AVPU

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The AVPU scale (Alert, Voice, Pain, Unresponsive) is a system by which a first aider, ambulance crew or health care professional can measure and record a patient's level of consciousness. [1]

It is a simplification of the Glasgow Coma Scale, which assesses a patient response in three measures - Eyes, Voice and Motor skills. The AVPU scale should be assessed using these three identifiable traits, looking for the best response of each.[2]

Meaning of the mnemonic

The AVPU scale has only 4 possible outcomes for recording (as opposed to the 13 possible outcomes on the Glasgow Coma Scale). The assessor should always work from best (A) to worst (U) to avoid unnecessary tests on patients who are clearly conscious. The four possible recordable outcomes are:[2]

  • Alert - a fully awake (although not necessarily orientated) patient. This patient will have spontaneously open eyes, will respond to voice (although may be confused) and will have bodily motor function.
  • Voice - the patient makes some kind of response when you talk to them, which could be in any of the three component measures of Eyes, Voice or Motor - e.g. patient's eyes open on being asked "are you okay?!". The response could be as little as a grunt, moan, or slight move of a limb when prompted by the voice of the rescuer.
  • Pain - the patient makes a response on any of the three component measures when pain stimulus is used on them. Recognized methods for causing the pain stimulus include a Sternal rub (although in some areas, it is no longer deemed acceptable), where the rescuers knuckles are firmly rubbed on the breastbone of the patient, pinching the patient's ear and pressing a pen (or similar instrument) in to the bed of the patient's fingernail. A fully conscious patient would normally locate the pain and push it away, however a patient who is not alert and who has not responded to voice (hence having the test performed on them) is likely to exhibit only withdrawal from pain, or even involuntary flexion or extension of the limbs from the pain stimulus. The person assessing should always exercise care when performing pain stimulus as a method of assessing levels of consciousness, as in some jurisdictions, it can be considered assault. This is a key reason why voice checks should always be performed first, and the person assessing should be suitably trained.
  • Unresponsive - Sometimes seen noted as 'Unconscious', this outcome is recorded if the patient does not give any Eye, Voice or Motor response to voice or pain.

In first aid, an AVPU score of anything less than A is often considered an indication to get further help, as the patient is likely to be in need of more definitive care. In the hospital or long term healthcare facilities, caregivers may consider an AVPU score of less than A to be the patient's normal baseline.

In some emergency medical services protocols, "Alert" can be subdivided into a scale of 1 to 4, in which 1, 2, 3 and 4 correspond to certain attributes, such as time, person, place, and event. For example, a fully alert patient might be considered "alert and oriented x 4" if he/she could correctly identify the time, their name, their location, and the event.

Ambulance crews may begin with an AVPU assessment, to be followed by a GCS assessment if the AVPU score is below "A."

The AVPU scale is not suitable for long-term neurological observation of the patient; in this situation, the Glasgow coma scale is more appropriate.

References

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