53 - Primary Assessment - Disability

KYJ 53- D= Disability
Part 4 of 5 part series on Primary Survey.
Disability- neuro assessment

Fourth step in the process of primary assessment is to determine if the patient is rousable.
The assessment is divided into two parts.
Alertness and pupils

Alertness is an assessment of the level of consciousness.  Altered consciousness exists on a spectrum of wide awake/alert/orientated through to Unresponsive/comatose.

Scored on the first part of a Glascow coma scale, the assessment of LOC uses the familiar mnemonic
A.V.P.U

Alert- spontaneous awake patient
Verbal- the patient needs your voice to rouse/stir. Speak the patients name. If he responds in any way, he scores a "V" for verbal
Pain- if he won't respond to your verbal stimuli, inflict a painful gesture.  There are only two acceptable stimuli.
Supra orbital pressure (if no obvious eye/face trauma)
Trapezeus pinch/twist.

Do NOT use Sternal rubs, nipple cripples, chest hair pulls, fingernail bed pressure, pinched earlobes, or any peripheral stimuli as it will not be effective if the patient had a high spinal injury.  All the Sternal rubbing in the world won't wake me up if I had a severed C7.  So do I not respond due to head related reasons, or because my spinal injury renders me anaesthetised from the neck down??!!
If your patient responds in any way to a painful stimulus, then they score a "P" for pain.
Finally is a patient who neither responds to voice or pain. These patients are unresponsive and score a "U".

If they are a P or a U they are in the PU ( poo ) !!  This refers to the fact that patients scoring A or V can maintain their own airway, and tongue obstruction is no risk.  Patients in the PU can't protect their airway, and an adjunct needs to be inserted.  Hence, AVPU assessment is a life saving assessment.

The final part of this assessment is pupil response.  Using a dedicated penlight, assess both eyes pupils for size , shape, and consensual reaction to light.  Both pupils should constrict briskly to light irrespective of which eye you shine the torch into.
A sluggish or poorly reacting pupil is an indicator that the cause of the patients altered conscious state is cerebral and not shock, or chemical related.  Despite narcotic induced constriction, pupils will still demonstrate reaction.
Note 20-25% of the population have one pupil at a different size to the other. Size is not diagnostic, reaction to light is.

Remember : AVPU- if they are a P or a U they're in the PU !

PEARL= pupils equal and reacting to light.

Remember to Share with your colleagues.