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 15 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 degree of disability is measured by the Patient’s level of consciousness: (AVPU)

A= Alert

V= response to VOICE

P= responsiveness to PAIN

U= Unresponsive

Secondary Survey of an Emergency Patient

Parameter
Exposure and
Environmental control
Full Set of Vital Signs
Five Interventions
Facilitate Family Presence
Intervention
Remove clothing for adequate examination.
Keep patient warm with blankets, warmed IV fluids, overhead lights
Obtain vitals signs: temperature, heart rate, respiratory rate, blood
pressure bilaterally
Determine heart rhythm and initiate ECG monitoring, O2 saturation;
insert urinary catheter (if not contraindicated), insert gastric tube; obtain
blood for laboratory studies
Determine family’s desire to be present during invasive procedures
and/or cardiopulmonary resuscitation; assign team member to support
 family.
Give Comfort Measures Assess and treat pain, anxiety; provide emotional support to patient and
family
HISTORY AND HEAD TO
TOE ASSESSMENT

 History  Obtain details of the incident/illness, mechanism and pattern of

injury, length of time since incident occurred, injuries suspected,
treatment provided and patient’s response, level of
consciousness
 Use the mnemonic AMPLE to determine Allergies, Medication
history, Past health history (e.g., pre-existing medical/psychiatric
conditions, last menstrual period), Last meal, and Events/
Environmental preceding illness or injury
 Head, neck and  Note general appearance, including skin color.
face  Examine face and scalp for lacerations, bone or soft tissue
deformity, tenderness, bleeding and foreign bodies.
 Examine eyes, nose, ears and mouth for bleeding, foreign bodies,
drainage, pain, deformity ecchymosis, lacerations
 Examine head for depressions of cranial or facial bones,
contusions, hematomas, areas of softness, bony crepitus.
 Examine neck for stiffness, pain in cervical vertebrae, tracheal
deviation, distended neck veins, bleeding, edema, difficulty
swallowing, bruising, subcutaneous emphysema, bony crepitus.
 Chest  Observe rate, depth and effort of breathing, including chest wall
movement and use of accessory muscles
 Palpate for bony crepitus, subcutaneous emphysema
 Auscultate breathing sounds
 Obtain 12-lead ECG
 Abdomen and  Inspect for external signs of injury; petechiae bleeding, cyanosis,
flanks bruises, abrasions, laceration, old scar
 Evaluate symmetry of external abdominal wall and bony
structures
 Inspect for external signs of injury: bruises abrasions, lacerations,
punctures, old scar
 Pelvis and  Assess for masses, guarding, femoral pulses
perineum  Assess type and location of pain, rigidity, or distension of
abdomen
 Auscultate for bowel sounds
 Gently palpate pelvis
 Extremities  Assess genitalia for blood at the meatus, priapism, ecchymosis,
rectal bleeding and anal sphincter tone
 Determine ability to void
 Inspect for signs of external injury: deformity, ecchymosis,
abrasions, lacerations, swelling.
 Assess for quality and location of pain and tenderness
 Evaluate movement, strength, and sensation inn arms and legs
  Observe skin color and palpate skin for temperature and crepitus
 Presence, quality and symmetry of peripheral pulses
Inspect Posterior surfaces  Logroll and inspect and palpate back for deformity, bleeding,
lacerations, bruises.