Author: David Romanelli Editor: Mitchell W. Farrell
Updated: 4/3/2023 5:39:34 PM
Definition/Introduction
Medical illness,traumatic brain injury, alcohol intoxication, drugs, and poisonings may all lead to aberrations in a patient's neurological and physiological statusin ways that cause an abnormal level of consciousness. AVPU is astraightforward scale that is useful to rapidly grade a patient's gross level of consciousness, responsiveness, or mental status. It comes into playduring pre-hospital care, emergency rooms, general hospital wards, and intensive care unit (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 independently. 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 can react to that verbal stimulus directly and in a meaningful way.
- Painfully Responsive: The patient's eyes do not open spontaneously. The patient will onlyrespondto the application of painful stimuli by an examiner. The patient may move, moan, or cry out directly in response tothe painful stimuli.
- Unresponsive: The patient does not respond spontaneously. The patient does not respond to verbal or painful stimuli.
Issues of Concern
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Issues of Concern
Comparison With Other Scales of Mental Status
Other scales forassessing mental status exist and may be superior to AVPU inspecificsettings.
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 both GCS and RASS in admitted patients were significantly more accurate predictors of mortality than AVPU. Further, the routine tracking of GCS and/or RASS on the wardsmay improve the accuracy of detecting patients with deteriorating clinical status.[4]
TheACDU Scale (alertness, confusion, drowsiness, and unresponsiveness) is another 4-point scale similar to AVPU. One study showed that ACDU might be superior forthe 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 ACDUis superior at identifying early deterioration in the conscious level when they occur in critically ill ward patients than AVPU.[5]
The Simplified MotorScore (SMS) categorizes and scores patients in the following three categories: obeys commands, localizes pain, and withdraws to pain or worse. It is useful in evaluating patientsin the pre-hospital and acute care setting for possible traumatic brain injury. One study has shown itto have the best interrater reliability for assessing the altered loss of consciousness (LOC) of traumatic and non-traumatic causes among AVPU, GCS, and ACDU.[6]
Clinical Significance
Utility in First Aid, Pre-Hospital Care, and Emergency Care
The AVPUscale is a quick and simple way of detecting altered mental status (AMS) in a patient.No formal training is necessary to use this scale. It can be utilized during first aid and in the pre-hospital setting asany scale lower than an "A" is considered abnormal until proven otherwise.This result should prompt the examiner to conduct additional assessments orbegin more definitive care. EMS crews may begin withAVPU, followed by a GCS assessment if the AVPU score is below "A." AVPU is less detailed than the Glasgow Coma Scale, but it is performablemore quickly.AVPU was initially used in the primary survey of trauma patients, as a decreased mental status could indicate inadequatecirculation of oxygenated blood to the brain.[4][7]
Utility in Hospital Care and Long Term Healthcare Facilities
AMSis one of the strongest predictors of death on the wards. Health care professionalswithina hospital utilize this scale during patient assessment for any patients at risk of having an abnormal level of consciousness.[4]It plays a role in RapidResponse Activation Criterion and Early Warning Scoresto 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 patient's hospitalstay.[4]Select patients, such as those in long-term health facilities or nursing homes, may have an AVPU scale of less than A,which is considered the patient's baseline. The AVPU scale is notintended for long-term neurological observation of the patient.
Correlation to the Glasgow Coma Scale and Airway Protection
Similar to GCS, where a scale of 8 or lower prompts health careproviders 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 AVPUscale correlates to distinct GSC ranges, as outlined below.[5][4]
- GCS Score 15 - Alert
- GCS 12 to 13 - Verbally Responsive
- GCS 5 to 6 - Physically Responsive
- GCS 3 - Unresponsive
Nursing, Allied Health, and Interprofessional Team Interventions
The nurses looking after the patient should be knowledgeable about the AVPU scoring system if they are using it frequently. A drop in score should immediatelygenerate an alert to the managing clincian.
References
[1]
Wasserman EB, Shah MN, Jones CM, Cushman JT, Caterino JM, Bazarian JJ, Gillespie SM, Cheng JD, Dozier A. Identification of a neurologic scale that optimizes EMS detection of older adult traumatic brain injury patients who require transport to a trauma center. Prehospital emergency care. 2015 Apr-Jun:19(2):202-12. doi: 10.3109/10903127.2014.959225. Epub 2014 Oct 7 [PubMed PMID: 25290953]
2: Moderate level of evidence", html: true, placement: "top", trigger:'hover' } ); $('a[refgrade*="(A2)"]').popover( { content: "A: Benefits outweigh the risks
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[2]
Hoffmann F, Schmalhofer M, Lehner M, Zimatschek S, Grote V, Reiter K. Comparison of the AVPU Scale and the Pediatric GCS in Prehospital Setting. Prehospital emergency care. 2016 Jul-Aug:20(4):493-8. doi: 10.3109/10903127.2016.1139216. Epub 2016 Mar 8 [PubMed PMID: 26954262]
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[3]
Trefan L, Houston R, Pearson G, Edwards R, Hyde P, Maconochie I, Parslow RC, Kemp A. Epidemiology of children with head injury: a national overview. Archives of disease in childhood. 2016 Jun:101(6):527-532. doi: 10.1136/archdischild-2015-308424. Epub 2016 Mar 14 [PubMed PMID: 26998632]
Level 3 (low-level) evidence
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