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ESI Triage Algorithm
Yes
requires immediate life-saving intervention?
1
A
No
high risk situation?
or
confused/lethargic/disoriented?
or
severe pain/distress?
Yes
B
How many different resources are needed?
--------------------------------------------------------------------------------------none
one
many
C
2
5
4
Danger zone vitals?
Age
HR
RR
< 3 mo > 180
> 50
3m-3y > 150
> 40
3y- 8y > 140
> 30
>8y
> 100
> 20
Consider
SaO2<92%
D
No
3
 Does
the patient require immediate life
saving intervention?

Airway



Obstructed or partially obstructed
Unable to protect their own airway
Breathing




Apneic
Intubated prehospital
Severe respiratory distress
SpO2 less than 90%
 Cont.

Circulation


Pulseless or concerned about rate, rhythm or quality
Drugs


Hemodynamic interventions
Immediate IV medications to correct hemodynamic
instability
 Does
this patient have an acute mental
status change that requires immediate life
saving intervention?



 Is
Hypoglycemia needs glucose
Heroin OD needs narcan
Subarachnoid bleed needs airway protection
this patient a P or U on the AVPU scale
 Cardiac
or respiratory arrest
 Overdose with a RR of 8
 Severe respiratory distress
 Acute SOA with SpO2 < 90%
 Anaphylactic shock
 Critically injured trauma patient
 Chest pain, pale, diaphoretic
 Chest palpitations, HR 180+
 Unresponsive with strong odor of alcohol
 Severe stroke needs airway protection
 Airway
and
breathing




Intubation
Surgical airway
CPAP, BiPAP
Bag valve mask
 Defibrillation
 External
pacing
 Chest needle
decompression
 Hemodynamics



Significant IV fluid
resuscitation
Blood
administration
IV medications

Vasopressors
 Control
of major
bleeding
Immediate Life-saving Interventions
Life-saving
Not life-saving
Airway breathing
BVM ventilation
Intubation
Surgical airway
Emergent CPAP
Emergency BiPAP
Oxygen administration
Nasal cannula
Non-rebreather
Electrical Therapy
Defibrillation
Emergent cardioversion
External pacing
Cardiac Monitor
Procedures
Chest needle decompression
Pericardiocentesis
Open thoracotomy
Intraoseous access
Diagnostic tests
ECG
Labs
Ultrasound
FAST (focused abdominal
scan for trauma)
Hemodynamics
Significant IV fluid
resuscitation
Blood administration
Control of major bleeding
IV access
Saline lock for medications
Medications
Naloxone
D50
Dopamine
Atropine
Adenocard
ASA
IV nitroglycerin
Antibiotics
Heparin
Pain medications
Respiratory treatments with
beta agonists
 Is
this a high risk situation?
 Is
this patient confused, lethargic or
disoriented?
 Is

this patient in severe pain or distress?
The triage nurse obtains pertinent subjective
and objective information to quickly answer
these questions
Decision Point B: Should the patient wait?
High risk situation?
or
confused/lethargic/disoriented?
or
severe pain/distress?
Yes
B
2
 Determination
is based on a brief patient
interview, gross observations, “sixth
sense”
 Do not require a full set of vital signs
 Unsafe for the patient to wait



Suggestive of a condition that could easily
deteriorate
Symptoms of a condition that’s treatment is
time sensitive
Potential for major life or organ threat
 Episodes
of chest pain, denies other
symptoms, known cardiac history
 R/O PE
 Newborn with a fever
 Rule out ectopic pregnancy
 Neutropenia with a fever
 Suicidal/homicidal
 Is
there an acute change in level of consciousness?
 Is this situation where the brain is structurally or
chemically compromised?
 New
onset of confusion in an elderly patient
 30 y.o. with a known brain tumor whose wife
reports that he is confused
 Adolescent found confused and disoriented
 Is




the patient currently in Pain?
Pain intensity rating
Chief complaint
PMH, medications
VS, physical assessment findings
 Assign


ESI level 2 if and only if:
Self reported 7/10 or greater
AND


RN cannot intervene AND they require immediate
intervention
Does this patient need your last bed?

? Kidney stone

Severe flank pain, vomiting
 Burn

victim
Burns to both arms
 Oncology
patient
 Possible dislocated shoulder

?
Rates pain 10+, diaphoretic, tearful
Compartment syndrome
 Sexual
assault victim
 Combative patient
 Homicidal/suicidal patient
 Bipolar patient who is manic
 Acute grief reaction
 Known alcohol use with head injury
How many
resources
None
One
2 or more
5
4
3
 Determined
by the experienced ED RN at
triage
 Based on the standard of care
 Independent of type of hospital, location,
physician on duty, acuity of the department
Resources:
 Labs
 ECG
 X-ray
 CT, MRI
 IV fluids
 IV, IM meds & nebs
 Specialty Consult
 Simple procedure=1
(lac repair, foley cath)
Complex procedure=2
(conscious sedation)
Not Resources:
 History and Physical
 Pelvic
 Point of care testing
 Saline or heplock
 PO medications
 Tetanus shot
 Prescription refills
 Phone call to PCP
 Simple wound care
 Crutches, gel splints,
slings
 No
Resources
 Examples
-Healthy 10y.o. with “poison ivy”
-Healthy 52y.o. Who ran out of his BP
med recently
-22y.o. involved in an MVC 2 days ago,
just wants to get checked
-46y.o. with a cold
 Stable,
can safely wait for hours to be seen
 Care by mid-level providers in a fast track or
urgent care setting
 Requires a physical exam and one resource
 Examples:
-Healthy 19y.o. with a sore throat and
fever
-Healthy 29y.o. with a UTI, denies
abdominal pain
-Healthy 43y.o. with a stubbed toe
-Healthy 12y.o. with a minor thumb
laceration
 30-40%
of patients seen in the ED
 Need 2 or more resources
 Require in-depth evaluation
 Long length of stay
 Before assigning a patient to ESI level 3 the
nurse must consider the patients vital signs
 ESI



Fractured ankle
Abdominal pain
Most migraines
 ESI


level 4
Sprained ankle
Abscess
 ESI

level 3
level 5
Toothache