ESTUDIOS DE CASOS
TRATO APLICABLE A LOS VEHÍCULOS DE MOTOR USADOS
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