ESI Levels Competency Study Guide 2023 with complete
solution
"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.
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.
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-week-old 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.
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.
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.
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 a cough. My
pediatrician said he had to be sure nothing bad is going on. What do you think?"
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.
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.
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.
ESI 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%.
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.
ESI level 5: No resources. This healthy-sounding 11-year-old will be examined by a
physician and then discharged home with appropriate instructions and a prescription if
indicated.
solution
"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.
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.
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-week-old 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.
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.
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.
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 a cough. My
pediatrician said he had to be sure nothing bad is going on. What do you think?"
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.
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.
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.
ESI 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%.
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.
ESI level 5: No resources. This healthy-sounding 11-year-old will be examined by a
physician and then discharged home with appropriate instructions and a prescription if
indicated.
