How to Use the Pediatric ESI Triage Tool

Choose the appropriate age group to ensure the tool applies correct pediatric vital-sign danger zones.

• Neonate: 0–28 days
• Infant: 29 days – 12 months
• Child: 1–10 years (requires exact age)

Select “Yes” if the patient requires immediate critical intervention such as:

• Bag-mask ventilation or respiratory support
• Intubation
• Emergent cardioversion
• Active seizure with airway compromise
• Severe respiratory distress or cyanosis

Choose “Yes” if the pediatric patient appears:

• Toxic, mottled, or severely ill-appearing
• Lethargic, inconsolable, or with altered mental status
• Poorly perfused (cool extremities, delayed cap refill)
• In significant pain or respiratory distress
• Presenting with a condition nurses recognize as high-risk

Count how many resources the child is expected to need:

• Laboratory tests
• X-rays or ultrasound
• CT scans
• IV fluids or medications
• Nebulizer treatments
• Procedures (lacerations, splinting, catheterization)

For patients classified as ESI 3, the tool evaluates their age-specific vital signs:

Neonates (0–28 days)

• HR < 100 or > 205
• RR < 30 or > 60
• SBP < 60
• Temp ≥ 100.4°F → automatically ESI 2
• SpO₂ < 90%

Infants (29 days–12 months)

• HR < 100 or > 190
• RR < 25 or > 53
• SBP < 70
• Temp ≥ 100.4°F = abnormal
• SpO₂ < 90%

Children (1–10 years)

• HR < 60 or > 140
• RR < 18 or > 37
• SBP below 70 + (2 × age)
• Temp ≥ 102.2°F
• SpO₂ < 90%

ESI 1: Immediate resuscitation required
ESI 2: High-risk, concerning appearance, or danger-zone vitals
ESI 3: Stable but needs multiple resources
ESI 4: Stable, needs one resource
ESI 5: Stable, needs no resources

For ESI Levels 3–5, the tool displays a bar graph showing the child’s vital signs.

This graph provides a quick, visual snapshot of the child’s physiologic stability.

Use the “Reset Tool” button to clear all fields and begin a new triage assessment. This is ideal for repeated training, simulations, and classroom scenarios.