Delta Tutor · Free, no sign-up
AVPU Scale and Alert & Oriented x4
AVPU is the fastest read on a patient’s level of consciousness: four steps, no equipment, a few seconds inside your primary survey. Alert and Oriented x4 is what you ask once you have established the patient is alert, and together they are the screen that tells you whether a full Glasgow Coma Scale is going to be a formality or the most important thing you do on this call.
Skip to the testThe scale
You are answering one question: how much stimulus does this patient need before they respond? Work down the letters and stop at the first one that fits.
Alert
Eyes open, responding to their environment without you having to do anything. Alert is where you stop using AVPU and start asking the orientation questions, because an alert patient can still be completely disoriented.
New ConfusionACVPU
Awake and talking, but newly confused, disoriented or agitated compared with their own baseline. This letter is the modern addition and is the one most often missed.
Voice
No response until you speak to them. Any reply counts: opening their eyes, a groan, moving. They needed a stimulus, so they are not Alert.
Pain
No response to voice, but responds to a central painful stimulus such as a trapezius pinch. Withdrawal, groaning or eye opening all count. Roughly the level where airway protection becomes a live concern.
Unresponsive
No response to voice or pain. Assume no protective airway reflexes and manage the airway first.
The C is the modern update. The National Early Warning Score 2 replaced plain AVPU with ACVPU because new confusion is an early sign of sepsis, metabolic derangement and intracranial pathology, and the old scale filed those patients under Alert and missed them. The word that matters is new: a patient with long-standing dementia sitting at their usual baseline is not scored C, which is why you ask family or staff what normal looks like for this person.
Alert and Oriented x4
Alert only tells you the patient is responding on their own. It says nothing about whether they are making sense. These four questions are what turn “alert” into something useful, and they cost you about twenty seconds.
1. Person
“Can you tell me your name?”
2. Place
“Do you know where you are right now?”
3. Time
“Do you know what day it is? The month? The year? The season?”
4. Event
“Do you know what happened? What brought us here today?”
Score it as the number they get right: a patient who knows who and where they are but not the date or what happened is A&Ox2. Name which two, because “x2” on its own makes the next provider guess. Orientation tends to erode in a predictable order, with time going first and person usually last, so a patient who does not know their own name is deeply impaired.
How this feeds the Glasgow Coma Scale
AVPU is the screen and the GCS is the score. AVPU fits in the primary survey and tells you in seconds whether you have a problem; the GCS is the reproducible number that gets trended and handed over. As a rough orientation only, an alert patient tends to sit near 15, voice-responsive around 12 or 13, pain-responsive around 8, and unresponsive at 3.
Do not convert one into the other
Those numbers are a feel for severity, not a conversion table. Published agreement between AVPU and GCS is loose, and a converted score in a chart looks like a measured one to whoever reads it next. Document the scale you actually used, and if the GCS is what your service records, take the GCS.
Test yourself
Ready to test yourself?
10 randomized questions drawn from a bank of 15, with an explanation after every answer. No score is kept or sent anywhere, so take it as many times as you like.
A free study aid from Delta Emergency Support Training. Not certification and not medical direction. Assessment techniques, including which painful stimulus is acceptable, are set by your own scope of practice, protocols and medical oversight.