The Emergency
Severity Index
Jassin M. Jouria, MD
Dr. Jassin M. Jouria is a medical doctor, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serve as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology.
Abstract
One of the main challenges encountered by emergency departments is determining how to appropriately triage patients. Although some systems only take into account a single determining factor, the Agency for Healthcare Research and Quality promotes a system that considers both the acuity of patients’ health care problems as well as the number of resources needed to treat them. This system provides emergency departments with a unique tool to ensure that the most at-risk patients are being seen and treated in the most efficient manner.
Policy Statement
This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology content 0.5 hours (30 minutes).
Statement of Learning Need
Statistics have shown that a majority of U.S. patients wait over 15 minutes in a waiting room and that there is crowding in emergency rooms. Triaging quickly and effectively is a way to avoid unsafe waits and to address needed resources. It is important for emergency department clinicians to be trained in triage in order to determine what patients cannot wait to be treated, and to know the difference between a time sensitive issue to treat a
life-threatening condition and what can be assigned a lesser critical or urgent need for treatment.
Course Purpose
guidelines and best practice principles for emergency triage.
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.
1. Emergency department (ED) clinicians use the Emergency Severity Index (ESI) and its triage algorithm primarily to
a. eliminate all decision-making in the emergency room. b. rate their performance after a patient is discharged. c. rate the intensity of care needed for a patient.
d. determine whether a patient should be admitted to the ED.
2. True or False: The Emergency Severity Index (ESI) rates patient
acuity from level 1 to level 5, with level 5 being the least emergent.
a. True b. False
3. Level 1 of the Emergency Severity Index (ESI) a. does not require immediate physician involvement. b. involves non-lifesaving intervention.
c. a Level 1 patient is always conscious.
d. requires immediate, lifesaving intervention. 4. An apneic condition refers to
a. an abdominal injury.
b. the suspension of breathing that is external. c. a Level 2 rating on the ESI.
d. a constant change in air volume in the lungs.
5. If gas exchange between the environment and lungs are impeded, permanent damage can occur to the _____________ in as few as three minutes without adequate ventilation.
a. heart
b. vascular tissue c. brain
Introduction
The Emergency Severity Index is a tool that includes five levels for use in the triage of patients arriving to an emergency department. Emergency clinicians use the emergency severity index and its triage algorithm to rate the intensity of care needed for patients. This measurement of needed care is referred to as patient acuity. Patient acuity is rated from most emergent (level 1) to least emergent (level 5). The Emergency Severity Index guides evaluation of the resources needed relative to the acuity level. This makes it unique among other assessment tools used to evaluate patients in an
emergency department. The Emergency Severity Index is a valuable tool to ensure that clinical care meets standards of patient safety, as well as to assist emergency staff to make good decisions and to effectively operate an emergency department based on clinical research and best practice.
ESI Triage Fundamentals
The Emergency Severity Index (ESI) triage algorithm has been developed to determine the acuity level or intensity of care needed for a patient.1,2
Funding for the initial development of the ESI index came from the Agency for Healthcare Research and Quality (AHRQ).3 The ESI consists of various levels of care (level 1 to level 5) relative to the severity of emergency conditions and interventions needed to lower morbidity and mortality.
Level 1
Level 1 of the ESI index requires immediate, lifesaving intervention. It can require emergency airway, medications, and hemodynamic interventions; and it can include any of the following conditions.4
• Apnea
• Pulselessness
• Severe Respiratory Distress • SPO2 Less Than 90
• Acute Mental Status Changes • Unresponsiveness
For the above conditions, intubation will be required to support resuscitation efforts. Intubation involves a process of inserting an endotracheal (ET) tube through the mouth and into the airway so that the patient can be placed on a ventilator for assistance with breathing. The ET tube is connected to a ventilator for breathes to be delivered since the patient is unable to breathe independently or without assistance.5
Apnea or an apneic condition refers to the suspension of breathing that is external. There is no movement of the muscles involved in respiration during apnea. The volume in the lungs does not change. Depending on the level of airway expansion, gas exchange between the environment and lungs could be impeded. Permanent damage can occur to the brain in as few as three minutes without adequate ventilation. Death can occur after a few more minutes unless ventilation is restored.6
When considering the ESI level it’s important for Emergency Department (ED) staff to understand its purpose. As mentioned, the ESI allows ED staff to evaluate resources needed relative to patient acuity in order to safely provide patient care. A triage team member (generally a nurse) starts by looking at the patient acuity level only. If a patient is not at a level 1 or 2 on the ESI, the triage team member goes on to evaluate expected resources needed. The determination is then made whether the patient is level 3, 4, or
5. The use of the ESI should be by clinicians with experience in emergency department triage, and is meant for use by a clinician who has been trained to triage ED patients.7
Triage is a process where trained clinicians determine the priority of ED treatment for patients. It is based on the severity of patient condition. To triage effectively clinicians must attempt to use ED resources that may be insufficient for the number of patients requiring immediate treatment. The triage staff determine the priority of treatment in an ED.8 Triage staff are assigned to evaluate patient acuity by determining stability of vital functions and the potential threat to life, an organ or limb. An estimation is made of the need for resources based on previous experiences with patients who have similar complaints and injuries. Triage staff are trained to understand: 1) Resources needed to meet patient care requirements, 2) Resources
needed based on admission, transfer, and discharge requirements of patient care, 3) The 5 ESI levels based on the ESI algorithm, and 4) That ESI levels do not overlap. A patient is in one and only one of the evaluation levels. Evaluation at Level 1
Triage staff should be aware of other algorithms used in emergency care. A medical algorithm uses a systematic approach to a treatment and includes a decision tree. This means if symptom A or B is observed then a particular treatment is indicated. These algorithms can be tools that reduce uncertainty of evaluation and treatment in healthcare settings.9 The ESI algorithm uses an approach similar to other medical algorithms used in emergency care. These include algorithms involving basic life support and advanced cardiac life support. While moving through each step of the process of evaluation, clinicians must answer specific questions and gather particular data. A decision is then made relative to triage. The ESI algorithm shows major
decision points. When considering the ESI algorithm there are four decision points: A, B, C, and D.10 These are shown in the Tables below.
A: Immediate Intervention
Immediate intervention is focused on lifesaving measures. What is included is
emergency medication or airway issues and hemodynamic intervention. Also included are conditions requiring intubation such as already intubated, apnea, SPO2 less than 90, pulseless, respiratory distress, unresponsive, and acute changes in mental health. What is not included is an intervention such as an IV, ECG, labs, supplemental O2, or
monitors.
Unresponsiveness is defined as a patient who 1) is nonverbal plus not following commands, and 2) requires a stimulus.
B: High Risk Situation
Severe pain or distress is determined by observation and/or when a patient rates pain at equal to or greater than 7 on a 0-10 scale.
C: Resources
Individual tests are not counted, but the number of different resources needed is
counted. For example, one resource would be a lab test that included electrolytes, CBC, and coagulation studies. Two resources would be a CT scan and a CBC.
Resource Not Resource
Lab tests – blood, urine History
ECG Physical testing (point of care)
Xray CT MRI ultrasound angiography
IV fluids for hydration Saline or heplock
Specialty consultation Phone call to primary care physician IV or IM or nebulized medication
Tetanus immunization Prescription refill Crutches
Splints/Slings Simple wound care (dressings, recheck)
Simple procedure = 1 (Foley catheter) Simple procedure = 1 (laceration repair) Complex procedure = 2 (conscious sedation)
Consider the procedure of Foley catheter insertion, for example, which is counted as a resource and considered as a simple procedure. Information about 1) the basic steps to initiate a Foley catheter must be included when 2) triaging according to the ESI.11 Foley catheter insertion is reviewed below.
Foley Catheter:
• It is a thin and sterile tube. It is inserted into the bladder for draining urine.
• Indwelling catheter is another term used as typically the catheter is left in place for some time.
• A balloon on one end holds the catheter in place. The balloon is filled with sterile water. This keeps the catheter from being removed from the bladder. Urine drains into a tube and in the bag.
• Catheterization is the process to insert the catheter.
Some of the disorders, problems and necessary procedures considered during Triage that may require a Foley catheter are listed below.
• Obstruction of urethra due to a condition such as prostate cancer, narrowing of the urethra, or prostate hypertrophy.
D: Danger Zone Vital Signs
Can place patient into level 2 if exceeding any vital sign evaluation. Pediatric fever conditions include these considerations.
Age of patient Level
1 to 28 days 2 if temperature is higher than 38.0 degrees C/100.4 degrees F 1 to 3 months 2 if temperature is higher than 38.0 degrees C/100.4 degrees F 3 months to 3 years 3 if temperature is higher than 39.0 degrees C/100.2 degrees F
• Urine monitoring of a critically ill person.
• Urine retention due to straining to urinate, urinary hesitancy, decrease in force of the urinary stream, interruption of urinary stream, and sensation of incomplete emptying.
• Collection of sterile urine specimens for diagnoses
• Bladder dysfunction that is nerve related as after spinal trauma
The example of Foley catheter insertion is just one example of how
emergency interventions influence decisions and triage levels. Given any patient injury or diseased condition, as ED clinicians go through each step of the ESI process specific questions are answered and information gathered. A decision can then be made about the triage level.
Using the decision points of A, B, C, and D a patient is placed into a triage level. These levels range from 1 to 5. The experienced triage clinician starts at the top of the algorithm of the ESI and can often move quickly from one decision point to the next. Four key decision questions are shown below.9
A: Does the patient require immediate intervention that is lifesaving? B: Is this a patient who should not wait?
C: How many resources does this patient need? D: What are the vital signs for the patient?
As the triage clinician answers the questions, the right ESI level is arrived at for the patient. The Decision Points are further explained below.
Decision Point A: Immediate Intervention?
The first question is straightforward; the patient is asked if an intervention is needed, and determination is made whether the needed intervention is
lifesaving. A “yes” answer at level 1 indicates a lifesaving intervention is needed.
The triage clinician is required to answer the question of whether the patient is dying. Level 1 is determined by asking the following questions to
determine whether the patient requires an immediate lifesaving intervention. Is There A Patent Airway?
A patent airway can be crucial to the health of a patient, and increases survival rates. A patent airway means the patient can inhale oxygen and exhale CO2. The airway is open and clear. Alternatively, the patient could have trouble breathing. In that case, clinicians should administer oxygen to the patient if needed. If a person is talking, there is likely a patent airway. If needed, the patient can use a face mask, nebulizer, or other device to help breathe.12
The next questions to ask are listed below. 1. Is the patient breathing?
2. Does the patient have a pulse?
3. Is there a concern about the pulse rate, quality, and rhythm?
4. Was the patient intubated before coming to the hospital? Was this due to issues such as maintaining a patent airway, adequate oxygen
saturation, or spontaneous breathing?
5. Are there concerns about the patient being able to deliver oxygen adequately to tissues?
6. Does the patient need medication immediately?
7. Does the patient need volume replacement of blood or other hemodynamic intervention?
The clinician should also ask whether the patient meets criteria of: 1) Already intubated, 2) Apneic, 3) Pulseless, 4) Experiencing severe
respiratory distress, 5) SpO2 under 90 percent, 6) Acute mental status changes, and 7) Unresponsive.
A triage clinician can predict the need of lifesaving intervention that is immediate. When a patient is apneic there is suspension of breathing. The muscles involved in inhalation do not move during apnea. Airways could be blocked, and there might not be gas exchange in the lungs.13 When apnea exists and in some cases during rapid sequence intubation, an option can be apneic oxygenation.14
With an SpO2 level below 90 percent there is a concern of hypoxemia. This refers to oxygen saturated hemoglobin as compared to total hemoglobin. The body needs a specific amount of oxygen in the blood. Normally, this should be at 95-100 percent. If the level goes below 80 percent, brain, heart, and other organ function could suffer. Lifesaving interventions that may be initiated are 1) secure an airway, 2) support circulation, 3) maintain breathing, and 4) address a change in the level of consciousness that is major.15 An intervention that is not considered lifesaving includes those that are either therapeutic and/or diagnostic.
Clinicians are trained to understand that in an ESI level 1 the patient is arriving at the emergency department in a condition that is unstable, and that without immediate care the patient could die. Emergency clinical help must therefore be immediate. Clinical staffing is needed to be able to provide critical care. Immediate lifesaving and non-lifesaving interventions that ED staff are trained to provide are listed below.16
Non-pharmacological Interventions Airway/Breathing Lifesaving: • Bag-valve-mask ventilation • Intubation • Surgical airway
• Emergent Continuous positive airway pressure (CPAP) • Emergent Bi-level positive airway pressure (BiPAP)
Non-lifesaving: • Oxygen administration • Nasal cannula • Non-rebreather Electrical Therapy Lifesaving: • Defibrillation • Emergent cardioversion • External pacing Non-lifesaving: Cardiac monitor Procedures Lifesaving:
• Chest needle decompression • Pericardiocentesis
• Intraosseous access Non-lifesaving: • Diagnostic Tests • ECG • Labs • Ultrasound
• FAST (Focused abdominal scan for trauma)
Hemodynamics Lifesaving:
• Significant IV fluid resuscitation • Blood administration
• Control of major bleeding
Non-lifesaving: • IV access
• Saline lock for medications
Ventilation
Bag-valve-mask (BVM) ventilation is an emergency skill that is essential as a basic airway management technique. It allows for ventilation and
oxygenation of patients until a more definitive airway is established.17 It is an option when endotracheal intubation is not possible. It can be the only option for airway management for an emergency medical clinician. For prehospital airway support for a pediatric application, BMV can be the best option. It is also used for ventilation in an operating room when no
intubation is required.
Noninvasive ventilation involves the use of CPAP and BiPAP. CPAP refers to
continuous positive airway pressure and BiPAP refers to bi-level positive airway pressure. This ventilation modality supports breathing with a patient who has undergone surgery and intubation. Noninvasive ventilation is used for adult respiratory management. It is seen in emergency department and intensive care unit settings. It is also seen in pediatric applications of
treatment.18 With noninvasive ventilation the adverse effect of invasive ventilation is avoided. Patient comfort is an advantage. An artificial airway is not inserted yet mechanically assisted breaths are delivered. It provides ventilator support both in- and outside of an Intensive Care Unit (ICU). Two techniques are negative pressure and positive pressure ventilation. CPAP and BiPAP each provide positive pressure ventilation that is continuous. With high flow nasal cannula therapy, a patient uses an air/oxygen blender, active humidifier, heated circuit, and nasal cannula. It delivers medical air that is heated and humidified. Delivery is at 60 L/min of flow. It can be a respiratory support technique for patients who are critically ill.19
A nonrebreather mask – also known as a nonrebreather and non-breather facemask – helps with delivery of oxygen therapy to patients. When in use, a patient can breathe unassisted. A nasal cannula can be set at low flow while the non-breather mask provides a higher oxygen concentration. Information and instructions for use about this mask is listed below.20
• The mouth and nose of a patient are covered by the mask.
• The mask attaches through an elastic cord around the head of the patient.
• The mask has an attached reservoir bag, typically, with a capacity of 1 liter that connects to a bulk oxygen system or external oxygen tank.
• Before placing the mask on a patient, the reservoir bag is inflated to more than 2/3 oxygen. A rate of 15 L/minute is used.
• About a third of the air is depleted from the reservoir as a patient inhales, and then the air is replaced from the oxygen supply. Cardiac Defibrillation and Cardioversion
The heart's electrical system controls the timing of a person’s heartbeat by sending an electrical signal through the heart cells. The signals that
determine heartbeat start at the upper right heart chamber. With atrial fibrillation, a very fast and irregular signal through both upper heart chambers occurs, resulting in a fast irregular heart rhythm.
Cardioversion is a way to restore a regular heart rhythm if a heart has an irregular rhythm (arrhythmia) or is beating too fast. An arrhythmia can
prevent proper blood circulation to the brain or heart. Cardioversion can help in treating atrial flutter, ventricular tachycardia, and atrial tachycardia.
Medication may be used to bring back a regular heartbeat, also known as pharmacologic (or chemical) cardioversion.
Cardiac Defibrillator:
Use of a cardiac defibrillator for a life-threatening arrhythmia can be
lifesaving. The defibrillator provides an electric current – sometimes called a counter shock – to the heart to end the dysrhythmia. When the heart muscle is shocked, depolarization of a large section of heart muscle occurs; and, the cardiac pacemaker then reestablishes the normal rhythm.
Types of defibrillators include external, implanted (cardio-defibrillator) and tranvenous.34
Electrical Cardioversion:
Electrical cardioversion also involves an electric shock.21 But with
cardioversion the shock is synchronized with the cardiac cycle, whereas with defibrillation synchronization is not needed. Cardioversion is used to end a cardiac dysrhythmia with poor blood perfusion. An example would be supraventricular tachycardia.
Needle Chest Decompression and Pericardiocentesis
Needle chest decompression may be used to relieve intrathoracic pressure. The procedure involves needle thoracentesis. It is a lifesaving procedure that may be given for the following reasons.22
• Accumulation of air under pressure located in pleural space
• When injured tissue forms a 1-way valve and allows air to enter the pleural space with prevention of air escaping naturally
• Tension pneumothorax
• A condition that can progress to cardiovascular collapse and, if untreated, death
With pericardiocentesis, aspiration of fluid from the pericardial space (surrounding the heart) is done. If a patient has cardiac tamponade the procedure of pericardiocentesis can be lifesaving. This is true even if it
complicates an acute aortic dissection and when the option of cardiothoracic surgery is not available. Aspects of cardiac tamponade are that it 1) is a life-threatening and time sensitive condition, 2) requires prompt management, 3) can include hypotension, a quiet heart, and increased venous pressure, and 4) can include acute intrapericardial hemorrhage.
The emergency bedside thoracotomy is an effort to save the life of patients with a chest injury. It has been in use since 1900 in emergency
departments. Some statistics show it has over 50% survival rate.24
Complications after a chest injury can include shock due to the condition of the heart vasculature, tension pneumothorax, and cardiac tamponade. Some reasons for performing a thoracotomy are control of hemorrhage,
management of cardiac tamponade, preventing air embolism, repairing a cardiac injury, repairing a pulmonary injury.25
Intraosseous Vascular Access
Intraosseous vascular access was introduced in the 1920’s for intravenous catheter access through a bone marrow cavity. By 1980, intraosseous (IO) vascular access was used for rapid fluid infusion during resuscitation. It is used for children and adults. Use with newborns could be faster than access via umbilical veins. The technique is recommended for children after two attempts at intravenous access that is not successful or during circulatory collapse. It is recommended if venous access is not reliable and quick.26
Electrocardiogram and Sonogram
An electrocardiogram (ECG) is a test that records the electrical activity of the heart. When the procedure is completed, electrodes are placed to the arms, chest, and legs. Generally, hair is clipped or shaved to make the electrodes adhere. The number of patches could vary to display an ECG graph and test result.The ECG image will help clinicians to identify a normal versus abnormal QRS complex.27
A sonogram, which is an ultrasound scan, can be used to detect problems in the heart, liver, kidney, abdomen, and womb. An ultrasound device uses
high frequency sound waves. These waves create an image of the inside of the body. It uses no radiation and is considered safe. An ultrasound scan can also be helpful for a surgeon in performing a biopsy in certain situations.28
FAST
The term FAST means focused assessment with sonography for trauma. It originally meant ‘focused abdominal scan for trauma’ when originally coined to describe ultrasound exams to evaluate a patient who was injured.
Ultrasound can provide an initial screen exam in a trauma patient, and also describes a standard set of exams. An ultrasound is used in addition to other imaging studies. These other studies can help identify injuries in patients with, for example, thoracic or abdominal issues. A FAST ultrasound
evaluation, in addition to an initial evaluation, may be invaluable during resuscitation efforts for a trauma patient.
Emergency scenarios where other diagnostic imaging studies might be incorporated into patient care include: 1) if a patient is unstable, has no visible source of bleeding, and initial ultrasound has shown no
intraperitoneal fluid, an angiography may be useful, 2) ultrasound of a pelvic fracture may not show as much as another imaging modality can in a case of pelvic bleeding, and 3) if a patient is stable, an additional CT scan can help with a diagnosis.29
Pharmacological Intervention
Medications typically used in an emergency room are listed here. Some are considered lifesaving and some non-lifesaving.
Lifesaving: • Naloxone • D50 • Dopamine • Atropine • Adenocard Non-lifesaving: • ASA • IV nitroglycerin • Antibiotics • Heparin • Pain medications
• Respiratory treatments with beta agonists
For drugs that can be lifesaving and used in an emergency room, clinicians need to be readily able to access drug information about the medication. A general reference of emergency drugs is included below.30-33
Adenocard
Generic Name: adenosine
Brand Name: Adenocard and Adenoscan
Adenocard is used for treating irregular heartbeat. Certain brands are used during a stress test. Adenocard is a nucleoside and antiarrhythmic. It works to treat irregular heartbeat and slows the electrical conduction in the heart, normalizing heart rhythm, or slowing heart rate. It can help during a stress test as it improves blood flowing to the heart.
Reasons not to use Adenocard include if a patient has 1) breathing problems such as asthma, 2) an allergy to an ingredient in Adenocard, 3) second or third degree heart block plus do not have an artificial pacemaker, and 4) sinus node disease such as sick sinus syndrome plus do not have an
artificial pacemaker.
Before using Adenocard, it should be known whether the patient has certain medical conditions that may contraindicate use of or interact with the drug, such as pregnancy or planning to become pregnant, breast-feeding, taking any prescription or nonprescription medication, taking herbal preparation or dietary supplements, allergies to medication, food or other substances, history of seizures, blood vessel problems, heart problems, low blood volume, and lung or breathing problems (such as emphysema, bronchitis).
Some medications can interact with Adenocard, such as:
• Aminophylline (the risk of seizures may be increased) • Beta-blockers (such as metoprolol)
• Digoxin, diltiazem, or verapamil (the risk of irregular heartbeat • may be increased)
• Carbamazepine or dipyridamole (they may increase the risk of Adenocard's side effects)
• Methylxanthines (such as caffeine, theophylline because they may decrease Adenocard's effectiveness)
Adenocard is given as an injection. Some recommendations and safety concerns include:
• Bad and even deadly heart problems such as irregular heartbeat after giving the drug.
• Avoiding drinks and food with caffeine before taking the drug. This includes coffee, tea, cocoa, cola, and chocolate.
• While using the drug a patient should have blood pressure measures, ECGs, and lab tests. The test helps monitor the condition of the patient and checks for side effects.
• Side effects can include stomach pain, dizziness, flushing, headache, and lightheadedness.
• Several side effects can include severe allergic reaction, chest pain, fainting, confusion, fast heartbeat, slow heartbeat,
irregular heartbeat, seizure, one sided weakness, shortness of breath, wheezing, speech problems, throat pain, and vision problems. Severe allergic reaction can include itching, hives, rash, difficulty breathing, tightness of the chest or throat, swelling of the tongue, face, lips, or mouth.
Dopamine
Generic Name: dopamine (injection) Brand Names: Intropin
Dopamine is a medication form of a chemical that occurs naturally in the body. Improvement of the heart pump strength and blood flow to the kidneys is how the medication works.
Dopamine is injected intravenously into the body. It is used to treat conditions such as low pressure when a patient is in shock that could be caused by a serious medical condition such as kidney failure, heart failure, heart attack, trauma, and surgery.
Before the patient receives dopamine, clinicians should record any of the following conditions.
• pheochromocytoma - tumor of the adrenal gland • history of blood clots
• hardening of arteries • circulation problems • diabetes • frostbite • asthma • sulfite allergy • Buerger’s disease
All the prescription and over-the-counter medications used be recorded, including use of an MAO inhibitor such as furazolidone (Furoxone),
isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam, Zelapar), or tranylcypromine (Parnate).
It is not known if Dopamine harms an unborn baby or passes into breast milk or harms a nursing baby.
When administered intravenously, the clinician should be alert to whether the patient is having any burning, pain, or swelling around the IV needle when dopamine is injected. Additionally, while receiving dopamine, the patient should be observed closely including vital signs, breathing, blood pressure, kidney function, and oxygen levels. To check for harmful effects, blood cells and kidney function should be tested often.
Dopamine side effects can include an allergic reaction such as difficulty breathing, hives, and swelling of the face lips, tongue, or throat. As
mentioned, serious side effects include burning and pain, as well as localized swelling, pounding heartbeat, chest pain, swelling of ankles or feet, urinating less than usual, painful urination, cold feeling, numbness, weak or shallow breathing, and skin changes in the feet or hands. Other side effects could include nausea, vomiting, chills, and feeling anxious.
The usual adult dose of Dopamine for nonobstructive oliguria includes: • Initial dose: 1 to 5 mcg/kg/min by continuous IV infusion.
• Titrate to desired response; administration at rates greater than 50 • mcg per kg per minute have been used safely in serious situations.
The usual adult dose of Dopamine for shock includes:
• Initial dose: 1 to 5 mcg/kg/min by continuous IV infusion.
• Titrate to desired response; administration at rates greater than 50 • mcg/kg/minute have been used safely in serious situations.
The usual pediatric dose for nonobstructive oliguria includes:
• Age less than 1 month: 1 to 20 mcg/kg/min by continuous IV infusion,
• titrated to desired response.
• Age 1 month or older: 1 to 20 mcg/kg/min by continuous IV infusion, titrated to desired response. Maximum dose 50 mcg/kg/min.
The hemodynamic effects of dopamine are dose dependent:
• Low dosage: 1 to 5 mcg/kg/minute, increased renal blood flow and urine output
• Intermediate dosage: 5 to 15 mcg/kg/minute, increased renal blood flow, heart rate, cardiac contractility, cardiac output, and blood pressure
• High dosage: greater than 15 mcg/kg/minute, alpha-adrenergic effects begin to predominate, vasoconstriction, increased blood pressure
The usual pediatric dose for shock includes:
• Age less than 1 month: 1 to 20 mcg/kg/min by continuous IV infusion,
• titrated to desired response
• Age 1 month or older: 1 to 20 mcg/kg/min by continuous IV infusion,
• titrated to desired response. Maximum dose 50 mcg/kg/min
Medications the patient may be taking should be noted, such as: • droperidol (Inapsine)
• epinephrine (EpiPen, Adrenaclick, Twinject, and others) • haloperidol (Haldol)
• midodrine (ProAmatine) • phenytoin (dilantin) • vasopressin (Pitressin) • diuretic medication
• an antidepressant such as amitriptyline (Elavil, Vanatrip, Limbitrol), • doxepin (Sinequan, Silenor), nortriptyline (Pamelor), and others • a beta blocker such as atenolol (Tenormin, Tenoretic), carvedilol
(Coreg), labetalol (Normodyne, Trandate), metoprolol (Dutoprol, Lopressor, Toprol), nadolol (Corgard), propranolol (Inderal, InnoPran), sotalol (Betapace), and others
• cough or cold medicine that contains an antihistamine or decongestant
• ergot medicine such as ergotamine (Ergomar, Cafergot, Migergot), dihydroergotamine (D.H.E. 45, Migranal), ergonovine (Ergotrate), or methylergonovine (Methergine)
• a phenothiazine such as chlorpromazine (Thorazine), fluphenazine (Permitil, Prolixin), perphenazine (Trilafon), prochlorperazine (Compazine, Compro), promethazine (Pentazine, Phenergan, Anergan, Antinaus), thioridazine (Mellaril), or trifluoperazine (Stelazine)
Other drugs can interact with dopamine. Over the counter and prescription drugs patients may be taking should be known. This includes herbal
products, vitamins, minerals, and over the counter drugs.
Atropine
Generic Name: Atropine sulfate Dosage Form: injection
The antispasmodic action of this drug can help in spastic conditions of the gastrointestinal (GI) tract and pylorospasm. For ureteral and biliary colic, atropine with morphine could be indicated. Atropine relaxes the colon and upper GI system during needed hypotonic radiography.
Small doses inhibit bronchial and salivary secretions. Moderate doses dilate the pupil, inhibit accommodation and increase the heart rate. Larger doses decrease motility of the urinary and GI system. Very large doses inhibit gastric acid secretion.
Atropine sulfate injection can be given parenterally as a pre-anesthetic medication. This is for surgical patients to reduce bronchial and salivation secretions. It can also be used during inhalation anesthesia.
In poisoning such as with use of certain insecticides and chemical warfare nerve gas, large doses of atropine relieve muscarine-like symptoms and central system manifestations. It is used also as an antidote to mushroom poisoning due to muscarine in certain species.
Information about atropine includes:
• It rarely occurs in plants. It must be prepared by synthesis. • It is usually used in the form of atropine sulfate.
• Large doses may block nicotinic receptors at the neuromuscular junction.
Contraindications include patients with:
• history of hypersensitivity to the drug.
• narrow-angle glaucoma, and adhesions (synechiae) between the iris and lens of the eye.
• tachycardia, and unstable cardiovascular status in acute hemorrhage.
• GI issues such as obstructive disease (for example, achalasia, pyloroduodenal stenosis, or pyloric obstruction, cardiospasm), paralytic ileus, intestinal atony of the elderly or debilitated patient, severe ulcerative colitis, toxic megacolon complicating ulcerative colitis, and hepatic disease.
• obstructive uropathy (for example, bladder neck obstruction due to prostatic hypertrophy), and renal disease.
A warning exists in the presence of high environmental temperature, as heat prostration can occur with anticholinergic drug use (fever and heat stroke due to decreased sweating). Diarrhea may be a symptom of incomplete intestinal obstruction, especially in patients with ileostomy or colostomy. Treatment of diarrhea with these drugs is not appropriate and is possibly harmful.
Situations where dosing, safety, and precautions should be considered includes:
• Elderly patients could react with excitement, agitation,
drowsiness and other untoward manifestations to even small doses of anticholinergic drugs.
• Use with a patient with gastric ulcer may produce a delay in gastric emptying time and may complicate such therapy (antral stasis).
• Atropine may produce drowsiness, dizziness or blurred vision.
Use atropine with caution in the following conditions: • CNS: Autonomic neuropathy
• Ocular: Glaucoma, light irides; if there is mydriasis and
photophobia, dark glasses should be worn. Atropine should be used with caution in patients over 40 years of age because of the increased incidence of glaucoma.
• GI: Hepatic disease, early evidence of ileus, as in peritonitis, ulcerative colitis (large doses may suppress intestinal motility and precipitate or aggravate toxic megacolon), hiatal hernia associated with reflux esophagitis (anticholinergics may aggravate it).
• GU: Renal disease and prostatic hypertrophy; patients with prostatism can have dysuria may require catheterization • Endocrine: Hyperthyroidism
• Cardiovascular: Coronary heart disease, congestive heart failure, cardiac arrhythmias, tachycardia, and hypertension.
• Usage in biliary tract disease: The use of atropine should not be relied upon in the presence of complication of biliary tract
disease.
• Special risk patients: Atropine should be used cautiously in
infants, small children and persons with Down’s syndrome, brain damage or spasticity.
• Pulmonary: Debilitated patients with chronic lung disease, reduction in bronchial secretions can lead to inspissation and formation of bronchial plugs. Atropine should be used cautiously in patients with asthma or allergies.
Drug interactions include:
• Antihistamines, antipsychotics, antiparkinson drugs, alphaprodine, buclizine, meperidine, orphenadrine,
benzodiazepines and tricyclic antidepressants may enhance the anticholinergic effects of atropine and its derivatives.
• Nitrates, nitrites, alkalinizing agents, primidone, thioxanthenes, methylphenidate, disopyramide, procainamide and quinidine may also potentiate side effects. Monoamine oxidase inhibitors block detoxification of atropine, and thus, potentiate its actions.
• Concurrent long-term therapy with corticosteroids or haloperidol may increase intraocular pressure.
• Atropine may antagonize the miotic actions of cholinesterase inhibitors.
• The bronchial relaxation produced by sympathomimetics is enhanced by Atropine.
Naloxone
Generic Name: naloxone Brand Names: Evzio, Narcan
Information about uses of Naloxone include:
• Naloxone blocks or reverses the effects of opioid medication, including extreme drowsiness, slowed breathing, or loss of consciousness. An opioid is sometimes called a narcotic.
• Naloxone is used to treat a narcotic overdose in an emergency situation. This medicine should not be used in place of
emergency medical care for an overdose.
• Naloxone is also used to help diagnose whether a person has used an overdose of an opioid.
Other precautionary information about the drug includes: 1) The clinician should know if the patient is pregnant or breast feeding, 2) Drinking alcohol can increase certain side effects of naloxone, 3) Naloxone may impair
thinking or reactions, 4) If a patient is using naloxone and any narcotic pain medication, the pain, 5) Relieving effects of the narcotic will be reversed by receiving naloxone.
Additionally, the clinician should note whether the patient’s allergies, history of heart disease, and whether the patient is pregnant or nursing a baby.
The signs of an opioid overdose in the patient should be noted. Overdose symptoms may include:
• slowed breathing, or no breathing
• very small or pinpoint pupils in the eyes • slow heartbeats
• extreme drowsiness, especially if unable to wake the person from sleep
Atropine
Each medication injector is for one use only. After one use the auto-injector should be thrown out, even if there is still some medicine left in it after injecting a dose.
Naloxone should be stored at room temperature away from moisture and heat. The auto-injector should be kept in its outer case until ready for use. The medicine should not be used if it has changed colors or has particles in it.
Naloxone side effects include an allergic reaction, such as hives, difficult breathing, swelling of the face, lips, tongue, or throat.
Because naloxone reverses opioid effects, this medicine may cause sudden withdrawal symptoms such as:
• nausea, vomiting, diarrhea, stomach pain • fever, sweating, body aches, weakness
• tremors or shivering, fast heart rate, pounding heartbeats, increased blood pressure
• goosebumps, shivering • runny nose, yawning
• in babies younger than 4 weeks old - seizures, crying, stiffness, overactive reflexes.
The usual adult dose for opioid overdose includes:
• 0.4 to 2 mg/dose IV/IM/subcutaneously. May repeat every 2 to 3 minutes as needed. Therapy may need to be reassessed if no response is seen after a cumulative dose of 10 mg.
• Continuous infusion: 0.005 mg/kg loading dose followed by an infusion of 0.0025 mg/kg/hr.
The usual pediatric dose for opioid overdose for infants, children, and adolescents include:
Opioid intoxication (full reversal):
• Is by intravenous (IV), the preferred route, or intraosseous (IO); may be administered intramuscularly (IM), subcutaneous (SQ), or by
endotracheal tube (ET) route, but onset of action may be delayed, especially if patient has poor perfusion. ET preferred if IV or IO route not available; doses may need to be repeated.
• Infants and Children less than or equal to 5 years or less than or equal to 20 kg: administer 0.1 mg/kg/dose, repeat every 2 to 3 minutes if needed, and may need to repeat doses every 20 to 60 minutes.
• Children greater than 5 years or greater than 20 kg and Adolescents: 2 mg/dose, and, if no response, repeat every 2 to 3 minutes; may need to repeat doses every 20 to 60 minutes.
Endotracheal (ET): the optimal endotracheal dose is unknown, and the current expert recommendations are 2 to 3 times the IV dose.
Manufacturer recommendations: IV (preferred), IM, Subcutaneous: • Initial: 0.01 mg/kg/dose; if no response, a subsequent dose of 0.1
mg/kg may be given
• If using IM or Subcutaneous route, dose should be given in divided doses.
Continuous IV infusion:
• Children: If continuous infusion is required, the initial dosage/hour should be calculated based on the effective intermittent dose used and duration of adequate response seen; the dose should be titrated, and a range of 2.5 to 160 mcg/kg/hour has been reported. Continuous infusion should be tapered gradually to avoid relapse.
Respiratory depression:
• Pediatric Advanced Life Support (PALS): Give IV: 0.001 to 0.005 mg/kg/dose; titrate to effect
• Manufacturer recommendations: Initial: 0.005 to 0.01 mg/kg; repeat every 2 to 3 minutes as needed based on response.
Other drugs may interact with naloxone, including prescription and over-the-counter medicines, vitamins, and herbal products. Clinicians should be alert to all medicines used by patients.
Level 1 Emergency Department Interventions
Level 1 of the ESI requires immediate medical involvement and evaluation is required to help the patient who is critically ill. Technical interventions that are immediate and lifesaving include obtaining oxygen saturation (spO2) and evaluating respiratory status. A patient can still be breathing with a SpO2 less than 90 percent or with severe respiratory distress. However, the
patient needs an immediate intervention to maintain oxygenation status and an airway. Medical clinicians will need to order medication, such as for rapid sequence intubation or other interventions to maintain breathing and the airway.
Oxygen saturations are trended using a pulse oximeter. The measurement is designated as SpO2 or peripheral oxygen saturation. The pulse oximeter is a device that clips to the body, such as the finger, earlobe and infant’s foot.35
Rapid sequence intubation (also called rapid sequence induction) is used when a patient is at risk of airway compromise. Management of the airway is an important procedure for the emergency team. Failure to provide an
airway can be fatal for the patient. A patient who needs intubation can have an inability to maintain airway patency, failure to ventilate, failure to
oxygenate, or inability to protect against aspiration.36,37
For a patient with chest, pain level 1 considerations need to be kept in mind during clinical evaluation and determination of lifesaving intervention(s). A patient meets level 1 and requires immediate intervention that is lifesaving if in acute respiratory distress, showing pallor, diaphoretic (profusely
Some patients with chest pain do not meet the level 1 consideration and should get a diagnostic ECG within 10 minutes of arrival to the ED. A hemodynamically unstable patient, however, will manifest hypotension, which may lead to tissue or cell death and organ failure. To determine if someone is hemodynamically unstable, the ED triage clinician needs to evaluate blood pressure and heart rate; and, in the ICU setting the pulmonary artery occlusion pressure, central venous pressure, cardiac output, and pulmonary artery pressure should be considered when evaluating hemodynamic stability of a patient.
Using the AVPU scale – Alert, Verbal, Pain, Unresponsive – a triage clinician can assess the level of responsiveness of a patient. The AVPU scale is used with the ESI algorithm. Patients who need immediate interventions are identified such as those having a sudden or recent change in their level of consciousness.
The scale is used to identify if a patient is nonverbal and needs painful
stimuli to get a response. If a patient score is U or P on the AVPU scale, this translates to level 1 on the ESI scale.
A summary of the AVPU scale and level of consciousness is raised here. A is best. U is worst. Clinicians should work from A to U.38
Alert
The alert patient is awake, and generally the eyes are open. The patient will respond to voice but may be confused. A triage clinician can get information from talking to the patient. The patient has motor functions.
Voice
The patient responds and opens the eyes when spoken to, and responds with a moan or slight movement. The patient may not be oriented to time and place.
Pain
The patient responds to a painful stimulus but not to voice. If someone is conscious they do not require a pain stimulus. The stimulus can be
squeezing of the hand.
Unresponsive
Also called unconscious, the unresponsive person does not respond to even a painful stimulus. No response by voice or eyes to a stimulus is given.
A level 1 assessment happens in less than 5 percent of those who come to an emergency department. When a level 1 patient arrives in an emergency department, lifesaving interventions can be provided by the health team, nurse, or physician. Such a patient can end up being admitted to an intensive care unit. In some cases, the patient is discharged from the emergency department following treatment of the patient’s condition, such as in the case of alcohol intoxication, anaphylaxis (as with an allergic
reaction to a bee sting), seizures, and hypoglycemia (also called low blood sugar or low blood glucose).39 Some case examples of level 1 include:40
• Cardiac or respiratory arrest • SpO2 at less than 90 percent
• Trauma patient with a critical injury and appears unresponsive • Flaccid baby
• Child who fell and is unresponsive to stimuli
• Patient who is dizzy and weak with a heart rate of 30
• Anaphylactic shock (as with an allergic reaction to a bee sting) • Drug overdose and respiratory rate of 6
• Patient who is unresponsive and has a strong odor of alcohol • Patient with hypoglycemia and a change in mental status • Respiratory distress that is severe with gasping
• Trauma patient who needs immediate fluid resuscitation (crystalloid and colloid)
• Intubated head bleed and unequal pupils
• Low blood pressure (hypotension) with signs of decreased blood flow (hypoperfusion)
• Heart beat that is too slow or too fast with signs of decreased blood flow (hypoperfusion)
• Chest pain, profusely perspiring, blood pressure 70 systolic by palpation
If determining blood pressure by palpation only, a rough estimation of the systolic pressure is obtained. A pulse at three major arteries – carotid, femoral, and radial – is felt. If the pulse is felt at all three arteries, then the blood pressure is about 70-80 mmHg. If the carotid and femoral arteries are only felt the blood pressure is about 50-70 mmHg. If the carotid artery only is felt the blood pressure is about 40-50 mmHg.41
ESI Level 2
If a triage clinician determines the patient is not a level 1, moving on to the next decision point, determination is made whether a patient can wait to be seen. If waiting is not an option, the patient moves to level 2. As a high risk situation, Level 2 involves the kind of patient placed immediately into any
open ED bed due to the risks involved. The patient could be confused, lethargic, and disoriented. Severe pain and distress could be accompanying symptoms. This level includes danger zone vitals shown in the examples below, with many resources needed.54,55
Heart Rate:
Less than 3 months/over 180 3 months – 3 years/over 160 3-8 years/over 140
Over 8 years/over 100
Respiratory Rate:
Less than 3 months/over 50 3 months – 3 years/over 40 3-8 years/over 30
Over 8 years/over 20
SaO2 less than 92%
Pediatric Fever:
1-28 days, assign at least L2 if temp is over 100.4 °F 1-3 months, consider assigning L2 if temp is over 100.4 °F
3 months – 3 years, consider assigning L3 if temp is over 102.2 °F, incomplete immunizations, or no obvious source of fever
Some examples of ESI resources needed for Level 2 patients include:56,57 • Labs
• ECG/X-rays
• IV Fluids
• Intravenous and intramuscular medications/nebulized • Specialty Consultation
• Simple Procedure (counts as 1 resource is uses only 1 resource) • Complex Procedure (counts as 2 resources with a procedure such as
conscious sedation that requires 2 resources)
Oral medications are not considered a resource. Prescriptions are not considered a resource.
It can be challenging to determine a patient at level 2. A scenario of a Level 2 patient where the triage clinician may assign differently is described here.
A patient at level 2 rating due to long waits and a large number of other patients in the level 2 category is given a level 1 rating. The triage clinician is influenced by long ED waits and how crowded the ED is rather than how acute the situation is and how the patient condition fits the ESI algorithm. The patient’s situation should be considered only and not conditions in the emergency room when determining an ESI level. If a triage clinician reports the wrong ESI level a patient could have a long wait and have a poor
outcome – possibly resulting in complications and legal issues.
Decision Point B: High Risk Situation?
These questions should be used to determine whether a patient is at level 2. • Is the patient in a high risk situation?
• Is the patient in severe distress or pain?
• Is the patient disoriented, lethargic, or confused?
The triage clinician must quickly answer the questions. The clinician can get and use information that is objective and subjective. In contrast with level 1, Level 2 is determined by asking some specific questions, such as is the
patient in a high risk situation?
The triage clinician can answer the above question based on the following assessment steps and actions.
• Interviewing the patient • Observing the patient • Working from experience
• Knowing the age of the patient
• Knowing the medical history of the patient
• Determining whether the condition easily deteriorate • Understanding the time sensitive element
The triage clinician can recognize a high risk patient due to their experience and observations. The clinician can determine whether it is unsafe for the patient to be in the waiting room for long.
Level 2 patients are at high risk generally and very ill. They should be a high priority. Their treatment should be started as much as possible with no
delay. The need is immediate.
A key difference in level 1 and level 2 is that with level 1 a physician should be immediately present. With level 2 the triage clinician notifies staff of a level 2 patient. The clinician can then start care without a physician at the
bedside immediately. The triage clinician knows that the patient must have interventions. But the clinician determines the condition will not get worse.
The clinician can do the following emergency interventions before a physician is needed:
• Obtain an ECG
• Place a cardiac monitor on the patient • Provide supplemental oxygen
• Start an IV (intravenous) access
Some examples of a patient in a high risk situation are highlighged here.42 • Signs of a stroke but not at a level 1
• Suicidal patient • Homicidal patient
• Patient taking chemotherapy, showing a fever, immunocompromised
• A needle stick for a health care worker
• Possible ectopic pregnancy with stable blood flow
• Active chest pain, stable, suspecting acute coronary syndrome, no immediate intervention needed that is lifesaving
Is the patient disoriented, confused, or lethargic?
With the question related to patient orientation and alertness, the clinician is looking for changes in consciousness that are acute. Examples of changes in level of consciousness include:
• An adolescent who is disoriented and confused • An elderly patient with sudden confusion
Is the patient in severe distress or pain?
The level of a patient’s pain is important to determine, and if the answer is ‘yes’, the triage clinician must determine the level of distress or pain. This can be determined by asking the patient of their pain level or through observation. If the patient reports pain at level 7 or higher on a 10-point scale with 10 being the most intense pain, the triage clinician could assign a level 2 rating. If the answer to the questions about severe distress or pain is ‘no’, the triage clinician can move to the next step.43
Not all patients who report pain at level 7 or above must be at level 1. For example, a twisted ankle may result in a pain rating of 8. In this case, the patient can possibly wait to be treated.
Some of the ways a patient can be assessed by observation include those listed below.
• Extreme perspiring • Crying
• Facial expression • Body position
• Vital sign changes as with hypertension • Vital sign changes as with rapid heart rate
• Vital sign changes as with an increased respiratory rate
Another example would be a patient complaining of nausea and vomiting with a history of renal failure. In this case, a level 2 could be assigned.45
When severe distress is referenced this can by psychological or physical. This can include a victim of domestic abuse, an assault victim, or a
combative person.
It was mentioned earlier that level 1 patients are less than 5 percent of those coming to an emergency department. Estimates show that 20 to 30 percent are at level 2. When a triage clinician identifies a patient as level 2, the clinician must make sure to care for the patient in a timely way. In such cases, it’s necessary to determine whether a family member could complete registration in the ED while the clinician arranges for the patient to have vital signs obtained, a comprehensive nursing assessment, and placement in a treatment area. About half of patients at level 2 will be admitted into the hospital.44,47 If the patient can wait, the next decision point is approached.
Decision Point C: Determining Resources
When moving to the decision point C, resources are determined. For each choice for resources, the clinician can answer ‘None’, ‘One’, or ‘Many’. For a physician to reach a decision on disposition, the triage clinician should ask how many resources a patient will need. The disposition could be to 1) Admit to the hospital, 2) Transfer to another institution, and 3) Admit to an
observation unit. Considerations on determining resources include:
• Assessment provided by the patient • Assessment provided by the triage nurse • Past medical history
• Age
• Medications • Gender
• What is the standard of care for an emergency department • Understanding of customary and prudent practices
Resources can include: • Procedures
• Lab tests
• Hospital services • Consultations • interventions
• Simple interventions such as bandaging
The following list shows types of resources to help determine a level
designation. As a reference point, two or more resources are needed for a level 3 designation. For a level 4 designation only one resource is needed. No resources are needed for a level 5.
Resources Not Resources
Labs (blood, urine) History & physical (including pelvic)
ECG Point-of-care testing
IV fluids (hydration) Saline or heplock
X-rays and CT Prescription refills
MRI, ultrasound, angiography Tetanus immunization IV, IM, or nebulized medications PO medications
Specialty consultation Phone call to primary care physician Simple procedure = 1 (i.e., Foley
catheter) Crutches
Simple procedure = 1 (i.e., laceration
repair) Splints, slings
Complex procedure = 2 (i.e., sedation) Simple wound care (dressings, recheck)
Resources can include imaging such as X-Rays, CT scans, MRIs, ultrasound, and angiography.48
Decision Point D: Vital Signs
When a triage clinician assigns a patient to level 3, patient vital signs should be obtained. The clinician must decide if the vital signs are such that there is concern. The clinician can put the patient at level 2 if vital signs are outside of acceptable parameters.
Predicting Resources: Levels 3,4, 5
To predict resources with a reference to levels 3, 4, and 5 in contrast to levels 1 and 2, the following criteria and example are considered.49
Level 5 – no resources
• 12 year old, with poison ivy – needs an exam and prescription • 50 year old, did not take medication for blood pressure – has blood
pressure of 150/92 – needs an exam and prescription
Level 4 – one resource
• 20 year old with sore throat – needs an exam and throat culture – lab resource needed
• 30 year old with a urinary tract infection – needs an exam and urine culture – lab resource needed
Level 3 – two or more resources
• 20 year old with abdominal pain, nausea, no appetite – needs exam, IV fluid, lab studies, CT scan
• 42 year old who is obese with swelling pain in the left leg – needs an exam, lab, and vascular study.
Vital signs are not part of a ESI level 1 or 2. Additional considerations include:50
• Taking the body temperature for a child under the age of 3
• Considering vital sign results a triage clinician can update a patient with a heart rate of 104 – to level 3
• A baby under the age of 1 with a respiratory rate of 48 and a cold could be triaged at a level 2 or 3
Getting vital signs is part of the assessment for level 3 and include data outlined below.
• Blood pressure – A high reading indicates strain on arteries and the heart, possibly contributing to a stroke or heart attack
• Heart rate – Number of beats per minute, measuring the beating of the heart
• Temperature – Measurement of temperature possibly indicates disease • Respiratory rate – Number of breaths per minute; how frequently the
patient breathes
• Oxygen saturation – Saturation of oxyhemoglobin, providing a possible warning of cardiovascular or pulmonary deterioration
• Pain – Sensation transmitted by the nervous system, with perception modified by emotion and cognition
Further details on vital sign trends will be discussed elsewhere in this course.
Physical And Medical Conditions Influencing ESI Triage Categories If a trauma patient arrives at an emergency room after a car accident, there may be corresponding organ complaints. The trauma patient may complain of pain in the right upper quadrant and have stable vital signs. The patient should be a level 2 because of the possibility of significant trauma such as a liver laceration.
In a trauma response level as used in an emergency department, both the triage level and trauma response level are important to how to treat a patient. For example, consider a patient involved in a car accident and having a blood pressure of 80 palpable. This patient should be at level 1.
Chest pain is another consideration for determining triage level for someone coming into an emergency department. If the patient is stable
physiologically but has chest pain, it could be an acute coronary syndrome. This would be a level 2 patient. The patient does not need an immediate intervention that is lifesaving but may be a high risk patient. Acute coronary syndrome includes a heart attack and unstable angina. Acute coronary
syndrome is a catch-all term for a condition where there is sudden blockage of blood to the heart muscle.51
In general, not everyone with chest pain is at a level 1. Getting vital signs is part of the assessment for level 3 and include the patient’s pulse, oxygen saturation and respiratory rate. Caring for someone with check pain is time sensitive, and that patient is not always at a level 1. A patient with chest pain should have an ECG within 10 minutes of arrival. The ECG is not lifesaving. It is diagnostic. The true level 1 patient needs immediate care that is lifesaving.
Some patients with chest pain are at level 1. If the blood pressure is 80 palpable and the patient is perspiring profusely, and is having chest pain, the patient is at level 1. Consider a patient who has signs of a stroke and complains of left arm weakness. A CT scan provides details that can help a stroke team. If the patient cannot maintain an airway, this is level 1.
Another scenario to consider is a senior citizen who falls. They could fracture a hip as a result of the fall. Assume they arrive by car and report being in pain. This would be a level 3 patient. But the triage clinician could put the patient into a bed before another level 3 patient. Arriving by ambulance is not automatically a level 1 or 2. Instead the patient should go through the ESI algorithm.
A note of caution is when there is emergency department overcrowding.52 A triage clinician could have a level 2 patient and no open bed. The clinician should not just make the patient a level 3 in this situation. This clinician puts the patient at greater risk. The clinician should make the patient a level 2 and determine who in the level 2 is at greatest risk and could deteriorate. The clinician would place into a bed a patient with chest pain before a patient with a kidney stone.
Remember that level 1 is one of the five levels of the ESI triage system. The system divides patients up by resource needs and patient acuity. The
clinician makes four decision points in the system. The patient is asked if they are dying, and the ESI clinician obtains vital signs, determines whether the patient waits, how many resources are needed. A triage clinician who has experience can quickly and appropriately triage patients when
appropriately trained to use the ESI system.
Level Name Description Examples
1 Resuscitation Immediate, lifesaving intervention required without delay Cardiac arrestMassive bleeding
2 Emergency High risk of deterioration, or signs of a time-critical problem
Cardiac-related chest pain Asthma attack
3 Urgent
Stable, with multiple types of resources needed to investigate or treat (such as lab tests plus X-ray imaging)
Abdominal pain High fever with cough 4 Less urgent Stable, with only one type of resource anticipated (such as only
an X-ray, or only sutures)
Simple laceration Pain on urination 5 Non urgent Stable, with no resources anticipated except oral or topical
medications, or prescriptions
Rash
Prescription refill
The clinician should identify the lifesaving intervention needed, such as supporting circulation, maintaining the airway and addressing a major
change in level of consciousness. Further, ED clinicians need to address time sensitive factors and whether a patient is:
• In severe distress or pain
• disoriented, lethargic, or confused
• in a high risk age category, such as elderly
• diagnosed with comorbid conditions (medical history) • At risk to easily deteriorate
Since Level 2 patients are at high risk generally and very ill, they should be a high priority. Their treatment should be started as much as possible with no delay. The need is immediate. The major determining factor should be if the condition could easily deteriorate. Characteristics of a Level 2-5 patient are outlined below.
Level Name Description
2 Emergency High risk of deterioration, or signs of a time-critical problem. 3 Urgent Stable, with multiple types of resources needed to investigate or treat (such as lab tests plus X-ray
imaging).
4 Less Urgent Stable, with only one type of resource anticipated (such as only an X-ray, or only sutures). 5 Non Urgent Stable, with no resources anticipated except oral or topical medications, or prescriptions.
The qualifications for Level 2-5 on the ESI are additionally important to note and shown in the table below, which identifies resources needed.
Level Name Resources
2 Emergency Many
3 Urgent Two or more
4 Less Urgent One
5 Non Urgent None
When caring for pediatric patients in the ED, clinicians should be guided by the maximum temperatures for pediatric fevers. Pediatric fever conditions include the following considerations highlighted in the table below.
Age of Patient Level
1 to 28 days 2 if temperature is higher than 38.0 degrees C or 100.4 degrees F
1 to 3 months 2 if temperature is higher than 38.0 degrees C or 100.4 degrees F
3 months to 3 years 3 if temperature is higher than 39.0 degrees C or 100.2 degrees F
