AVPU Responsiveness Scale

The AVPU scale has only four possible outcomes for recording, as opposed to the 13 possible outcomes on the Glasgow Coma Scale (GCS).

The assessor should always work from best (A) to worst (U) to avoid unnecessary testing in patients who are clearly conscious.

Utility

• The AVPU scale is simpler to use than the Glasgow Coma Scale, which assesses responses in three domains (Eyes, Voice, and Motor) but in a more complex manner.
• In first aid, a persistent AVPU level below A is often considered an indication to call an ambulance for hospital assessment.
• In hospital or long-term care settings (e.g. nursing homes), the AVPU scale may form part of routine observations and some patients may persist at a level other than Alert.

Approximate AVPU to GCS Correspondence¹

AVPU	Approximate GCS Score
A	15
V	13
P	8
U	3

Application

The four possible AVPU outcomes are:

Alert

• The patient is fully awake (though not necessarily oriented).
• The patient will have spontaneously open eyes, will respond to voice (though may be confused), and will demonstrate bodily motor function.

In many EMS protocols, Alert may be further graded from 1 to 4, depending on the number of orienting attributes the patient exhibits (Time, Person, Place, Events).

Voice

• The patient gives some kind of response to verbal stimulation:
  • Could be in any of the Eyes, Voice, or Motor domains.
  • Example: patient’s eyes open on hearing “Are you okay?”.
  • Response could be a grunt, moan, or slight movement of a limb.

Pain

• The patient responds to painful stimulus in any of the Eyes, Voice, or Motor domains.
• Recognised methods for applying a pain stimulus include:
  • Sternal rub — knuckles rubbed firmly on the patient’s sternum.
  • Pinching the ear.
  • Pressing a pen or similar object onto the patient’s fingernail bed.
• A fully conscious patient would typically localise the pain and push it away.
• A patient who is not alert and has not responded to voice may exhibit:
  • Simple withdrawal.
  • Involuntary flexion or extension of limbs.
• Care must be exercised when performing any painful stimulus.
• Always perform voice checks first and ensure the assessor is appropriately trained.

Unresponsive

• Sometimes recorded as “unconscious“.
• The patient shows no Eye, Voice, or Motor response to verbal or painful stimuli.

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References

Publications

• 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 Aug;44(2):108-13. 

FOAMed

• Nickson C. Clinical Examination of the Critically Ill. CCC
• Nickson C. Glasgow Coma Scale (GCS). CCC