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.

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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]

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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