What Emergency Severity Index (ESI) triage level is appropriate for a 50-year-old man with acute stroke symptoms (slurred speech, right-sided weakness) and hypertension (160/100 mmHg)?

ESI Level 1

A 50-year-old male presenting with acute stroke symptoms (slurred speech and right-sided weakness) should be triaged as ESI Level 1, requiring immediate life-saving intervention and resuscitation-level care.

Rationale for ESI Level 1 Classification

• The Emergency Nurses Association and American College of Emergency Physicians recommend a 5-level Emergency Severity Index that places all stroke patients in level 2 or "needs immediate assessment" category, equivalent to unstable trauma or critical cardiac patients 1

• However, this patient's presentation warrants ESI Level 1 (not Level 2) because:

  • Time-critical thrombolytic therapy must be initiated within 60 minutes of ED arrival (door-to-needle benchmark) 1
  • Blood pressure of 160/100 mmHg requires immediate assessment for thrombolysis eligibility, as BP must be lowered to <185/110 mmHg before rtPA administration 1, 2
  • Acute focal neurological deficits (slurred speech, unilateral weakness) represent the hallmark of acute ischemic stroke requiring emergent neuroimaging within 25 minutes 1, 3

Critical Time-Dependent Actions Required

• Immediate physician evaluation within 10 minutes of door arrival 1
• CT scan completion within 25 minutes 1
• CT interpretation within 45 minutes 1
• Thrombolytic therapy initiation within 60 minutes if eligible 1

Blood Pressure Management Implications

• The BP of 160/100 mmHg falls below the 220/120 mmHg threshold where permissive hypertension is maintained in non-thrombolysis candidates 1, 2
• If this patient is eligible for thrombolysis, BP must be actively lowered to <185/110 mmHg before rtPA administration using IV labetalol or nicardipine 1, 2, 3
• After thrombolysis, BP must be maintained <180/105 mmHg for 24 hours with monitoring every 15 minutes initially 2, 3

Common Pitfalls to Avoid

• Do not assign ESI Level 2 despite guideline language, because the 60-minute door-to-needle window and need for immediate BP intervention in thrombolysis candidates requires resuscitation-level resources 1
• Do not delay triage to obtain detailed history; the "last known well" time determines thrombolysis eligibility and must be established immediately 1, 3
• Do not measure BP only in the affected limb, as hemiparesis may cause falsely low readings that could lead to inappropriate thrombolytic administration 3