In any first aid situation, determining the level of consciousness of the casualty is paramount. It is the foundation upon which all subsequent assessments and treatments are built. A person’s level of consciousness indicates the severity of their condition and guides your immediate actions. This comprehensive guide will provide a step-by-step approach to accurately assess the level of consciousness, equipping you with the knowledge and skills to provide effective first aid.
Why is Assessing Level of Consciousness Important?
Assessing a casualty’s level of consciousness helps you:
- Determine the severity of the situation: A reduced level of consciousness can indicate a serious underlying medical condition, such as head injury, stroke, poisoning, or severe infection.
- Prioritize care: Unconscious or partially conscious individuals require immediate attention to ensure their airway is open, they are breathing, and their circulation is maintained (ABC).
- Identify potential causes: The level of consciousness, in conjunction with other signs and symptoms, can provide clues about what might be wrong.
- Monitor changes in condition: Repeated assessments of consciousness help track whether the casualty’s condition is improving, deteriorating, or remaining stable. This information is crucial for communicating with emergency medical services (EMS).
- Inform medical professionals: A clear and accurate assessment provides vital information for paramedics and doctors to make informed decisions about treatment.
The AVPU Scale: A Practical Assessment Tool
The most widely used and easily remembered method for assessing level of consciousness in first aid is the AVPU scale. AVPU stands for:
- A – Alert: The person is fully awake, aware of their surroundings, and responding appropriately to questions and commands.
- V – Responds to Voice: The person is not fully alert but responds in some way (e.g., opens their eyes, moans, or moves) when you speak to them.
- P – Responds to Pain: The person does not respond to voice but responds to a painful stimulus.
- U – Unresponsive: The person does not respond to voice or pain.
Let’s break down each level in detail:
A – Alert
An alert person is fully conscious and aware. To determine if someone is alert, observe their:
- Eye contact: Are they making eye contact with you?
- Orientation: Can they tell you their name, where they are, and the current time (approximately)? This assesses their orientation to person, place, and time. A simple way to remember this is asking: “What’s your name? Where are you? And what day is it?”
- Response to questions: Do they answer questions appropriately and logically?
- Ability to follow commands: Can they follow simple instructions, such as “squeeze my hand” or “open your eyes”?
- General demeanor: Do they appear calm, anxious, confused, or agitated?
If the person is alert and oriented to person, place, and time (often abbreviated as A&O x 3), they are considered fully conscious. However, being alert doesn’t necessarily mean they are unharmed. They may still have underlying injuries or medical conditions that require further assessment and treatment.
V – Responds to Voice
If the person does not appear fully alert, the next step is to see if they respond to your voice. Try the following:
- Speak loudly and clearly: Call their name (if you know it) or use a simple command like “Open your eyes” or “Squeeze my hand.”
- Observe for any response: Look for any sign of awareness, such as:
- Opening their eyes
- Moaning or groaning
- Moving their limbs
- Attempting to speak
- Repeat the command: If there is no initial response, repeat the command in a slightly louder tone.
If the person responds in any way to your voice, they are classified as "V" on the AVPU scale. Note the type of response (e.g., "opens eyes to voice" or "moans to voice") as this provides more detailed information.
P – Responds to Pain
If the person does not respond to your voice, the next step is to assess their response to a painful stimulus. It is crucial to use appropriate and controlled painful stimuli, avoiding any actions that could cause further injury. Acceptable methods include:
- Trapezius Squeeze: Gently but firmly pinch the trapezius muscle, located at the top of the shoulder, between your thumb and forefinger. Apply pressure for a few seconds and observe for a response.
- Supraorbital Pressure: Apply firm pressure with your thumb on the supraorbital notch, located on the bony ridge above the eye socket.
- Sternal Rub (Use with caution and avoid if possible): Use your knuckles to firmly rub the sternum (breastbone). This should only be used if other methods are not eliciting a response, as it can cause bruising.
When applying a painful stimulus, observe for any of the following responses:
- Facial grimacing: A change in facial expression, such as frowning or wincing.
- Withdrawal: Moving a limb away from the painful stimulus.
- Moaning or groaning: Vocalizations in response to the pain.
If the person responds to pain, they are classified as "P" on the AVPU scale. As with the "V" response, document the type of response observed (e.g., "withdraws arm to pain").
Important Considerations When Using Painful Stimuli:
- Avoid unnecessary pain: Only use painful stimuli if the person does not respond to voice.
- Use appropriate pressure: Apply enough pressure to elicit a response but avoid causing injury.
- Observe for subtle responses: Look closely for any sign of reaction, even a slight grimace.
- Avoid in specific situations: Do not use painful stimuli if you suspect a spinal injury, as it could potentially worsen the condition.
- Legal and Ethical Considerations: Be mindful of legal and ethical implications of inflicting pain, even in a first aid context. Your actions should always be in the best interest of the casualty and proportionate to the situation.
U – Unresponsive
If the person does not respond to voice or painful stimuli, they are classified as "U" (unresponsive) on the AVPU scale. This indicates a serious medical emergency, and immediate action is required.
Beyond AVPU: Additional Observations and Assessments
While the AVPU scale provides a quick and simple assessment of level of consciousness, it is important to gather additional information to gain a more complete picture of the casualty’s condition. Consider the following observations:
- Appearance: Note their general appearance. Are they pale, flushed, sweaty, or cyanotic (bluish)? These signs can indicate underlying problems such as shock, dehydration, or respiratory distress.
- Breathing: Assess their breathing rate, depth, and rhythm. Is it fast, slow, shallow, deep, or labored? Are they using accessory muscles (e.g., neck muscles) to breathe? Listen for any unusual sounds, such as wheezing, gurgling, or stridor.
- Circulation: Check their pulse rate and strength. Is it fast, slow, weak, or bounding? Assess their skin temperature and moisture. Is it cold and clammy, warm and dry, or hot and dry? Check capillary refill time by pressing on a fingernail or toenail and observing how quickly the color returns. A prolonged capillary refill time (greater than 2 seconds) can indicate poor circulation.
- Skin Color: Observe the color of their skin, particularly around the lips and fingertips. Bluish discoloration (cyanosis) suggests a lack of oxygen.
- Pupils: Examine their pupils for size, equality, and reaction to light. Unequal pupils, constricted pupils, or dilated pupils that do not react to light can indicate a head injury or neurological problem. Use a penlight to check pupillary response. Shine the light briefly into each eye and observe if the pupil constricts. Also, observe for consensual pupillary response, where the other pupil also constricts when light is shone into one eye.
- Posture: Note their posture and any unusual movements. Are they lying still, restless, or twitching? Are they guarding a particular area of their body? Decorticate or decerebrate posturing (abnormal body positioning) can indicate severe brain injury.
- Seizures: Are they actively seizing or have they recently had a seizure? Note the duration and characteristics of the seizure.
- Medical Alert Tags: Look for any medical alert tags or bracelets that might provide information about underlying medical conditions, allergies, or medications.
- Surroundings: Assess the environment for clues about what might have happened. Are there empty pill bottles, spilled chemicals, or signs of trauma?
- Smell: Note any unusual odors, such as alcohol, acetone (which may indicate diabetic ketoacidosis), or certain chemicals.
The Glasgow Coma Scale (GCS): A More Detailed Assessment (For Advanced First Aiders)
While AVPU is excellent for initial assessment, the Glasgow Coma Scale (GCS) provides a more detailed and nuanced assessment of level of consciousness. It is often used by paramedics and other healthcare professionals. Learning and understanding the GCS can significantly improve your ability to communicate a patient’s condition accurately. It assesses three aspects of responsiveness:
- Eye Opening (E):
- 4 – Spontaneous: Opens eyes spontaneously without any stimulation.
- 3 – To Speech: Opens eyes in response to verbal command.
- 2 – To Pain: Opens eyes in response to painful stimulus.
- 1 – No Opening: Does not open eyes, even to painful stimulus.
- Verbal Response (V):
- 5 – Oriented: Answers questions correctly (name, place, time).
- 4 – Confused: Answers questions but is confused or disoriented.
- 3 – Inappropriate Words: Utters inappropriate words or phrases.
- 2 – Incomprehensible Sounds: Makes incomprehensible sounds (e.g., groaning).
- 1 – No Response: Makes no verbal response.
- Motor Response (M):
- 6 – Obeys Commands: Follows simple commands (e.g., “squeeze my hand”).
- 5 – Localizes Pain: Moves hand above clavicle to stimulus on head or trunk.
- 4 – Withdraws to Pain: Withdraws limb from painful stimulus.
- 3 – Abnormal Flexion (Decorticate): Flexes arm at elbow, hand at wrist, and pronates.
- 2 – Abnormal Extension (Decerebrate): Extends arm at elbow, pronates hand, and flexes wrist.
- 1 – No Response: Makes no motor response.
The GCS score is the sum of the scores for eye opening, verbal response, and motor response. The total score ranges from 3 to 15:
- 15: Fully conscious and alert
- 13-14: Mild impairment
- 9-12: Moderate impairment
- 8 or less: Severe impairment (coma)
Example: A person who opens their eyes to speech (3), is confused (4), and withdraws to pain (4) would have a GCS score of 11.
Note: The GCS requires practice and familiarity to use accurately. It is best learned through formal first aid training or advanced medical courses.
Common Causes of Altered Level of Consciousness
Understanding potential causes of altered level of consciousness can help you provide more effective first aid. Some common causes include:
- Head Injury: Concussion, skull fracture, brain bleed.
- Stroke: Blockage or rupture of a blood vessel in the brain.
- Hypoglycemia (Low Blood Sugar): Often seen in people with diabetes.
- Hyperglycemia (High Blood Sugar): Also seen in people with diabetes.
- Seizures: Uncontrolled electrical activity in the brain.
- Poisoning or Overdose: Ingestion of toxic substances or excessive amounts of drugs.
- Alcohol Intoxication: Excessive alcohol consumption.
- Hypoxia (Lack of Oxygen): Due to airway obstruction, lung disease, or other causes.
- Shock: Inadequate blood flow to the brain.
- Infection: Meningitis or encephalitis.
- Electrolyte Imbalance: Abnormal levels of electrolytes in the blood.
- Cardiac Arrest: Sudden cessation of heart function.
- Heatstroke or Hypothermia: Extremely high or low body temperature.
First Aid Management for an Unconscious Casualty
If you find someone unconscious, follow these steps:
- Ensure Safety: Make sure the scene is safe for you and the casualty. Remove any hazards that could cause further injury.
- Check for Responsiveness: Use the AVPU scale to assess their level of consciousness.
- Call for Help: Immediately call emergency medical services (EMS) or ask someone else to do so. Provide them with as much information as possible, including the casualty’s level of consciousness, breathing status, and any other relevant observations.
- Open the Airway: Use the head-tilt/chin-lift maneuver (unless spinal injury is suspected). Place one hand on the forehead and gently tilt the head back while lifting the chin with the other hand. If you suspect a spinal injury, use the jaw-thrust maneuver instead. Place your fingers behind the angles of the jaw and lift the jaw forward without tilting the head.
- Check for Breathing: Look, listen, and feel for signs of breathing for up to 10 seconds. Look for chest rise and fall, listen for breath sounds, and feel for air movement on your cheek.
- If Breathing: If the person is breathing, place them in the recovery position. This helps to keep the airway open and prevent aspiration (inhalation of fluids into the lungs). To place someone in the recovery position:
- Kneel beside the casualty.
- Extend the arm closest to you above their head.
- Place the arm farthest from you across their chest.
- Bend the leg farthest from you at the knee.
- Gently roll the casualty towards you onto their side.
- Adjust the top leg so that the hip and knee are bent at right angles.
- Tilt the head back to keep the airway open.
- Monitor their breathing continuously.
- If Not Breathing: If the person is not breathing or is only gasping, begin CPR immediately. Perform chest compressions at a rate of 100-120 compressions per minute, and a depth of at least 2 inches (5 cm) but no more than 2.4 inches (6 cm). Give rescue breaths after every 30 compressions (30:2 ratio). Continue CPR until EMS arrives or the person shows signs of life.
- Control Bleeding: If there is any visible bleeding, control it by applying direct pressure to the wound.
- Keep the Casualty Warm: Cover them with a blanket to prevent heat loss.
- Monitor Vital Signs: Continue to monitor their level of consciousness, breathing, and circulation until EMS arrives. Note any changes in their condition and report them to the paramedics.
- Document Your Findings: Record your observations, interventions, and the time they were performed. This information will be valuable for EMS and other healthcare providers.
Special Considerations
- Children and Infants: Assessing level of consciousness in children and infants can be more challenging. Use age-appropriate methods and be patient. Observe their behavior, responsiveness to stimuli, and muscle tone.
- Language Barriers: If you don’t speak the same language as the casualty, use gestures, pictures, or a translation app to communicate.
- Mental Health Conditions: Be aware that some mental health conditions can affect a person’s level of consciousness or responsiveness.
- Drug or Alcohol Use: Drug or alcohol use can significantly impair a person’s level of consciousness and make assessment more difficult.
Legal and Ethical Considerations
When providing first aid, it is important to be aware of the legal and ethical considerations involved. You have a duty to act in good faith and to provide care to the best of your ability. You should also respect the casualty’s autonomy and right to refuse treatment, if they are conscious and capable of making decisions. Implied consent is assumed for unconscious individuals requiring emergency medical attention.
Training is Key
This guide provides a comprehensive overview of how to assess level of consciousness in first aid. However, it is not a substitute for formal training. Take a certified first aid course to learn these skills in a hands-on environment and gain the confidence to respond effectively in an emergency. Regular refresher courses are also essential to keep your knowledge and skills up-to-date.
Conclusion
Assessing level of consciousness is a fundamental skill in first aid. By understanding the AVPU scale, observing other vital signs, and following the steps outlined in this guide, you can accurately assess a casualty’s condition and provide appropriate care. Remember to always prioritize safety, call for help, and continue to monitor the casualty until EMS arrives. Proper training is vital to confidently and effectively manage emergency situations.