AVPU Scale
The AVPU scale is a rapid four-level assessment of consciousness used in pre-hospital care, triage, and the ABCDE primary survey. It provides a quick snapshot of neurological status without the complexity of the GCS.
✦ The Mnemonic
"Alert, Voice, Pain, Unresponsive"
Four levels of consciousness — assessed in under 10 seconds
Clinical Breakdown
The AVPU scale maps approximately to the Glasgow Coma Scale (GCS): A = GCS 15, V = GCS 12, P = GCS 8, U = GCS 3. A patient who is 'P' on AVPU has a GCS of approximately 8 — the threshold at which airway protective reflexes are compromised and intubation must be considered. This makes 'P' a critical decision point.
Painful stimuli should be central (sternal rub, trapezius pinch, supraorbital pressure) to avoid spinal reflex withdrawal responses. Peripheral stimuli (nail bed pressure) can produce localised withdrawal even in patients with no higher cortical function — this can falsely suggest a better response.
AVPU is part of the NEWS2 score (National Early Warning Score 2) used across UK NHS hospitals. A new AVPU score of V, P, or U scores 3 points — the maximum for any single parameter — and triggers an immediate clinical review. Any deterioration from baseline AVPU is significant even if the patient remains 'A'.
⭐ Clinical Pearl
'P' on AVPU = airway emergency. GCS ≤8 means the patient cannot reliably protect their own airway. In the primary survey, a patient responding only to pain requires immediate airway assessment, senior review, and preparation for definitive airway management. Do not wait for deterioration to U before acting.
⚠ Exam Trap
AVPU vs GCS: AVPU is rapid but insensitive — it cannot detect subtle neurological deterioration that GCS would capture. A patient can deteriorate from GCS 15 to GCS 10 and still score 'A' on AVPU. For ongoing neurological monitoring (head injury, post-op neurosurgery), use full GCS, not AVPU.