The EMERGENCY SEVERITY INDEX

The EMERGENCY SEVERITY INDEX (ESI) is a five- level triage system that incorporates concepts of illness,
severity and resources utilization (e.g., ECG, laboratory work, radiology studies, IV fluids) to determine
who should be treated first.
FIVE LEVEL EMERGENCY SEVERITY INDEX (ESI)
Definitio ESI 1 ESI 2 ESI 3 ESI 4 ESI 5

n
Stability Unstable Threatened Stable Stable Stable
of vital
function
s (ABC)
Life Obvious Likely but not Unlikely but No No
threat or always obvious possible
organ
threat
How Immediately Minutes Up to 1 hour Could be Could be
soon delayed delayed
should
patient
be seen
by a
physicia
n?
Expecte High resource High resource Medium high Low resources Low resources
d intensity; staff intensity; resource intensity; one intensity;
resource at bedside multiple often intensity; simple examination
s continuously: complex multiple diagnostic only
intensity often diagnostic diagnostic study or a
mobilization of studies; studies or brief simple
team response frequent observation or procedure
consultation, complex
continuous procedure
(remote)
monitoring
Example  Cardiac  Chest  Abdomin  Closed  Cold
s arrest pain al pain extrem sympto
from from or ity ms
ischem ischemi gynecolo trauma  Minor
ia a gic  Simple burns
 Intubat  Multipl disorder lacerati
ed e s unless on
trauma trauma in severe  Cystitis
patient unless stress  Typical
respons  Hip
 SIDS ive fracture migrain
in e
elderly
patient
Systematic approaches to the initial patient assessment in emergent situation are: primary survey and
secondary survey.
 Primary Survey
 Focuses on airway, breathing, circulation and disability and serves to identify life-
threatening condition so that appropriate interventions can be initiate.
 Causes of life – threatening conditions identified during the PRIMARY SURVEY
AIRWAY
o Inhalation injury
o Obstruction (partial and complete) from foreign bodies, debris (e.g., vomitus) or
tongue
o Penetrating wounds and/or blunt trauma to upper airway structures.
BREATHING
o Anaphylaxis
o Flail chest with pulmonary contusion
o Hemathorax
o Pneumothorax (e.g., open, tension
CIRCULATION
o Direct cardiac injury (e.g., myocardial infarction, trauma)

o Pericardial tamponade
o Shock (e.g., massive burns, hypovolemia)
Primary Survey of an Emergency Patient
Airway with simultaneous Cervical Spine Stabilization and/or Immobilization
ASSESSMENT
 Clear and open airway

 Assess for obstruction airway
 Assess for respiratory distress
 Check for loose teeth, foreign objects
 Assess for bleeding, vomitus or edema
INTERVENTION
 Suction
 Jaw – thrust maneuver
 Nasal or oral airway, endotracheal tube, cricothyroidotomy
 Cervical spine immobilization using rigid cervical collar; backboard, towel rolls, forehead secured to
backboard
BREATHING
ASSESSMENT
 Assess ventilation
o Look for paradoxic movement of chest wall during inspiration and expiration
o Note use of accessory muscles or abdominal muscles
o Listen for air being expired through nose and mouth
o Feel for air being expelled
 Observe and count respiratory rate
 Note color of nail beds, mucous membrane, skin
 Auscultate lungs
 Asses for the jugular venous distention and position of trachea
INTERVENTION
 Give supplemental O2 via delivery system

 Ventilate with bag-valve-mask with O2 if respiration are inadequate or absent
 Prepare to intubate if respiratory arrest
 Have suction available
 If absent breath sounds, prepare for needle thoracostomy and chest tube insertion
CIRCULATION
ASSESSMENT
 Check carotid pulse or femoral pulse

 Palpate pulse for quality and rate
 Assess color, temperature, and moisture of skin
 Check for capillary refill
 Assess for external bleeding measure blood pressure
INTERVENTION
 If absent pulse, initiate cardiopulmonary resuscitation and advanced life support measures.
 If shock symptoms or hypotensive, start two large – bore (14-to-16-gauge) IVs and initiate infusions
of normal saline or lactated Ringer’s solution.
 Administer blood products if ordered
 Consider autotransfusion if isolated chest trauma.
 Consider use of pneumatic antishock garment or pelvic splint in the presence of pelvic fracture with
hypotension
 Obtain blood samples for type and crossmatch
 Control bleeding with direct pressure
DISABILITY
Brief Neurologic Assessment
 Assess the level of consciousness by determining response to verbal and/or painful stimuli.
 Assess pupils for size, shape, equality and response to light.
Identify deformities
 Inspect extremities for any obvious deformities

 Determine range of movement and strength in extremities
Brief Pain Assessment
 Assess pain (e.g., PQRST)
INTERVENTION
 Periodically reassess level of consciousness, mental status

 Immobilize (e.g., splint) any obvious deformities
 Periodically reassess pain using standardized pain scale

The EMERGENCY SEVERITY INDEX

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The EMERGENCY SEVERITY INDEX (ESI) is a five- level triage system that incorporates concepts of illness,

FIVE LEVEL EMERGENCY SEVERITY INDEX (ESI)

Definitio ESI 1 ESI 2 ESI 3 ESI 4 ESI 5

o Direct cardiac injury (e.g., myocardial infarction, trauma)

Primary Survey of an Emergency Patient

Airway with simultaneous Cervical Spine Stabilization and/or Immobilization

 Clear and open airway

 Give supplemental O2 via delivery system

 Check carotid pulse or femoral pulse

Brief Neurologic Assessment

 Inspect extremities for any obvious deformities

Brief Pain Assessment

 Assess pain (e.g., PQRST)

 Periodically reassess level of consciousness, mental status

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