ESI Levels Competency Set Questions and Answers with complete solutions

"I think I picked up a bug overseas," reports a 34-year-old male who presented in the emergency department complaining of frequent watery stools and abdominal cramping. "I think I am getting dehydrated." T 98°F, RR 22, HR 112, BP 120/80, SpO2 100%. Pain 6/10. - Answer-ESI level 3: Two or more resources. From the patient's history, he will require labs and IV fluid replacement—two resources. When asked why she came to the emergency department, the 18-year-old college student begins to cry. She tells the triage nurse that she was sexually assaulted last night at an off-campus party. - Answer-ESI level 3: Two or more resources. It looks as though this patient has a displaced fracture and will need a closed reduction prior to casting or splinting. At a minimum, he needs x-rays and an orthopedic consult. This patient may also require procedural sedation. However, there are already two or more resources, so it is not necessary to be overly concerned about counting resources beyond two. "I don't know what's wrong with my baby girl," cries a young mother. She reports that her 2-weekold baby is not acting right and is not interested in eating. As you begin to undress the baby, you notice that she is listless and her skin is mottled. - Answer-ESI level 1: Requires immediate lifesaving intervention; possible aggressive fluid resuscitation. "My pain medications are not working anymore. Last night I couldn't sleep because the pain was so bad," reports a 47-year-old female with metastatic ovarian cancer. "My husband called my oncologist, and he told me to come to the emergency department." The patient rates her pain as 9/10. Vital signs are within normal limits. - Answer-ESI level 2: Severe pain or distress. This patient needs aggressive pain management with IV medications. There is nothing the triage nurse can do to decrease the patient's pain level. The answer to "Would you give your last open bed to this patient?" should be yes. A 48-year-old male tells you that he has a history of kidney stones and thinks he has another one. He has right costovertebral angle pain that radiates around to the front and into his groin. He is nauseous but tells you he took a pain pill, and right now he has minimal pain. He denies vomiting. T 98°F, RR 16, HR 80, BP 136/74, SpO2 100%. Pain 3/10. - Answer-ESI level 3: Two or more resources. The patient is presenting with signs and symptoms of another kidney stone. At a minimum, he will need a urinalysis and CT scan. If his pain increases, he may need IV pain medication. At a minimum, two resources are required. If the pain level was 7/10 or greater and the triage nurse could not manage the pain at triage, the patient could meet level-2 criteria. "After my pediatrician saw my son's rash, he said I had to bring him to the emergency department immediately. He has this rash on his face and chest that started today. He has little pinpoint purplish spots he called petechiae. My son is a healthy kid who has had a cold for a couple of days and acough. My pediatrician said he had to be sure nothing bad is going on. What do you think?" - Answer-ESI level 2: High risk. Rashes are difficult to triage, but the presence of petechiae is always a high-risk situation. Even if the patient looks good, it is important to recognize that petechia can be a symptom of a life-threatening infection, meningococcemia. "Her grandfather pulled her by the wrist up and over a big puddle. Next thing you know, she is crying and refusing to move her left arm," the mother of a healthy 3-year-old tells you. Vital signs are within normal limits. - Answer-ESI level 4 or 5: This case is an example of variations in practice around the country. Many emergency departments would examine the child and then attempt to reduce the dislocation of the radial head without an x-ray. Others may x-ray the child's arm, which is considered one ESI resource. Relocation is not considered a resource. A 46-year-old asthmatic in significant respiratory distress presents via ambulance. The paramedics report that the patient began wheezing earlier in the day and had been using her inhaler with no relief. On her last admission for asthma, she was intubated. Vital signs: RR 44, SpO2 93% on room air, HR 98, BP 154/60. The patient is able to answer your questions about allergies and medications. - Answer-ESI level 2: High-risk. An asthmatic with a prior history of intubation is a high-risk situation. This patient is in respiratory distress as evidenced, by her respiratory rate, oxygen saturation, and work of breathing. She does not meet the criteria for ESI level 1, requires immediate lifesaving intervention. A 56-year-old male with a recent diagnosis of late-stage non-Hodgkin's lymphoma was brought to the ED from the oncology clinic. He told his oncologist that he had facial and bilateral arm swelling and increasing shortness of breath. The patient also reports that his symptoms are worse if he lies down. Vital signs: BP 146/92, HR 122, RR 38, SpO2 98% on room air, temperature normal. - AnswerESI level 2: High risk. This patient is demonstrating respiratory distress with his increased respiratory rate and decreased oxygen saturation. Symptoms are caused by compression of the superior vena cava from the tumor. It is difficult for blood to return to the heart, causing edema of the face and arms. EMS arrives with a 28-year-old male who was stabbed in the left side of his neck during an altercation. You notice a large hematoma around the wound, and the patient is moaning he can't breathe. HR 110, RR 36, SpO2 89%. - Answer-ESI level 1: Requires immediate lifesaving intervention. Depending on the exact location penetrating neck trauma can cause significant injury to underlying structures. Based on the presenting vital signs, immediate actions to address airway, breathing, and circulation are required. Intubation might be necessary due to the large neck hematoma, which may expand. An 11-year-old presents to triage with his mother, who reports that her son has had a cough and runny nose for a week. The child is running around the waiting room and asking his mother for a snack. Vital signs are within normal limits. - Answer-ESI level 5: No resources. This healthy-sounding11-year-old will be examined by a physician and then discharged home with appropriate instructions and a prescription if indicated. "I don't know what is wrong with my son," reports the worried mother of a normally healthy eightyear-old male. "He's losing weight and acting so cranky. Last night he was up to the bathroom every hour, and he can't seem to get enough to drink." The child is alert and appropriately. Vital signs: T 98.6°F, RR 30, HR 98, BP 92/78, SpO2 98%. - Answer-ESI level 2: High risk. This patient has an elevated respiratory rate and heart rate. The symptoms of polydipsia and polyuria are two classic signs of diabetic ketoacidosis. "He has had diarrhea for 2 days, and he just started throwing up this morning. This has been going around the family, and he seems to have it the worst. He has been drinking before today, but now he doesn't want anything to drink," reports the mother of a 19-month-old. The toddler is awake and alert but quiet in the mother's arms, and you notice his lips are dry and cracked. Vital signs: T 99°F, RR 30, HR 130, SpO2 100%. - Answer-ESI level 3: Two or more resources. This 19-month-old is dehydrated and will require a minimum of two resources: labs and IV fluids. In addition the physician may order an IV antiemetic.