What it is
AVPU is a four-point shorthand for level of consciousness, used in the Disability (D) step of the ABCDE primary survey. It trades the granularity of the Glasgow Coma Scale for speed and reproducibility — anyone can apply it in seconds, with little inter-rater disagreement.
The four levels
- A — Alert: awake, eyes open, responds spontaneously to the environment.
- V — Voice: responds (eyes, voice, or movement) only when spoken to.
- P — Pain: responds only to a painful stimulus (e.g. trapezius squeeze, supraorbital pressure).
- U — Unresponsive: no response to voice or pain.
It is graded on the best response the child gives.
When to use it
As the first-pass consciousness check in any acutely unwell or injured child — triage, prehospital, the resus room, ward escalation. It is built into most pediatric early-warning scores. Use it for rapid serial reassessment; a drop from A to V to P is an urgent deterioration signal.
The key clinical link
A child responding only to Pain (P) or Unresponsive (U) is presumed to have a GCS of roughly 8 or less — the threshold at which protective airway reflexes are unreliable. In practical terms: P or U means consider the airway is at risk — position, suction, adjuncts, and call for senior/anaesthetic help. This is the single most useful thing AVPU tells you.
Worked example
A toddler post-seizure, drowsy: doesn’t open eyes or respond when called by name, but grimaces and withdraws to a trapezius squeeze → P (Pain). This flags airway risk and prompts recovery positioning, suction readiness, and conversion to a formal GCS plus glucose check, while the cause is sought.
Pitfalls and caveats
- Less granular than GCS — it cannot track subtle change, so escalate to a full pediatric GCS once the patient is stabilised or if trends matter (e.g. head injury monitoring).
- “Voice” is ambiguous in infants who don’t follow commands — judge by any response (turning, settling, eye-opening) to your voice versus needing pain.
- Always pair it with a glucose check (“Don’t Ever Forget Glucose”) — hypoglycaemia is a rapidly reversible cause of reduced consciousness.
- Some services use ACVPU, inserting C for new Confusion before V; know which version your protocol uses.
Run it: AVPU Scale
Decision support for qualified clinicians only — verify against current primary guidelines and your clinical judgement.