Emergency Severity Index (ESI): A Triage Tool for Emergency Department
Table 3-1. Examples of Possible High-risk Situations
|System||Demographics, Chief Complaint||ESI 2: Yes/No
88-year-old female with severe right lower quadrant abdominal pain, vital signs stable.
22-year-old male with generalized abdominal pain, nausea, vomiting, and diarrhea for 3 days, vital signs stable.
45-year-old female who has been vomiting blood and is tachycardic.
22- year-old female noticed a spot of blood on toilet paper this a.m. after having a bowel movement. Has a history of hemorrhoids.
|Yes. High risk for acute abdominal emergency which is associated with a high mortality in the elderly.
No. Symptoms are more indicative of gastroenteritis than an acute surgical emergency. Patient is stable to wait.
Yes. High risk for gastrointestinal bleeding and patient can deteriorate rapidly.
No. This patient most likely has a hemorrhoid and this is not a high-risk situation.
|Cardiovascular||35-year-old female with a sudden onset of palpitations, anxious, heart rate of 160, blood pressure of 120/70.
35-year-old female with sudden onset of palpitations, anxious, heart rate of 90, blood pressure of 120/70.
65-year-old female with sudden onset of shortness of breath and discomfort in chest for 3 hours.
45-year-old male with generalized fatigue, chest pain when coughing, productive cough with green sputum, fever and chills for 4 days.
52-year-old male with sudden onset of pain to left foot, a history of diabetes requiring insulin therapy; left foot is cold to touch, and the nurse is unable to palpate a pulse in the foot.
|Yes. High risk for possible supraventricular tachycardia.
No.This patient may be having an anxiety attack.
Yes. High risk for possible myocardial ischemia.
No.This patient has classic non-cardiac symptoms, despite having chest pain.
Yes. High risk for acute arterial occlusion.
|Eye, ENT||65-year-old female with sudden onset of loss of vision.
22-year-old male patient with trauma to eye in a bar fight, unable to open eye.
|Yes. All complaints with sudden loss of vision are high-risk.
Yes. High risk for globe rupture or other trauma.
|General medicine||40-year-old female diabetic with vomiting for 2 days.
69-year-old male who is weak and dizzy, and undergoes regular kidney dialysis.
29-year-old female with a recent history of headaches, blood pressure of 210/120, and no known history of HTN.
55-year-old male with a laceration to the thumb. Blood pressure of 204/102, known history of HTN and admits to skipping a few doses of blood pressure medication, denies other complaints.
|Yes. At high risk for diabetic ketoacidosis which requires rapid evaluation and management.
Yes. High risk for hyperkalemia and other electrolyte imbalances.
Yes. High risk for hypertensive emergency.
No. Patient will not require emergent treatment of his blood pressure, but will require re-evaluation of his anti-hypertensive dose and agents.
|Genitourinary||22-year-old male with sudden onset of severe left testicle pain.
29-year-old female with a 3-day history of urinary frequency and voiding in small amounts.
|Yes. High risk for testicular torsion vs. epididymitis.
No.This patient most likely has a urinary tract infection which does not require rapid evaluation.
24-year-old female, 8 weeks pregnant, left lower quadrant abdominal pain and spotting.
24-year-old female with severe left lower quadrant pain abdominal, denies vaginal bleeding.
32-year-old female with generalized abdominal cramping and vaginal bleeding, 14 weeks pregnant, vital signs stable.
|Yes. High risk for possible ectopic pregnancy.
Yes. High risk for ectopic pregnancy, unless the triage nurse can confirm the absence of pregnancy.
No. Most likely this is a threatened abortion which does not require emergent evaluation with stable vital signs.
|Mental Health||19-year-old female who is combative and hostile.
22-year-old male with suicidal thoughts.
35-year-old female who was brought in by the police, alcohol on breath, unsteady gait, a large laceration to head, slurred speech but oriented.
52-year-old female feeling overwhelmed and requesting a referral to counseling. Denies homicidal or suicidal thoughts. Alert, oriented, and cooperative.
|Yes. High risk for safety and this patient should not be left in the waiting room.
Yes. High risk for patient injury if left alone.
Yes. High risk for a serious head injury.
No.This patient is not at high risk.
|Neurological||35-year-old female with a severe headache, stiff neck, rash, temperature 102.0.
55-year-old male with a sudden onset of worst headache of life after stressful activity.
52-year-old male with sudden onset of slurred speech.
33-year-old male with "pins and needles" feeling to right first and second fingers for several weeks.F
|Yes. High risk for possible meningitis; rapid deterioration is common.
Yes. High risk for subarachnoid hemorrhage.
Yes. High risk for acute stroke.
No. Does not require rapid evaluation.
40-year-old female with lymphoma, currently receiving chemotherapy, and a temperature of 102.2.
66-year-old male with lung cancer, reports increasing shortness of breath over the past few days. Just completed chemotherapy 2 weeks ago.
60-year-old female who cut finger while slicing a bagel. Currently receiving radiation for breast cancer.
|Yes. High risk for neutropenia and infection.
Yes. High risk for pleural effusion, pulmonary embolus and other emergent conditions.
No. Not a high-risk situation.
|Pediatric||9-month-old baby with vomiting and diarrhea. She is able to drink, has a wet diaper, and is fussy and crying tears during triage.
9-month-old baby with vomiting and diarrhea. She is unable to drink, hasn't wet a diaper for several hours, is unable to hold anything down, and has very dry mucous membranes.
6-year-old male with a sudden onset of wheezing that is audible during triage without auscultation, oxygen saturation of 97% on room air, and is in moderate respiratory distress.
14-day-old baby with a fever of 100.8F.
|No. While may be dehydrated, this does not appear to be a high-risk situation.
Yes.This baby is at high-risk.
Yes. Moderate respiratory distress indicates a possible high risk for deterioration.
Yes. Infants in the first 30 days of life with a fever greater than100.4 are at high risk for bacteremia.
|Respiratory||5-year-old female presents with drooling and difficulty swallowing.
25-year-old male with mild wheezing, oxygen saturation of 98% on room air, no obvious respiratory distress. Recent upper respiratory infection.
20-year-old tall thin male with sudden onset of severe shortness of breath after coughing.
|Yes. High risk for an airway management problem such as epiglotitis, peri-tonsillar abscess, foreign body, angioedema.
No.This is not a high-risk situation.
Yes.Tall thin young males are at risk for spontaneous pneumothorax.
|Trauma||45-year-old male involved in a motor vehicle crash immediately prior to arrival. Unable to remember the events, moderately severe headache.
17-year-old male with a stab wound to groin, bleeding controlled.
34-year-old female involved in a low speed motor vehicle crash while driving. 32 weeks pregnant, denies complaints.
6-year-old male fell from the top of the monkey bars today. Reports a 1 minute loss of consciousness at the time. Patient is vomiting, and was sent by pediatrician for head scan.
|Yes. At high-risk for a traumatic brain injury and possible epidural hematoma.
Yes. High risk for vascular injury.
Yes. High risk for maternal and fetal injuries.
Yes. High-risk situation.