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<title>Emergency Severity Index Implementation Handbook: Chapter 10 </title>
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<h2>Chapter 10. Competency Cases</h2>
<p>This chapter can be used to assess competency.
Please read each case and based on the information
provided assign a triage acuity rating using ESI.</p>
<p>1. EMS arrives with a 76-year-old male found on
the bathroom floor. The family called 911 when
they heard a loud crash in the bathroom. The
patient was found in his underwear and the
toilet bowl was filled with maroon-colored
stool. Vital signs (VS) on arrival: blood pressure
(BP) 70/palp, heart rate (HR) 128, respiratory
(RR) 40. His family tells you he has a history of
atrial fibrillation and takes a &quot;little blue pill to
thin his blood.&quot;</p>
<p>2. &quot;The pediatrician sent us to the emergency
department (ED) because my son may have
appendicitis,&quot; reports the mother of a healthy
7-year-old. The child is sitting quietly next to
his mother holding an emesis basin. &quot;He woke
me up this morning and told me his tummy
hurt. Usually he gets up and runs downstairs to
watch cartoons, but not today. The poor kid
vomited all over the doctor's office.&quot; VS:
temperature (T) 99.6&deg; F, HR 94, RR 20, BP 88/62.</p>
<p>3. A 63-year-old cachectic male is brought in
from the local nursing home because his
feeding tube fell out again. The patient is
usually unresponsive. He has been in the
nursing home since he suffered a massive stroke
about 4 years ago.</p>
<p>4. You are trying to triage an 18-month-old whose
mother brought him in for vomiting. The
toddler is very active and trying to get off his
mother's lap. To distract him the mother hands
him a bottle of juice, which he immediately
begins sucking on. The child looks well
hydrated and is afebrile.</p>
<p>5. &quot;I think I need a tetanus shot,&quot; a 29-year-old
female tells you. &quot;I stepped on a rusty nail this
morning and I know I haven't had one for
years.&quot; No past medical history (PMH), no
known drug allergies (NKDA), no medications.</p>
<p>6. A 72-year-old female with obvious chronic
obstructive pulmonary disease (COPD) and
increased work of breathing is wheeled into
triage. Between breaths she tells you that she
&quot;is having a hard time breathing and has had a
fever since yesterday.&quot; The SpO<sub>2</sub> monitor is
alarming and displaying a saturation of 84
percent.</p>
<p>7. &quot;Why the hell don't you just leave me alone?,&quot;
yells a 73-year-old disheveled male who was
brought to the ED by EMS. He was found
sitting on the curb drinking a bottle of vodka
with blood oozing from a 4-cm forehead
laceration. He is oriented to person, place, and
time and has a Glasgow Coma Scale (GCS) of
14.</p>
<p>8. EMS arrives in the ED with a 57-year-old female
with multiple sclerosis. She is bedridden and
her family provides care in the home. The
visiting nurse sent her to the ED because her
Foley catheter came out this morning. No other
complaints. Vital signs are within normal range,
currently on antibiotics for a UTI.</p>
<p>9. &quot;How long am I going to have to wait before I
see the doctor?,&quot; asks a 27-year-old female with
a migraine. The patient is well known to you
and your department. She rates her pain as
20/10 and tells you that she has been like this
for 2 days. She vomited twice this morning.
PMH: migraines, no allergies, medications
include fioricet.</p>
<p>10. A young male ambulates into triage and tells
you that he has been shot. As he rolls up the
left leg of his shorts you notice two wounds. He
tells you that he heard three shots. He is alert
and responding appropriately to questions.
Initial VS: T 98.2&deg; F, HR 78, RR 16, BP 118/80.</p>
<p>11. A 26-year-old female walks into the triage room
and tells you that she needs to go into detox
again. She has been clean for 18 months but
started using heroin again 2 weeks ago when
her boyfriend broke up with her. She had called
several detox centers but was having no luck
finding a bed. She denies suicidal or homicidal
ideation. She is calm and cooperative.</p>
<p>12. EMS radios in that they are in route with a 17-year-old with a single gun shot wound to the
left chest. On scene the patient was alert,
oriented and had a BP of 82/palp. Two large
bore IV's were immediately inserted. Two
minutes prior to arrival in the ED the patient's
HR was 130 and BP was 78/palp.</p>
<p>13. &quot;My son needs a physical for camp,&quot; an
anxious mother tells you. &quot;I called the clinic
but they can't see him for two weeks and camp
starts on Monday.&quot; Her son, a healthy 9-yearold
will be attending a summer day camp. </p>
<p>14. &quot;Nurse, I have this pressure in my chest that
started about an hour ago. I was shoveling that
wet snow and I may have over done it,&quot; reports
an obese 52-year-old male. He tells you his pain
is 10 out of 10 and that he is nauseous and short
of breath. His skin is cool and clammy. VS: BP
86/50, HR 52 and irregular.</p>
<p>15. This patient is the restrained driver of an SUV
involved in a high-speed, multicar accident. Her
only complaint is right thigh pain. She has a
laceration on her left hand and an abrasion on
her left knee. VS: BP 110/74, HR 72, RR 16, no
medications, no allergies, no PMH.</p>
<p>16. &quot;My doctor told me to come to the ED. I had a
gastric bypass 3 weeks ago and have been doing
fine but today I started vomiting and having this
belly pain.&quot; The patient, an obese 33-year-old
female rates her pain as 6/10. VS: BP 126/70, HR
76, RR 14, T 98&deg; F.</p>
<p>17. &quot;I was seen in the ED last night for my fractured
wrist. The bone doctor put this cast on and told
me to come back if I had any problems. As you
can see my hand is really swollen and the cast is
cutting into my fingers. The pain is just
unbearable.&quot; Circulation, sensation, and
movement are decreased.</p>
<p>18. A 42-year-old male presents to triage with a chief
complaint of &quot;something in his right eye.&quot; He
was cutting tree limbs and thinks some sawdust
went into his eye. No PMH, no allergies, no
medications. On exam his right eye is reddened
and tearing.</p>
<p>19. An 88-year-old female is brought to the ED by
EMS. This morning she had an episode of slurred
speech and weakness of her left arm that lasted
about 45 minutes. She has a history of a previous
stroke and she takes an aspirin every day. She is
alert and oriented with clear speech and equal
hand grasps.</p>
<p>20. &quot;It hurts so much when I urinate,&quot; reports an
otherwise healthy 25-year-old. She denies fever,
chills, abdominal pain, or vaginal discharge. VS:
T 98.2&deg; F, HR 66, RR 14, BP 114/60.</p>
<p>21. &quot;I think my son has swimmer's ear. He spends
half the day in the pool with his friends so I am
not surprised,&quot; the mother of a 10-year-old boy
tells you. The child has no complaints except
painful, itchy ears. VS: T 97&deg; F, HR 88, RR 18, BP
100/68.</p>
<p>22. The medical helicopter is en route to your facility
with a 16-year-old male who was downhill skiing
and hit a tree. Bystanders report that he lost
control and hit his head. He was intubated at the
scene and remains unresponsive.</p>
<p>23. &quot;I have this aching pain in my left leg,&quot; reports
an obese 52-year-old female. &quot;The whole ride
home it just ached and ached.&quot; The patient tells
you that she has been sitting in a car for the last
two days. &quot;We drove my daughter to college and
I thought it was the heat getting to me.&quot; She
denies any other complaints. VS: BP 148/90, HR
86, RR 16, T 98&deg; F.</p>
<p>24. &quot;My baby has a temperature of 101 rectally. I
called the pediatrician and he told me to come
here,&quot; reports the mother of a 3-week-old. The
baby is alert and sucking on a pacifier. Delivered
vaginally, no complications. &quot;He's nursing fine. I
just wonder if he has the bug my other kids
had.&quot;</p>
<p>25. EMS arrives with a 45-year-old asthmatic who
has had a cold for a week. She started wheezing a
few days ago and then developed a cough and a
fever of 103. VS: T 101.6&deg; F, HR 92, RR 24, BP
148/86. SpO<sub>2</sub> 97%.</p>
<p>26. &quot;My right breast is so sore, my nipples are
cracked, and now I have a fever. Do you think I
will have to stop nursing my baby?,&quot; asks a
tearful 34-year-old female. She is 3 months post
partum and has recently returned to work part
time. VS: T 102.8&deg; F, HR 90, RR 18, BP 108/60,
pain 5/10. No PMH, taking multivitamins,
allergic to penicillin.</p>
<p>27. A six-year-old male tells you that he was running
across the playground and fell. He presents with
three-centimeter laceration over his right knee.
Healthy, no medications and no allergies,
immunizations are up to date.</p>
<p>28. A 41-year-old male involved in a bicycle accident
walks into the emergency department with his
right arm in a sling. He tells you that he fell off
his bike and landed on his right arm. He is
complaining of pain in the wrist area and has a
two-centimeter laceration on his chin. &quot;My
helmet saved me.&quot;</p>
<p>29. &quot;I ran out of my blood pressure medicine and
my doctor is on vacation. Can someone here
write me a prescription?&quot; requests a 56-year-old
male with a history of hypertension. VS: BP
128/84, HR 76, RR 16, T 97&deg; F.</p>
<p>30. EMS presents to the ED with an 18-year-old
female with a suspected medication overdose.
Her college roommates found her lethargic and
&quot;not acting right&quot; so they called 911. The
patient has a history of depression. On exam
you notice multiple superficial lacerations to
both wrists. Her respiratory rate is 10 and her
SpO<sub>2</sub> on room air is 86 percent.</p>
<p class="size2"><a href="esi1.htm#Contents">Return to Contents</a></p>
<h3>Answers and Discussion</h3>
<p>1. <strong>ESI level 1: requires immediate lifesaving
intervention.</strong> This 76-year-old patient
is in hemorrhagic shock from his GI bleed. His
blood pressure is 70, his heart rate is 128 and
his respiratory rate is 40, all indicating an
attempt to compensate for his blood loss. He
probably takes warfarin (Coumadin&reg;) for his
atrial fibrillation. This patient needs immediate
IV access and the administration of fluid, blood,
and medications.</p>
<p>2. <strong>ESI level 3: two or more resources.</strong> The
child's pediatrician has already examined him
and referred the family to the emergency
department for further evaluation. At a
minimum he will need labs, an IV with fluid,
and other diagnostic tests in order to reach a
disposition.</p>
<p>3. <strong>ESI level 4: one resource.</strong> This patient will
be sent back to the nursing home after the
feeding tube is reinserted. There is no acute
change in his medical condition that warrants
any further evaluation. Yes, he is unresponsive
but that is the patient's baseline mental status
so he is not an ESI level 1.</p>
<p>4. <strong>ESI level 5: no resources.</strong> A physical exam
and providing the mother with reassurance and
education is what this 18-month-old will
require. His activity level is appropriate and he
is taking PO fluids.</p>
<p>5. <strong>ESI level 5: no resources.</strong> A tetanus
immunization does not count as a resource. The
patient will be seen by a physician or mid-level
provider, receive a tetanus immunization, and
discharge instructions. This patient will require
no resources.</p>
<p>6. <strong>ESI level 1: requires immediate lifesaving
intervention.</strong> Immediate aggressive
airway management is what this patient
requires. Her saturation is very low and she
appears to be tiring. The triage nurse does not
need the other vital signs in order to decide
that this patient needs immediate care.</p>
<p>7. <strong>ESI level 2: high-risk situation.</strong> The history
of events is unclear. How did this 73-year-old
gentleman get the laceration on his forehead?
Did he fall? Get hit? Because of his age,
presentation, and presence of alcohol he is at
risk for a number of complications.</p>
<p>8. <strong>ESI level 4: one resource.</strong> The patient has
been referred to the emergency department for
a new Foley catheter&#8212;one resource. There are
no other changes in her condition and she is
already on antibiotics for a UTI so no further
evaluation is needed.</p>
<p>9. <strong>ESI level 3: two or more resources.</strong> At a
minimum this patient will require an IV with
fluid, IV pain medication, and an antiemetic.
Although she rates her pain as 20/10 she should
not be assigned to ESI level 2. She has had the
pain for 2 days and the triage nurse can't justify
giving the last open bed to this patient. The
triage nurse will need to address this patient's
concerns about wait time.</p>
<p>10. <strong>ESI level 2: high-risk situation.</strong> This
patient has two obvious wounds but until he is
thoroughly examined in the trauma room you
can't rule out the possibility that he has
another GSW. The wounds on his thigh look
non-life-threatening but a bullet could have
nicked a blood vessel or other structure;
therefore, he meets ESI level-2 criteria. His vital
signs are within normal limits so he does not
meet ESI level 1 criteria.</p>
<p>11. <strong>ESI level 4: one resource.</strong> This patient is
seeking help finding a detoxification program
that will help her. She is not a danger to her self
or others. The social worker or psychiatric
counselor should be consulted to assist her.
Once a placement has been found she can be
discharged from the emergency department and
can get herself to the outpatient program. If
your social worker or psychiatric counselor
requires a urine toxicology or other lab work,
the patient will require 2 or more resources and
then meet ESI level-3 criteria.</p>
<p>12. <strong>ESI level 1: requires immediate lifesaving
interventions.</strong> The trauma team
needs to be in the trauma room and ready to
aggressively manage this 17-year-old with a
single GSW to the left chest. He will require
airway management, fluid resuscitation and,
depending on the injury, a chest tube or rapid
transport to the operating room.</p>
<p>13. <strong>ESI level 5: no resources.</strong> Because the mother
could not get an appointment with a primary
care physician, she brought her son to the
emergency department for a routine physical
exam. He will be examined and discharged.</p>
<p>14. <strong>ESI level 1: requires immediate life-saving
intervention.</strong> The history combined with the
signs and symptoms indicate that this patient is
probably having an MI. The &quot;pressure&quot; started
after shoveling wet snow and now he is
nauseous, short of breath and his skin is cool
and clammy. He needs immediate IV access, the
administration of medications, and external
pacing pads in place.</p>
<p>15. <strong>ESI level 2: high-risk situation.</strong> Based on
mechanism of injury this patient will need rapid
evaluation by the trauma team.</p>
<p>16. <strong>ESI level 3: two or more resources.</strong> She will
need two or more resources&#8212;laboratory tests,
intravenous fluid, medication for her nausea,
and probably a CT of her abdomen. This patient
will be in your emergency department an
extended period of time being evaluated. If her
pain was 10/10 and she was tachycardic the
patient would meet the ESI level-2 criteria.</p>
<p>17. <strong>ESI level 2: high-risk situation.</strong> Again, this
is a high-risk situation. The recent application of
a cast along with swelling of the hand and pain
that is unbearable justifies an ESI level-2 acuity
level. He may have compartment syndrome.</p>
<p>18. <strong>ESI level 4: one resource.</strong> The only resource
this patient will require is irrigation of his eyes.
A slit lamp exam is not considered a resource
but is part of the physical exam.</p>
<p>19. <strong>ESI level 2: high-risk situation.</strong> The
patient's history indicates that she may have had
a transient ischemic attack this morning. This
patient is high risk and it would not be safe for
her to sit in the waiting room for an extended
period of time.</p>
<p>20. <strong>ESI level 4: one resource.</strong> This patient will
require one resource&#8212;lab. A urinalysis and urine
culture will be sent and depending on your
institution, a urine pregnancy test. One or all of
these tests count as one resource.</p>
<p>21. <strong>ESI level 5: no resources.</strong> This child needs a
physical exam. Even if eardrops are administered
in the emergency department, this does not
count as a resource. The family will be sent
home with instructions and a prescription.</p>
<p>22. <strong>ESI level 1: requires immediate life-saving
intervention.</strong> Prehospital intubation is one of
the criteria for ESI level 1. This patient has
sustained a major head injury and will require
an immediate trauma team evaluation.</p>
<p>23. <strong>ESI level 3: two or more resources.</strong> At a
minimum she will require labs and noninvasive
vascular studies of her lower leg. She should be
placed in a wheelchair with her leg elevated and
instructed not to walk until the doctor has seen
her.</p>
<p>24. <strong>ESI level 2: high-risk situation.</strong> Any
neonate (day 1-28) with a fever over 100.4
rectally should be considered high risk regardless
of how they look at triage. At this age they have
limited ability to localize an infection.</p>
<p>25. <strong>ESI level 3: two or more resources.</strong> This
history sounds more like pneumonia. Because
the patient is not in acute respiratory distress he
or she doesn't meet ESI level-2 criteria. This
patient will require labs, a chest x-ray, and
perhaps IV antibiotics.</p>
<p>26. <strong>ESI level 3: two or more resources.</strong> At a
minimum she will require labs and IV
antibiotics.</p>
<p>27. <strong>ESI level 4: one resource.</strong> The laceration will
need to be sutured&#8212;one resource.</p>
<p>28. <strong>ESI level 3: two or more resources.</strong> At a
minimum this patient will require an x-ray of
his right arm and suturing of his chin laceration.</p>
<p>29. <strong>ESI level 5: no resources.</strong> The patient needs a
prescription refill and has no other medical
complaints. His blood pressure is controlled with
his current medication. If at triage his blood
pressure was 188/124, and he complained of a
headache then he would meet the criteria for a
high-risk situation and be assigned to ESI level 2.
If this patient's BP was elevated and the patient
had no complaints, he or she would still remain
an ESI level 5. The blood pressure would be
repeated and would most likely not be treated in
the ED or treated with PO medications.</p>
<p>30. <strong>ESI level 1: requires immediate life-saving
intervention.</strong> The patient's respiratory rate,
oxygen saturation, and inability to protect her
own airway indicate the need for immediate
endotracheal intubation.</p>
<p class="size2"><a href="esi1.htm#Contents">Return to Contents</a><br />
<a href="esiappa.htm">Proceed to Next Section</a></p>
<p>&nbsp;</p>
<div class="footnote">
<p> The information on this page is archived and provided for reference purposes only.</p></div>
<p>&nbsp;</p>
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