The most important steps in initial assessment and resuscitation

  • Airway
  • Breathing
  • Circulation

Anoxia can kill in 4 minutes with hypoxic brain damage occuring in a shorter space of time.
Relative hypoxia will cause rapid hypoxia and ischaemia, with eventual hypoxic cardiac arrest.
Cessation of circulation stops blood flow to the brain with brain death and overall death in minutes.


AVPU score is a quick and simple description of neurological state:

  • Alert – Patient is alert
  • Voice – Responding to voice
  • Pain – Responding to pain
  • Unresponsive – Unresponsive

A ‘P’ on the AVPU score approximates to a GCS of 8.

Glasgow coma scale

Glasgow coma scale (GCS) was designed by the Glasgow neurosurgeons Teasdale and Jennett to deal with patients predominately with head injuries. It has stood the test of time as a consistent and reproducible and ubiquitous method of assessing consciousness.

The GCS is a score out of 15, where 15 is the normal mental state. The scores are nice but in communication most clinicians prefer to talk in actual terms of what the patient can and cannot do; the gradation provided is priceless in economy of conveying clinical information.

The scale is used to calculate the total score. This is a subtle, but important difference. When communicating with other health professionals, it is preferable to give the scores for the individual components and to describe what the patient can or cannot do (rather than the total).


Eyes (E)

  1. Open spontaneously
  2. Open to verbal command
  3. Open to pain
  4. No eye opening

This effectively tests ‘AVPU’ (alert, verbal, pain, unresponsive)

Verbal (V)

  1. Orientated
  2. Confused
  3. Inappropriate words / phrases
  4. Incomprehensible sounds
  5. No response

Motor (M)

  1. Obeys commands
  2. Localises to pain
  3. Withdrawal from pain
  4. Abnormal flexion to pain
  5. Extension to pain
  6. No response

A score of 8 or less indicates coma. The patient may not be able to protect their own airway and intubation should be considered.

ABC always comes before assessing GCS!


Although widely accepted and easy to perform, it may not give much more information than the AVPU scale. Another limitation is that the score can be misleading out of the clinical context.

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