ESI practice thread

Specialties Emergency

Published

I am starting this tread for people to post scenarios (easy or hard) and for others to say how they would triage this patient according to ESI and their rationale for doing so. I think we can learn a lot from each other. Especially newer ER nurses learning from those more experienced.

Does anyone want to start?

It can be based off real patient scenarios.

Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
I gave her an ESI 3 but another nurse changed it to ESI 2 for sever pain or distress.

Probably based on the tachycardia (danger zone vitals) and 10/10 pain. Probably an overtriage, too.

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Specializes in Med-Tele; ED; ICU.
How about ESI for the following patient: 28-year-old female presents with severe abdominal pain is screaming at the top of her lungs "help me help me" She is brought in by EMS. She has a history of diabetes and is often non compliant with medication. She also has a history of gastroperesis and is a frequent patient at EDs in the area. Her vitals are stable, with a BP of 160s/100s, HR 110s, SpO2 98% on room air, afibrile. She screams that her pain is 10/10.
She's an ESI 2 due to the complaint alone. Every female abdominal pain with a functional uterus and operational ovaries is presumed to have an ectopic until proven otherwise.
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Specializes in EMS, ED, Trauma, CEN, CPEN, TCRN.
She's an ESI 2 due to the complaint alone. Every female abdominal pain with a functional uterus and operational ovaries is presumed to have an ectopic until proven otherwise.

Really? You make every female abd pain a 2 if they are of childbearing age with all their parts? I could understand based on a report of a positive home pregnancy test, but I have never seen that applied to all female abd pain patients. We keep it in the differential, but don't automatically assign a 2. If vitals are out of range, we'd uptriage.

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Specializes in ED, Cardiac-step down, tele, med surg.
She's an ESI 2 due to the complaint alone. Every female abdominal pain with a functional uterus and operational ovaries is presumed to have an ectopic until proven otherwise.

The reason I gave her a 3 instead of 2 is because "she's here all the time" with the same complaints, but that's not a good reason. I do think she should be a 2 in retrospect per ESI for severe pain or distress. Because her abdominal pain was generalized, not sharp and localized to one side I did not consider the possibility of an ectopic pregnancy.

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The reason I gave her a 3 instead of 2 is because "she's here all the time" with the same complaints, but that's not a good reason. I do think she should be a 2 in retrospect per ESI for severe pain or distress. Because her abdominal pain was generalized, not sharp and localized to one side I did not consider the possibility of an ectopic pregnancy.

The first action I always do in this situation is quickly try to give some reassurance and establish a rapport wherein the screaming can stop momentarily so I can get a better picture of what's going on. I will make my observations and I will take vitals after we have a brief but calm discussion about what's going on.

And no, if there's nothing different about this story today, I would NOT consider ovarian torsion, nor make this an ESI 2 for that reason alone. That's not unlike saying all chest pains are a STEMI until proven otherwise.

This is justifiably an ESI 2 based on severe pain and distress combined with VS that [may] suggest the same...provided that one's triage observations and quick therapeutic communications don't lead to a different conclusion. But I'm officially not happy about it, as I tend to be most concerned about high risk situations.

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Specializes in Family Nurse Practitioner.
She's an ESI 2 due to the complaint alone. Every female abdominal pain with a functional uterus and operational ovaries is presumed to have an ectopic until proven otherwise.

Even with diffuse abdominal pain that is not unilateral and no lady partsl bleeding/discharge/cramping?

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Specializes in Family Nurse Practitioner.
The reason I gave her a 3 instead of 2 is because "she's here all the time" with the same complaints, but that's not a good reason. I do think she should be a 2 in retrospect per ESI for severe pain or distress...

Severe pain/distress does not automatically warrant an ESI 2. If this is a patient you know who comes in with the same complaint and presenting symptoms every time and she is A&Ox4, I would triage her as an ESI 3 unless her HR was like 157 or something.

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Specializes in Family Nurse Practitioner.

57 year old female - comes in with right lower extremity pain, swelling, and redness x 1 week, which is gradually getting worse. "I tripped and fell and scraped my leg 2 weeks ago." VS as follows: T: 37.6, HR: 86, BP 140/78, RR: 16, Pulse ox 99% on RA. Reports chills off and on. Didn't check temperatures.

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57 year old female - comes in with right lower extremity pain swelling, and redness x 1 week, which is gradually getting worse. "I tripped and fell and scraped my leg 2 weeks ago." VS as follows: T: 37.6, HR: 86, BP 140/78, RR: 16, Pulse ox 99% on RA. Reports chills off and on. Didn't check temperatures.[/quote']

What I would do:

ESI 5 = simple and local cellulitis (I'm guessing d/t time frame it's more than this)

ESI 4 = may require lab or imaging but probably not IV abx

ESI 3 = riskier PMH such as immune compromise, systemic sx, OR lab &/or imaging r/o osteo/gas etc, IV abx

My guess is the tendency will be to do more with this, I say that based on the amount of time since the injury and the report of worsening and report of systemic sx (chills). Assuming it looks fairly nasty I'll hedge my bets on ESI 3.

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Specializes in ED, Cardiac-step down, tele, med surg.
57 year old female - comes in with right lower extremity pain swelling, and redness x 1 week, which is gradually getting worse. "I tripped and fell and scraped my leg 2 weeks ago." VS as follows: T: 37.6, HR: 86, BP 140/78, RR: 16, Pulse ox 99% on RA. Reports chills off and on. Didn't check temperatures.[/quote']

ESI 3, may need ultrasound and labs

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Specializes in Med-Tele; ED; ICU.

Good points regarding the generalized, non-specific abd pain in a FF w/ a history of gastroparesis. I'm trying to visualize the case and I imagine that my mind wouldn't immediately go to ectopic. Certainly the history and presentation doesn't scream 'ectopic' but boy can those go all kinds of bad in a hurry.

I think I would still make her a 2, though.

Certainly she appears in severe pain and it's important not to let our biases and experience with her dramatic lack of coping skills color our assessment. If I knew nothing about her except what I could get from my initial triage, I think she'd be a 2. I don't think it's appropriate to drop her to a 3 based on prior experiences... but I feel a little wishy-washy in what I just typed.

I hate these kinds of cases.

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Specializes in Med-Tele; ED; ICU.
57 year old female - comes in with right lower extremity pain swelling, and redness x 1 week, which is gradually getting worse. "I tripped and fell and scraped my leg 2 weeks ago." VS as follows: T: 37.6, HR: 86, BP 140/78, RR: 16, Pulse ox 99% on RA. Reports chills off and on. Didn't check temperatures.[/quote']

ESI 3

Going to require labs, IV abx are likely.

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