Level of Consciousness

Medical illness, traumatic brain injury, alcohol intoxication, drugs, and poisonings may all lead to aberrations in a patient’s 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 comes into play during pre-hospital care, emergency rooms, general hospital wards, and intensive care unit (ICU) settings.

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 independently. 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 can react to that verbal stimulus directly and 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.

Orientation

Asking if the patient knows where they are , who they are, the approximate time can reveal a patient who may be conscious, but not oriented. This assessment is particular important for a patient who possibly has sustained a concussion. Following up with what is the patient doing at this location and time can provide clues that point to amnesia.

Pupils

Pupils are assessed in a darkened room. Unless it’s dark outside, pupils pretty much have to be checked in the back of the ambulance without the lights on. Pupils equally react to light.

Speech and Motor Activity

Listening to spontaneous speech as the patient relates answers to open-ended questions yields much useful information. One might discern problems in output or articulation or the rapid and pressured speech of the manic or amphetamine-intoxicated patient. Overall motor activity should also be noted, including any tics or unusual mannerisms. Abnormal posture (slumped over vs straight back) can provide clues as to the presence of a head injury.

Affect and Mood

Affect is the patient’s immediate expression of emotion; mood refers to the more sustained emotional makeup of the patient’s personality. Patients display a range of affect that may be described as broad, restricted, labile, or flat. Affect is inappropriate when there is no consonance between what the patient is experiencing or describing and the emotion he is showing at the same time (e.g., laughing when relating the recent death of a loved one). Both affect and mood can be described as dysphoric (depression, anxiety, guilt), euthymic (normal), or euphoric (implying a pathologically elevated sense of well-being). Affect must be judged in the context of the setting and those observations that have gone before.

Observing the patient’s facial expressions can provide clues of a head injury. Slurred speech and facial flaccidity can point to a intracerebral hemorrhage as well as a stroke.

Thought and Perception

How the patient perceives and responds to stimuli is therefore a critical psychiatric assessment. Does the patient harbor realistic concerns, or are these concerns elevated to the level of irrational fear? Is the patient responding in exaggerated fashion to actual events, or is there no discernible basis in reality for the patient’s beliefs or behavior?

Attitude and Insight

The patient’s attitude is the emotional tone displayed toward the examiner, other individuals, or his illness. It may convey a sense of hostility, anger, helplessness, pessimism, overdramatization, self-centeredness, or passivity. Likewise, the patient’s attitude toward the illness is an important variable. Is the patient a help-rejecting complainer? Does the patient view the illness as psychiatric or nonpsychiatric? Does the patient look for improvement or is he or she resigned to suffer in silence?

Patient attitude often changes through the course of the interview, and it is important to note any such changes.