1. Unit 3 Lesson 2: AVPU, GCS, and PEARL

2. No cells, ear buds, or I-pads!

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Disability or LOC. Disability refers to assessment of the patient’s neurological condition. The goal is to determine the patient’s level of consciousness (LOC) and ascertain the potential or level of hypoxia. A decreased LOC should alert a CP to the possibility of decreased oxygenation, central nervous system injury, drug or alcohol overdose, or metabolic failure (such as seizure or cardiac arrest).

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Some patients are not awake but will respond to verbal stimuli, such as talking or shouting. At a more depressed level, the patient will respond only to painful stimuli, such as pinching a toe or rubbing the sternum briskly. The lowest and most serious status is unresponsiveness, when the patient will not respond to even painful stimulus.

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An easy way to keep levels of responsiveness in mind is by remembering the mnemonic, AVPU, which stands for the following: A – alert, V – responds to verbal stimuli, P – responds to painful stimuli, and U – unresponsive. However, the Glasgow Coma Scale (GCS) provides a more comprehensive standard of cerebral function.

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The maximum GCS score is 15, indicating a patient with no disability, whereas the lowest score of 3 indicates a very critical injury. The GCS is divided into three sections: Eye Opening, Best Verbal Response, and Best Motor Response. The PHCP assigns the patient a score according to the best response to each component of the GCS.

9. https://www.youtube.com/watch?v=8bcn1V4G 7e0

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If the patient is not awake, oriented, and able to follow commands, the CP should assess the pupils quickly. Are the pupils equal, round, and reactive to light (PEARL)? Or are the pupils unequal to each other, unresponsive and dilated?

11. dilated pupil

12. constricted pupil

13. NOT – PEERL (PEARL)

14. possible concussion – fixed and constricted

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A GCS score of less than 14 in combination with an abnormal pupil examination can indicate the presence of a life threatening brain injury. Although AVPU is quicker to assess than the GCS, it provides less useful information and because GCS is used more extensively in the ER, it should be used in the pre hospital setting to provide important baseline information.

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Every trauma patient with a significant mechanism of injury is suspected of spinal Injury until it is conclusively ruled out. Therefore when establishing an open airway, the PHCP must remember that the possibility of a cervical spine injury exists. The solution is to ensure that the patient’s neck is manually maintained in the neutral position during the opening of the airway in order to protect the patient’s spine from unnecessary movement.

17. Let’s take a break for now…

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Necessity often dictates that the steps of patient assessment are performed concurrently and not in order. In other words, do not delay the interventions needed to ensure ABC’s in order to take the time to perform a focused history and physical exam. Often times a focused history must be done concurrently with treatment interventions in order to stabilize a patient and prevent life-threatening conditions. An important aspect of the focused history in a patient with a significant M of I is an emphasis on a thorough evaluation of the patient’s body.

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Repeated baseline vitals and a focused history are usually conducted after the primary survey has been accomplished and after interventions used to ensure ABC’s have been initiated. This focused history is also known as the secondary survey.

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Expose / Environment. An early step in the secondary assessment process is to remove a patient’s clothing because exposure of the trauma patient is critical to finding all injuries. The saying that “the one part of the body that is not exposed will be the most severely injured part” may not always be true, but it is true often enough to warrant a total body examination.

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Remember to limit assessment and scene time to 10 minutes or less when any of the following life-threatening conditions are present in the field: Inadequate or threatened airway, impaired ventilation, significant external hemorrhage or suspected internal hemorrhage. Abnormal neurological status such as a GCS score of < 13 and or seizure. Or penetrating trauma to the head, neck, or torso, and amputation or near amputation.

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If the patient has an immediately life threatening problem – such as a blocked airway, a stoppage of breathing or heartbeat or severe bleeding – you must immediately perform interventions – actions to correct these problems – and consider whether you need to transport the patient without delay – if you are EMS – or institute more invasive interventions and treatments if you are ER.

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To get the trauma patient to definitive care the CP must quickly identify the seriousness of the patient’s condition and injuries and provide only those essential lifesaving interventions at the scene that provide for rapid stabilization and transportation to an appropriate medical facility because every additional minute spent on the scene is additional time taken away from the Golden Period.

24. We’re done!