AVPU Scale

About the AVPU scale

The AVPU is a consciousness evaluation system aimed at checking responsiveness to a series of stimuli. It was initially aimed at offering a more simple and rapid evaluation than that of the Glasgow Coma Scale.

The evaluation focuses on eye, voice and motor skills and there are four possible outcomes (described further in the text). Any result below A (Alert and orientated) requires immediate medical attention.

Acute illness and trauma are the main causes of a decreased level of consciousness and may lead to airway obstruction and loss of protective airway reflexes. If intervention is not rapid, there is risk of respiratory or cardiac arrest.

If the patient is unconscious, then the vital signs are to be checked, along with ensuring the patient’s airway is not obstructed and that they are placed in a recovery position. Any oxygen saturation below 94% requires oxygen supplementation.

The following table summarises some of the causes of a decreased conscious level:

I Alert and oriented

A patient who is alert is fully awake and reacts to external environmental stimuli and can identify people around, even if with slight confusion.

The orientation state is evaluated by asking the patient to answer simple questions such as:

■ What is your name?

■ Where are you now?

■ What time and date is it?

Questions where the patient can detail the answer are preferred to yes or no questions. Alert state is reported on a scale from 1 to 4, that depends on how specific the patient’s answers were.

II Verbal stimulus, voice answer

The patient responds to verbal stimulation but did not appear aware or fully awake before this stimulation took place.

Questions asked here may be similar to those testing alertness, however, in this part of the AVPU, it should be noted whether the responses are appropriate or inappropriate. In the former case, there is a high likelihood of lack of orientation.

III Responsive to pain

The patient is stimulated using mild pain such as a central pain stimulus, stern rub or peripheral stimulus like pinching the ear or pressing a fingernail and the reaction is observed.

It is important to note whether the patient has a localizing reaction (shows feeling where the stimulus was applied). Second reaction, that of either opening eyes, moaning, talking or movement, needs to be recorded.

In this case, movement may be a voluntary or involuntary reaction, flexion or extension of a limb or total movement of the body away from the stimulus.

IV Unresponsive

This outcome means the patient is not awake, does not answer to verbal or pain stimulation and remains flaccid. There is no movement and the patient does not produce any sounds, intelligible or not.

It is important to note whether the patient is unconscious with response to stimuli or completely unresponsive.

AVPU vs. Glasgow coma scale

The AVPU is often used in conjunction with the Glasgow coma scale, as a supplement to the LOC (level of consciousness) section in the GCS. The best response that the patient can maintain is recorded.

The main limitation of the AVPU refers to the fact that it cannot provide long term follow up on neurologic status, something the GCS can.

The following table introduces the correlation between AVPU outcomes and GCS scores:

References

1. Kelly CA, Upex A, Bateman DN. Comparison of consciousness level assessment in the poisoned patient using the alert/verbal/painful/unresponsive scale and the Glasgow Coma Scale. Ann Emerg Med. 2004; 44(2):108-13.

2. McNarry AF, Goldhill DR. Simple bedside assessment of level of consciousness: comparison of two simple assessment scales with the Glasgow Coma scale. Anaesthesia. 2004; 59(1):34-7.

3. Raman S, Sreenivas V, Puliyel JM, Kumar N. Comparison of alert verbal painful unresponsiveness scale and the Glasgow Coma Score. Indian Pediatr. 2011; 48(4):331-2.