AVPU (Alert, Voice, Pain, Unresponsive)

Article Author:
David Romanelli
Article Editor:
Mitchell Farrell
Updated:
2/10/2019 11:08:41 AM
PubMed Link:
AVPU (Alert, Voice, Pain, Unresponsive)

Definition/Introduction

Medical illness, traumatic brain injury, alcohol intoxication, drugs, and poisonings may all lead to aberrations in a patients neurological and physiological status in ways that cause an abnormal level of consciousness. AVPU is a straightforward scale that is useful to rapidly grade a patient’s gross level of consciousness, responsiveness, or mental status. It is used during pre-hospital care, emergency rooms, general hospital wards, and ICU settings.[1][2][3][4] 

The basis of the AVPU scale is on the following criterion:

  • Alert: The patient is aware of the examiner and can respond to the environment around them on their own. The patient can also follow commands, open their eyes spontaneously and track objects.
  • Verbally Responsive: The patient’s eyes do not open spontaneously. The patient’s eyes open only in response to a verbal stimulus directed toward them. The patient is able to directly react to that verbal stimulus in a meaningful way.
  • Painfully Responsive: The patient’s eyes do not open spontaneously. The patient will only respond to the application of painful stimuli by an examiner. The patient may move, moan, or cry out directly in response to the painful stimuli.
  • Unresponsive: The patient does not respond spontaneously. The patient does not respond to verbal or painful stimuli.

Issues of Concern

Comparison with other scales of Mental Status

Other scales for assessing mental status exist and may be superior to AVPU in specific settings.

The Glasgow Coma Scale (GCS) and the Richmond Sedation and Agitation Scale (RASS) are two scales used for assessing mental status. One study showed that in admitted patients, both GCS and RASS were significantly more accurate predictors of mortality then AVPU. Further, the routine tracking of GCS and/or RASS on the wards may improve the accuracy of detecting patients with deteriorating clinical status.[4]

The ACDU Scale (alertness, confusion, drowsiness, and unresponsiveness) is another 4-point scale similar to AVPU. One study showed that ACDU might be superior for the simple ward assessment of seriously ill patients compared to AVPU. Additionally, median GCS scores associated with ACDU were 15, 13, 10 and 6. The median values of ACDU were more evenly distributed than AVPU when researchers compared both scales to GCS. This even distribution may indicate that ACDU is superior at identifying early deteriorations in the conscious level when they occur in critically ill ward patients compared to AVPU.[5]

The Simplified Motor Score (SMS) categorizes and scores patients in the following three categories: obeys commands, localizes pain, and withdraws to pain or worse. It is used to evaluate patients in the pre-hospital and acute care setting for possible traumatic brain injury. One study has shown it to have the best interrater reliability for assessing the altered loss of consciousness (LOC) of traumatic and non-traumatic cause among AVPU, GCS, and ACDU.[6] 

Clinical Significance

Utility in First Aid, Pre-Hospital Care, and Emergency Care

The AVPU scale is a quick and simple way of detecting altered mental status (AMS) in a patient. No formal training is necessary to use this score. It can be utilized during first aid and in the pre-hospital setting as any score lower than an "A" is considered abnormal until proven otherwise. This should prompt the examiner to conduct additional assessments or begin more definitive care. EMS crews may begin with AVPU, to be followed by a GCS assessment if the AVPU score is below "A." AVPU is less detailed than the Glasgow Coma Scale, but it is performed at a much faster rate. AVPU was initially used in the primary survey of trauma patients, as a decreased mental status could indicate inadequate circulation of oxygenated blood to the brain.[4][7]

Utility in Hospital Care and Long Term Healthcare Facilities

AMS is one of the strongest predictors of death on the wards, and health care professionals within a hospital utilize this scale during patient assessment for any patients who are at risk of having an abnormal level of consciousness.[4] It plays a role in Rapid Response Activation Criterion and Early Warning Scores to detect changes in a patient’s physiologic status in hopes of becoming aware of and correcting any potentially life-threatening issues that could have arisen during a patients hospital stay.[4] Select patients, such as those in long term health facilities or nursing homes may have an AVPU score of less than A which is considered to be the patient's baseline. The AVPU scale is not intended for long-term neurological observation of the patient. 

Correlation to the Glasgow Coma Scale and Airway Protection

Similarly to GCS, where a score of 8 or lower prompts health care providers to consider the need for airway protection, the AVPU scale also addresses airway management and aspiration risks. Patients scoring "P" or “U” may have decreased or absent gag reflexes and thus are unable to maintain a patent airway. This status should prompt the healthcare provider to consider initiating a means of airway protection to avoid airway compromise or aspiration. 

The AVPU scale correlates to distinct GSC ranges, as outlined below.[5][4] 

  • GCS Score 15 ~ Alert
  • GCS 12-13 ~ Verbally Responsive
  • GCS 5-6 ~ Physically Responsive 
  • GCS 3 ~ Unresponsive

References

[1] Identification of a neurologic scale that optimizes EMS detection of older adult traumatic brain injury patients who require transport to a trauma center., Wasserman EB,Shah MN,Jones CM,Cushman JT,Caterino JM,Bazarian JJ,Gillespie SM,Cheng JD,Dozier A,, Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 2015 Apr-Jun     [PubMed PMID: 25290953]
[2] Comparison of the AVPU Scale and the Pediatric GCS in Prehospital Setting., Hoffmann F,Schmalhofer M,Lehner M,Zimatschek S,Grote V,Reiter K,, Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 2016 Jul-Aug     [PubMed PMID: 26954262]
[3] Epidemiology of children with head injury: a national overview., Trefan L,Houston R,Pearson G,Edwards R,Hyde P,Maconochie I,Parslow RC,Kemp A,, Archives of disease in childhood, 2016 Mar 14     [PubMed PMID: 26998632]
[4] Comparison of mental-status scales for predicting mortality on the general wards., Zadravecz FJ,Tien L,Robertson-Dick BJ,Yuen TC,Twu NM,Churpek MM,Edelson DP,, Journal of hospital medicine, 2015 Oct     [PubMed PMID: 26374471]
[5] Simple bedside assessment of level of consciousness: comparison of two simple assessment scales with the Glasgow Coma scale., McNarry AF,Goldhill DR,, Anaesthesia, 2004 Jan     [PubMed PMID: 14687096]
[6] Interrater reliability of 3 simplified neurologic scales applied to adults presenting to the emergency department with altered levels of consciousness., Gill M,Martens K,Lynch EL,Salih A,Green SM,, Annals of emergency medicine, 2007 Apr     [PubMed PMID: 17141146]
[7] Planas JH,Waseem M, Trauma Primary Survey 2018 Jan;     [PubMed PMID: 28613551]