Document Type: Letter to Editor

Author

Department of Forensic Medicine and Toxicology, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Abstract

I read with interest a recent paper in your journal, in which three consciousness assessment scales were compared in poisoned patients and finally a new scale "AVPU plus" was proposed (1). The study was very interesting with a worthy objective. I would like to admire the authors for exploring how the Alert/Verbal/Painful/Unresponsive (AVPU) responsive scale corresponds with the Glasgow Coma Scale (GCS) and Richmond Agitation-Sedation Scale (RASS) scores in drug-poisoned patients, and for proposing an augmented AVPU scale.
The GCS was developed by Teasdale and Jennet in 1974 (2), aimed at standardizing assessment of level of consciousness in head trauma victims (3). The AVPU scale has been developed for rapid neurologic assessment of 
traumatic patients and for those in need of advanced life support (1,4). RASS has been developed to assess agitation-sedation status of critical patients in intensive care unit (5,6).
Because there has been no standardized unified method for assessment of consciousness impairment in patients with drug and chemical poisoning, physicians have used different methods or scales in different medical settings. Therefore, developing a research-based scale that is agreed among most medical toxicologists seems necessary. My colleagues and I usually use the AVPU scale in our routine practice. Nonetheless, looking at this newly proposed scale, we believe using AVPU plus for poisoned patients in emergency setting or clinical toxicology ward would be helpful and practical. As a recommendation, I think if the grading of AVPU plus is scaled in numerical instead of alphabetical, it would be easier to use.

Keywords

I read with interest a recent paper in your journal, in which three consciousness assessment scales were compared in poisoned patients and finally a new scale "AVPU plus" was proposed (1). The study was very interesting with a worthy objective. I would like to admire the authors for exploring how the Alert/Verbal/Painful/Unresponsive (AVPU) responsive scale corresponds with the Glasgow Coma Scale (GCS) and Richmond Agitation-Sedation Scale (RASS) scores in drug-poisoned patients, and for proposing an augmented AVPU scale.

The GCS was developed by Teasdale and Jennet in 1974 (2), aimed at standardizing assessment of level of consciousness in head trauma victims (3). The AVPU scale has been developed for rapid neurologic assessment of traumatic patients and for those in need of advanced life support (1,4). RASS has been developed to assess agitation-sedation status of critical patients in intensive care unit (5,6).

Because there has been no standardized unified method for assessment of consciousness impairment in patients with drug and chemical poisoning, physicians have used different methods or scales in different medical settings. Therefore, developing a research-based scale that is agreed among most medical toxicologists seems necessary. My colleagues and I usually use the AVPU scale in our routine practice. Nonetheless, looking at this newly proposed scale, we believe using AVPU plus for poisoned patients in emergency setting or clinical toxicology ward would be helpful and practical. As a recommendation, I think if the grading of AVPU plus is scaled in numerical instead of alphabetical, it would be easier to use (Table 1).

 

Table 1. Comparison of the original and the proposed grading for AVPU (+) scale

Clinical parameter

Original grading

Proposed grading

Alert & Calm

AC

1a

Alert & Restless

AR

1b

Alert & Drowsy

AD

1c

Verbal & Calm

VC

2a

Verbal & Restless

VR

2b

Verbal & Agitated

VA

2c

Verbal & Drowsy

VD

2d

Verbal & Lightly Sedated

VLS

2e

Verbal & Moderately Sedated

VMS

2f

Painful & Agitated

PA

3a

Painful & Deeply Sedated

PS

3b

Unresponsive & Combative

UC

4a

Unresponsive & Highly Agitated

UA

4b

Unresponsive & Unarousable

UU

4c

 

Conflict of interest: None to be declared.

 

 

  1. Rajabi Kheirabadi A, Tabeshpour J, Afshari R. Comparison of Three Consciousness Assessment Scales in Poisoned Patients and Recommendation of a New Scale: AVPU Plus. Asia Pac J Med Toxicol 2015;4:58-63.
  2. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2:81-4.
  3. Matis G, Birbilis T. The Glasgow Coma Scale--a brief review. Past, present, future. Acta Neurol Belg 2008;108:75-89.
  4. Mostafazadeh B, Farzaneh E. Risks and risk factors of repeated suicidal attempt: Study on unconscious poisoned patients. Asia Pac J Med Toxicol 2013;2:28-31.
  5. Sessler CN, Grap MJ, Brophy GM. Multidisciplinary management of sedation and analgesia in critical care. Semin Respir Crit Care Med 2001;22:211-26.
  6. Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O'Neal PV, Keane KA, et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002;166:1338-44.