ESI practice thread

Yay! For the new kids on the block tell us why you suspect a pneumo and why you made him an ESI 2.

Whether the 'growth spurt' theory or underlying genetic or familial tendency, Marfan, etc., this is a classic presentation of primary spontaneous pneumo (tall, thin, teen or young adult male reports non-traumatic onset sharp unilateral pleuritic chest pain). He doesn't require a life-saving intervention right this instant, but does need further evaluation of his condition and initiation of nursing protocol interventions right away (vital signs, oxygen, IV, monitor, imaging, anticipate intervention).

How about this:

30-something ambulatory female also with non-traumatic unilateral pleuritic chest pain. Looks okay in triage but concerned about herself. I can't remember her meds but, if any, they were irrelevant to the presentation. No pregnancy concerns (current menses). Has had this complaint before. And.......GO!

78 year old comes in c/o palpitations.Hx afib. HR 176. BP 126/72. Feels "lightheaded and dizzy" No CP[/QUOT

esi 1, needs a physician at the bedside now and emergent treatment for likely symptomatic SVT or afib or vtach.

78 year old comes in c/o palpitations.Hx afib. HR 176. BP 126/72. Feels "lightheaded and dizzy" No CP

This would be set as a 2 at every hospital I have worked. We would have notified the doctor right away and started the line and obtained EKG and all that. But I would have put him at a 2 with just that info. I know not everyone will agree and it can be argued either way. Just what my experience has been.

Mid-twenties, tall gangly male with right-sided chest pain that worsens with inspiration and mild SOB. Go!

ESI 2, possible pneumo.

53 y/o male comes in by EMS for AMS, lethargy, and hypoglycemia. Finger stick in the field was 27 and he was given D10 in the field with a recheck of 70 in route. On arrival pt is still lethargic and confused. Pt is mildly hypotensive 90s/60s. Pt is NSR with a rate of 66 on the monitor. Pt's O2 sat is 89% on room air. Past medical history of diabetes, COPD, and GI bleed. What is the ESI?

Hmmmmmmmmmm. He could merely need more dextrose (more than D10, hello, he's an adult, let's go with D-fitty, D-10 might have not done it despite the 70 retest), a repeat fingerstick, a solid meal and a ride home, which would make him a 4 (point of care testing is not a resource, meds are 1 resource). Is the 89% where he lives? Possibly, with COPD. If he remains altered and his repeat fingerstick is good, he would be a 2 due to AMS. But if we had to assign it at the door without knowing the future, he would be a 2 just because of the AMS and out of range sats.

I gave him an esi 2. We immediately gave D50 prior to the finger stick, the recheck after the D50 was normal and he started to perk up a little but was still pretty lethargic so he was put on BiPAP for a while, which restored his cognition. His ABG showed he had elevated CO2 which was why he was put on BiPAP. It also turned out he had a GI bleed with a HGB of 6ish.

Technically though, would he be an ESI 1 because of life-saving intervention required, the dextrose and BiPAP?

I have another one. A 58-year-old male found down on the kitchen floor at home by his wife for an unknown length of time. Pt was soaked in urine when he came in, did not follow commands but was reaching out with his left arm. He could move all extremities but his left side was stronger than the right. He had bruising and swelling over his right eye and right hip. He had a history of alcoholism, HTN and high cholesterol. His vitals were stable, with mild hypertension 160s/90s, pulse and oxygen sat within normal limits. He was afibrile. He was breathing spontaneously. His finger stick was also within normal limits. What would you designate his esi?

2... definitely high risk but not in need of immediate life-saving intervention.

I gave him an esi 2. We immediately gave D50 prior to the finger stick, the recheck after the D50 was normal and he started to perk up a little but was still pretty lethargic so he was put on BiPAP for a while, which restored his cognition. His ABG showed he had elevated CO2 which was why he was put on BiPAP. It also turned out he had a GI bleed with a HGB of 6ish.

Technically though, would he be an ESI 1 because of life-saving intervention required, the dextrose and BiPAP?

As you describe his presentation, I'd have made him a 2.