Based on the history, this patient will require at a minimum labs and IV antibiotics. In addition she may need a gyn consult and IV pain medication.
ESI level 1: Requires immediate lifesaving interventions. The trauma team needs to be in the trauma room and ready to aggressively manage this 17-year-old with a single gunshot wound to the left chest. He will require airway management, fluid resuscitation and, depending on the injury, a chest tube or rapid transport to the operating room.
ESI level 4: One resource. The history is suggestive of an orbital fracture. The patient will require one resource—an x-ray. She will need a visual acuity check and eye evaluation, but these are not ESI resources.
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. He needs immediate IV access, aggressive fluid resuscitation, and perhaps blood prior to surgery.
ESI level 3: Two or more resources. Abdominal pain and vomiting post gastric bypass needs to be evaluated. This patient needs labs, IV, antiemetics, and a CT.
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.
ESI level 2: High risk. Voice changes, fever, difficulty swallowing, and swelling on one side of the throat can be signs of a peritonsilar abscess. The patient needs to be monitored closely for increasing airway compromise and respiratory distress.
ESI level 3: Two or more resources. This patient has a complex medical history and presented with an infected hand. At a minimum she will need labs, an IV, and IV antibiotics to address her presenting complaint. Her vital signs are normal, so there is no reason to up-triage her to ESI level 2.
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
ESI level 5. No resources. No resources should be necessary. He will require a physical exam, but without signs of an abscess or cellulitis, this patient will be referred to a dentist. In the ED, he may be given oral medications and prescriptions for antibiotics and/or pain medication. He is not an ESI level 2, even though he rates his pain as 10/10. Based on the triage assessment, he would not be given the last open bed.
ESI level 3: Two or more resources. This patient probably has been on antibiotics for 5 days for mastitis and now presents to the ED due to fever, chills, and feeling rundown. She will require labs, IV antibiotics, a lactation consult if available, and perhaps admission.
ESI level 2: High-risk situation. This patient has two obvious wounds, but until he is thoroughly examined in the trauma room, you can't rule out the possibility that he has another gunshot wound. The wounds on his thigh look non-life-threatening, but a bullet could have nicked a blood vessel or other structure; therefore, he meets ESI level-2 criteria. His vital signs are within normal limits, so he does not meet ESI level-1 criteria.
ESI level 2: High risk and severe pain and distress. Abdominal pain in the elderly can be indicative of a serious medical condition, and a pain score of 10/10 is significant. The triage nurse needs to keep in mind that due to the normal changes of aging, the elderly patient may present very differently than a younger patient and is more likely to present with vague symptoms.
ESI level 4: One resource. This patient will require a laceration repair. A tetanus booster is not a resource.
ESI level 5: No resources. Following a physical exam, this 4-year-old will be sent home with appropriate discharge instructions and perhaps a prescription.
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.
ESI level 2: High-risk. This 75-year-old male tried to kill himself by cutting his throat. Because of the anatomy of the neck, this type of laceration has the potential to cause airway, breathing, and/or circulation problems. At the same time, he is suicidal, and the ED needs to ensure that he does not leave or attempt to harm himself further.
ESI level 2: New onset confusion, lethargy, or disorientation. The daughter reports that her mother has a change in level of consciousness. The reason for her change in mental status may be a UTI that has advanced to bacteremia. She has an acute change in mental status and is therefore high risk.
ESI level 4: One resource. The patient was brought to the emergency department for a new Foley catheter—one resource. There are no other changes in her condition, and she is already on antibiotics for a UTI, so no further evaluation is needed.
ESI level 3: Two or more resources. Based on the history, this patient may have a cellulitis from the navel piercing. At a minimum she will require labs and IV antibiotics.
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.
ESI level 2: High risk. This patient may be describing a penile fracture, a medical emergency. It is most often caused by blunt trauma to an erect penis. This patient needs to be evaluated promptly.
ESI level 4: One resource. This young woman needs an incision and drainage of her paronychia. She will require no other resources.
ESI level 2: Severe pain and distress. The triage nurse is unable to manage his pain at triage other than applying a sling and ice. He will require IV opioids to reduce his pain and relocate his shoulder.
ESI level 1: Requires immediate lifesaving 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 the other vital signs in order to decide that this patient needs immediate care.
ESI level 2: High-risk situation. Homicidal ideation is a clear high-risk situation. This patient needs to be placed in a safe, secure environment, even though he is calm and cooperative at triage.
ESI level 5: No resources. A tetanus immunization does not count as a resource. The patient will be seen by a physician or midlevel provider and receive a tetanus immunization and discharge instructions. This patient will require no resources.
ESI level 4: One resource. This patient will be sent back to the nursing home after the feeding tube is reinserted. There is no acute change in his medical condition that warrants any further evaluation. He is unresponsive, but that is the patient's baseline mental status so he is not an ESI level 1.
ESI level 2: High-risk situation for allergic reaction. The patient has used his EpiPen but still requires additional medications and close monitoring.
ESI level 5: No resources. A physical exam and providing the mother with reassurance and education is what this 18-month-old will require. His activity level is appropriate, and he is taking fluids by mouth.
ESI level 3: Two or more resources. A laceration through the vermilion border requires the physician to line up the edges exactly. Misalignment can be noticeable. A healthy 19-month-old will probably not cooperate. In most settings, he will require conscious sedation, which counts as two resources. The toddler's vital signs are within normal limits for his age, so there is no reason to up-triage to ESI level 2.
ESI level 2: High risk. A 44-year-old diabetic with continuous vomiting is at risk for diabetic ketoacidosis. The patient's vital signs are a concern, as her heart rate and respiratory rate are both elevated. It is not safe for this patient to wait for an extended period of time in the waiting room.
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.

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Page last reviewed October 2014

Internet Citation: Chapter 9. Practice Cases. October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/esi/esi9.html