ESI LEVELS COMPETENCY SET
QUESTIONS AND ANSWERS
"IfithinkfiIfipickedfiupfiafibugfioverseas,"fireportsfiafi34-year-
oldfimalefiwhofipresentedfiinfithefiemergencyfidepartmentficomplainingfioffifrequentfiwateryfistools
fiandfiabdominalficramping.fi"IfithinkfiIfiamfigettingfidehydrated."fiTfi98°F,fiRRfi22,fiHRfi112,fiBPfi120
/80,fiSpO2fi100%.fiPainfi6/10.fi-fianswer--
ESIfilevelfi3:fiTwofiorfimorefiresources.fiFromfithefipatient'sfihistory,fihefiwillfirequirefilabsfiandfiIVfiflui
dfireplacement—twofiresources.
Whenfiaskedfiwhyfisheficamefitofithefiemergencyfidepartment,fithefi18-year-
oldficollegefistudentfibeginsfitoficry.fiShefitellsfithefitriagefinursefithatfishefiwasfisexuallyfiassaultedfil
astfinightfiatfianfioff-campusfiparty.fi-fianswer--
ESIfilevelfi3:fiTwofiorfimorefiresources.fiItfilooksfiasfithoughfithisfipatientfihasfiafidisplacedfifracturefia
ndfiwillfineedfiaficlosedfireductionfipriorfitoficastingfiorfisplinting.fiAtfiafiminimum,fihefineedsfix-
raysfiandfianfiorthopedicficonsult.fiThisfipatientfimayfialsofirequirefiproceduralfisedation.fiHowever
,fitherefiarefialreadyfitwofiorfimorefiresources,fisofiitfiisfinotfinecessaryfitofibefioverlyficoncernedfiabo
utficountingfiresourcesfibeyondfitwo.
"Ifidon'tfiknowfiwhat'sfiwrongfiwithfimyfibabyfigirl,"ficriesfiafiyoungfimother.fiShefireportsfithatfiherfi2-
week-
oldfibabyfiisfinotfiactingfirightfiandfiisfinotfiinterestedfiinfieating.fiAsfiyoufibeginfitofiundressfithefibaby,fi
youfinoticefithatfishefiisfilistlessfiandfiherfiskinfiisfimottled.fi-fianswer--
ESIfilevelfi1:fiRequiresfiimmediatefilifesavingfiintervention;fipossiblefiaggressivefifluidfiresuscitati
on.
"Myfipainfimedicationsfiarefinotfiworkingfianymore.fiLastfinightfiIficouldn'tfisleepfibecausefithefipainfi
wasfisofibad,"fireportsfiafi47-year-
oldfifemalefiwithfimetastaticfiovarianficancer.fi"Myfihusbandficalledfimyfioncologist,fiandfihefitoldfim
efitoficomefitofithefiemergencyfidepartment."fiThefipatientfiratesfiherfipainfiasfi9/10.fiVitalfisignsfiarefi
withinfinormalfilimits.fi-fianswer--
ESIfilevelfi2:fiSeverefipainfiorfidistress.fiThisfipatientfineedsfiaggressivefipainfimanagementfiwithfiI
Vfimedications.fiTherefiisfinothingfithefitriagefinurseficanfidofitofidecreasefithefipatient'sfipainfilevel.fi
Thefianswerfitofi"Wouldfiyoufigivefiyourfilastfiopenfibedfitofithisfipatient?"fishouldfibefiyes.
Afi48-year-
oldfimalefitellsfiyoufithatfihefihasfiafihistoryfioffikidneyfistonesfiandfithinksfihefihasfianotherfione.fiHefih
asfirightficostovertebralfianglefipainfithatfiradiatesfiaroundfitofithefifrontfiandfiintofihisfigroin.fiHefiisfin
auseousfibutfitellsfiyoufihefitookfiafipainfipill,fiandfirightfinowfihefihasfiminimalfipain.fiHefideniesfivomit
ing.fiTfi98°F,fiRRfi16,fiHRfi80,fiBPfi136/74,fiSpO2fi100%.fiPainfi3/10.fi-fianswer--
ESIfilevelfi3:fiTwofiorfimorefiresources.fiThefipatientfiisfipresentingfiwithfisignsfiandfisymptomsfioffia
notherfikidneyfistone.fiAtfiafiminimum,fihefiwillfineedfiafiurinalysisfiandfiCTfiscan.fiIffihisfipainfiincreas
, es,fihefimayfineedfiIVfipainfimedication.fiAtfiafiminimum,fitwofiresourcesfiarefirequired.fiIffithefipainfil
evelfiwasfi7/10fiorfigreaterfiandfithefitriagefinurseficouldfinotfimanagefithefipainfiatfitriage,fithefipatien
tficouldfimeetfilevel-2ficriteria.
"Afterfimyfipediatricianfisawfimyfison'sfirash,fihefisaidfiIfihadfitofibringfihimfitofithefiemergencyfidepart
mentfiimmediately.fiHefihasfithisfirashfionfihisfifacefiandfichestfithatfistartedfitoday.fiHefihasfilittlefipin
pointfipurplishfispotsfiheficalledfipetechiae.fiMyfisonfiisfiafihealthyfikidfiwhofihasfihadfiaficoldfiforfiafico
uplefioffidaysfiandfiaficough.fiMyfipediatricianfisaidfihefihadfitofibefisurefinothingfibadfiisfigoingfion.fiW
hatfidofiyoufithink?"fi-fianswer--
ESIfilevelfi2:fiHighfirisk.fiRashesfiarefidifficultfitofitriage,fibutfithefipresencefioffipetechiaefiisfialwaysfi
afihigh-
riskfisituation.fiEvenfiiffithefipatientfilooksfigood,fiitfiisfiimportantfitofirecognizefithatfipetechiaficanfibef
iafisymptomfioffiafilife-threateningfiinfection,fimeningococcemia.
"Herfigrandfatherfipulledfiherfibyfithefiwristfiupfiandfioverfiafibigfipuddle.fiNextfithingfiyoufiknow,fishefii
sficryingfiandfirefusingfitofimovefiherfileftfiarm,"fithefimotherfioffiafihealthyfi3-year-
oldfitellsfiyou.fiVitalfisignsfiarefiwithinfinormalfilimits.fi-fianswer--
ESIfilevelfi4fiorfi5:fiThisficasefiisfianfiexamplefioffivariationsfiinfipracticefiaroundfitheficountry.fiManyfi
emergencyfidepartmentsfiwouldfiexaminefithefichildfiandfithenfiattemptfitofireducefithefidislocationf
ioffithefiradialfiheadfiwithoutfianfix-ray.fiOthersfimayfix-
rayfithefichild'sfiarm,fiwhichfiisficonsideredfionefiESIfiresource.fiRelocationfiisfinotficonsideredfiafire
source.
Afi46-year-
oldfiasthmaticfiinfisignificantfirespiratoryfidistressfipresentsfiviafiambulance.fiThefiparamedicsfirep
ortfithatfithefipatientfibeganfiwheezingfiearlierfiinfithefidayfiandfihadfibeenfiusingfiherfiinhalerfiwithfinof
irelief.fiOnfiherfilastfiadmissionfiforfiasthma,fishefiwasfiintubated.fiVitalfisigns:fiRRfi44,fiSpO2fi93%fio
nfiroomfiair,fiHRfi98,fiBPfi154/60.fiThefipatientfiisfiablefitofianswerfiyourfiquestionsfiaboutfiallergiesfia
ndfimedications.fi-fianswer--ESIfilevelfi2:fiHigh-
risk.fiAnfiasthmaticfiwithfiafipriorfihistoryfioffiintubationfiisfiafihigh-
riskfisituation.fiThisfipatientfiisfiinfirespiratoryfidistressfiasfievidenced,fibyfiherfirespiratoryfirate,fioxy
genfisaturation,fiandfiworkfioffibreathing.fiShefidoesfinotfimeetfitheficriteriafiforfiESIfilevelfi1,firequire
sfiimmediatefilifesavingfiintervention.
Afi56-year-oldfimalefiwithfiafirecentfidiagnosisfioffilate-stagefinon-
Hodgkin'sfilymphomafiwasfibroughtfitofithefiEDfifromfithefioncologyficlinic.fiHefitoldfihisfioncologistfit
hatfihefihadfifacialfiandfibilateralfiarmfiswellingfiandfiincreasingfishortnessfioffibreath.fiThefipatientfi
alsofireportsfithatfihisfisymptomsfiarefiworsefiiffihefiliesfidown.fiVitalfisigns:fiBPfi146/92,fiHRfi122,fiR
Rfi38,fiSpO2fi98%fionfiroomfiair,fitemperaturefinormal.fi-fianswer--
ESIfilevelfi2:fiHighfirisk.fiThisfipatientfiisfidemonstratingfirespiratoryfidistressfiwithfihisfiincreasedfire
spiratoryfiratefiandfidecreasedfioxygenfisaturation.fiSymptomsfiareficausedfibyficompressionfioffit
hefisuperiorfivenaficavafifromfithefitumor.fiItfiisfidifficultfiforfibloodfitofireturnfitofithefiheart,ficausingfie
demafioffithefifacefiandfiarms.
EMSfiarrivesfiwithfiafi28-year-
oldfimalefiwhofiwasfistabbedfiinfithefileftfisidefioffihisfineckfiduringfianfialtercation.fiYoufinoticefiafilarg
efihematomafiaroundfithefiwound,fiandfithefipatientfiisfimoaningfihefican'tfibreathe.fiHRfi110,fiRRfi36
QUESTIONS AND ANSWERS
"IfithinkfiIfipickedfiupfiafibugfioverseas,"fireportsfiafi34-year-
oldfimalefiwhofipresentedfiinfithefiemergencyfidepartmentficomplainingfioffifrequentfiwateryfistools
fiandfiabdominalficramping.fi"IfithinkfiIfiamfigettingfidehydrated."fiTfi98°F,fiRRfi22,fiHRfi112,fiBPfi120
/80,fiSpO2fi100%.fiPainfi6/10.fi-fianswer--
ESIfilevelfi3:fiTwofiorfimorefiresources.fiFromfithefipatient'sfihistory,fihefiwillfirequirefilabsfiandfiIVfiflui
dfireplacement—twofiresources.
Whenfiaskedfiwhyfisheficamefitofithefiemergencyfidepartment,fithefi18-year-
oldficollegefistudentfibeginsfitoficry.fiShefitellsfithefitriagefinursefithatfishefiwasfisexuallyfiassaultedfil
astfinightfiatfianfioff-campusfiparty.fi-fianswer--
ESIfilevelfi3:fiTwofiorfimorefiresources.fiItfilooksfiasfithoughfithisfipatientfihasfiafidisplacedfifracturefia
ndfiwillfineedfiaficlosedfireductionfipriorfitoficastingfiorfisplinting.fiAtfiafiminimum,fihefineedsfix-
raysfiandfianfiorthopedicficonsult.fiThisfipatientfimayfialsofirequirefiproceduralfisedation.fiHowever
,fitherefiarefialreadyfitwofiorfimorefiresources,fisofiitfiisfinotfinecessaryfitofibefioverlyficoncernedfiabo
utficountingfiresourcesfibeyondfitwo.
"Ifidon'tfiknowfiwhat'sfiwrongfiwithfimyfibabyfigirl,"ficriesfiafiyoungfimother.fiShefireportsfithatfiherfi2-
week-
oldfibabyfiisfinotfiactingfirightfiandfiisfinotfiinterestedfiinfieating.fiAsfiyoufibeginfitofiundressfithefibaby,fi
youfinoticefithatfishefiisfilistlessfiandfiherfiskinfiisfimottled.fi-fianswer--
ESIfilevelfi1:fiRequiresfiimmediatefilifesavingfiintervention;fipossiblefiaggressivefifluidfiresuscitati
on.
"Myfipainfimedicationsfiarefinotfiworkingfianymore.fiLastfinightfiIficouldn'tfisleepfibecausefithefipainfi
wasfisofibad,"fireportsfiafi47-year-
oldfifemalefiwithfimetastaticfiovarianficancer.fi"Myfihusbandficalledfimyfioncologist,fiandfihefitoldfim
efitoficomefitofithefiemergencyfidepartment."fiThefipatientfiratesfiherfipainfiasfi9/10.fiVitalfisignsfiarefi
withinfinormalfilimits.fi-fianswer--
ESIfilevelfi2:fiSeverefipainfiorfidistress.fiThisfipatientfineedsfiaggressivefipainfimanagementfiwithfiI
Vfimedications.fiTherefiisfinothingfithefitriagefinurseficanfidofitofidecreasefithefipatient'sfipainfilevel.fi
Thefianswerfitofi"Wouldfiyoufigivefiyourfilastfiopenfibedfitofithisfipatient?"fishouldfibefiyes.
Afi48-year-
oldfimalefitellsfiyoufithatfihefihasfiafihistoryfioffikidneyfistonesfiandfithinksfihefihasfianotherfione.fiHefih
asfirightficostovertebralfianglefipainfithatfiradiatesfiaroundfitofithefifrontfiandfiintofihisfigroin.fiHefiisfin
auseousfibutfitellsfiyoufihefitookfiafipainfipill,fiandfirightfinowfihefihasfiminimalfipain.fiHefideniesfivomit
ing.fiTfi98°F,fiRRfi16,fiHRfi80,fiBPfi136/74,fiSpO2fi100%.fiPainfi3/10.fi-fianswer--
ESIfilevelfi3:fiTwofiorfimorefiresources.fiThefipatientfiisfipresentingfiwithfisignsfiandfisymptomsfioffia
notherfikidneyfistone.fiAtfiafiminimum,fihefiwillfineedfiafiurinalysisfiandfiCTfiscan.fiIffihisfipainfiincreas
, es,fihefimayfineedfiIVfipainfimedication.fiAtfiafiminimum,fitwofiresourcesfiarefirequired.fiIffithefipainfil
evelfiwasfi7/10fiorfigreaterfiandfithefitriagefinurseficouldfinotfimanagefithefipainfiatfitriage,fithefipatien
tficouldfimeetfilevel-2ficriteria.
"Afterfimyfipediatricianfisawfimyfison'sfirash,fihefisaidfiIfihadfitofibringfihimfitofithefiemergencyfidepart
mentfiimmediately.fiHefihasfithisfirashfionfihisfifacefiandfichestfithatfistartedfitoday.fiHefihasfilittlefipin
pointfipurplishfispotsfiheficalledfipetechiae.fiMyfisonfiisfiafihealthyfikidfiwhofihasfihadfiaficoldfiforfiafico
uplefioffidaysfiandfiaficough.fiMyfipediatricianfisaidfihefihadfitofibefisurefinothingfibadfiisfigoingfion.fiW
hatfidofiyoufithink?"fi-fianswer--
ESIfilevelfi2:fiHighfirisk.fiRashesfiarefidifficultfitofitriage,fibutfithefipresencefioffipetechiaefiisfialwaysfi
afihigh-
riskfisituation.fiEvenfiiffithefipatientfilooksfigood,fiitfiisfiimportantfitofirecognizefithatfipetechiaficanfibef
iafisymptomfioffiafilife-threateningfiinfection,fimeningococcemia.
"Herfigrandfatherfipulledfiherfibyfithefiwristfiupfiandfioverfiafibigfipuddle.fiNextfithingfiyoufiknow,fishefii
sficryingfiandfirefusingfitofimovefiherfileftfiarm,"fithefimotherfioffiafihealthyfi3-year-
oldfitellsfiyou.fiVitalfisignsfiarefiwithinfinormalfilimits.fi-fianswer--
ESIfilevelfi4fiorfi5:fiThisficasefiisfianfiexamplefioffivariationsfiinfipracticefiaroundfitheficountry.fiManyfi
emergencyfidepartmentsfiwouldfiexaminefithefichildfiandfithenfiattemptfitofireducefithefidislocationf
ioffithefiradialfiheadfiwithoutfianfix-ray.fiOthersfimayfix-
rayfithefichild'sfiarm,fiwhichfiisficonsideredfionefiESIfiresource.fiRelocationfiisfinotficonsideredfiafire
source.
Afi46-year-
oldfiasthmaticfiinfisignificantfirespiratoryfidistressfipresentsfiviafiambulance.fiThefiparamedicsfirep
ortfithatfithefipatientfibeganfiwheezingfiearlierfiinfithefidayfiandfihadfibeenfiusingfiherfiinhalerfiwithfinof
irelief.fiOnfiherfilastfiadmissionfiforfiasthma,fishefiwasfiintubated.fiVitalfisigns:fiRRfi44,fiSpO2fi93%fio
nfiroomfiair,fiHRfi98,fiBPfi154/60.fiThefipatientfiisfiablefitofianswerfiyourfiquestionsfiaboutfiallergiesfia
ndfimedications.fi-fianswer--ESIfilevelfi2:fiHigh-
risk.fiAnfiasthmaticfiwithfiafipriorfihistoryfioffiintubationfiisfiafihigh-
riskfisituation.fiThisfipatientfiisfiinfirespiratoryfidistressfiasfievidenced,fibyfiherfirespiratoryfirate,fioxy
genfisaturation,fiandfiworkfioffibreathing.fiShefidoesfinotfimeetfitheficriteriafiforfiESIfilevelfi1,firequire
sfiimmediatefilifesavingfiintervention.
Afi56-year-oldfimalefiwithfiafirecentfidiagnosisfioffilate-stagefinon-
Hodgkin'sfilymphomafiwasfibroughtfitofithefiEDfifromfithefioncologyficlinic.fiHefitoldfihisfioncologistfit
hatfihefihadfifacialfiandfibilateralfiarmfiswellingfiandfiincreasingfishortnessfioffibreath.fiThefipatientfi
alsofireportsfithatfihisfisymptomsfiarefiworsefiiffihefiliesfidown.fiVitalfisigns:fiBPfi146/92,fiHRfi122,fiR
Rfi38,fiSpO2fi98%fionfiroomfiair,fitemperaturefinormal.fi-fianswer--
ESIfilevelfi2:fiHighfirisk.fiThisfipatientfiisfidemonstratingfirespiratoryfidistressfiwithfihisfiincreasedfire
spiratoryfiratefiandfidecreasedfioxygenfisaturation.fiSymptomsfiareficausedfibyficompressionfioffit
hefisuperiorfivenaficavafifromfithefitumor.fiItfiisfidifficultfiforfibloodfitofireturnfitofithefiheart,ficausingfie
demafioffithefifacefiandfiarms.
EMSfiarrivesfiwithfiafi28-year-
oldfimalefiwhofiwasfistabbedfiinfithefileftfisidefioffihisfineckfiduringfianfialtercation.fiYoufinoticefiafilarg
efihematomafiaroundfithefiwound,fiandfithefipatientfiisfimoaningfihefican'tfibreathe.fiHRfi110,fiRRfi36
