Patients in severe pain may have normal vital signs

Research proves longstanding belief is incorrect

Patients in severe pain often have normal heart rate, blood pressure, and respiratory rate, according to a new study. Researchers compared self-reported triage pain scores and vital signs for 1,063 adult ED patients with painful conditions such as dislocations, corneal abrasions, fractures, burns, stab wounds, and small bowel obstructions. No link was found between the pain scores and the patients' vital signs.1

The study disproves a longstanding belief in emergency medicine: that pain is associated with abnormal vital signs, says Catherine A. Marco, MD, FACEP, the study's author and faculty in the Department of Emergency Medicine at St. Vincent Mercy Medical Center in Toledo, OH.

ED physicians and nurses often make this erroneous conclusion, says Marco. "I was taught as a medical student that if someone is experiencing significant pain, they should be tachycardic or hypertensive," she says. "I have heard people making similar statements over the years." If a patient says he or she is in pain, believe them and treat the pain regardless of vital signs, says Marco.

"We have all heard people say, 'I don't believe that the patient is really in pain, because the vital signs are normal. If they were really in pain, they would be tachycardic or hypertensive,'" she says. "We showed that is not true, and that many patients in significant pain have normal vital signs."

In fact, most patients with documented painful conditions have normal vital signs, says Marco. "We as clinicians must trust the patient's self-report of pain. At least for the present, we have no objective measure of pain, and it is still a subjective self-reported measurement," she says.

Strive for accurate score

At St. Mary's Hospital in Grand Junction, CO, ED nurses ask every patient about their pain level using a numeric scale during the initial assessment. "We accept their number at whatever they say it is," says Karen Donnahie, RN, an emergency nurse at the hospital.

Donnahie words the question, "On a scale of 0-10, with 0 being no pain, and 10 being the worst possible discomfort you can imagine, what number would you give your discomfort now? We also have the FACES scale on all of our patient clipboards, so it is handy for kids and non-English-speaking patients," she says.

During the ED visit, particularly after medications are given, the patient is asked again to rate their level of pain. "We have a space for it in our vital signs. We also have a space for it in the discharge vital signs," says Donnahie. The goal is to help the patient feel better, whether that requires a position of comfort, application of ice, elevation, or pain medication. "Even if they still have pain, we want the patient to leave feeling at least a little better," she adds.

Patients may state their pain is a "10" when there is no physical manifestation of that pain, such as crying or holding the affected extremity, says Donnahie. "It is difficult trying to elicit accurate pain scores with patients who seem to have no sense of past discomforts," she says. For these cases, nurses may offer a comparison for clarification, such as asking the patient, "Are you having as much pain as if I dropped a bowling ball on your foot?"

"I have had a number of patients rethink their pain scale when something worse is offered, such as the bowling ball," says Donnahie. "Many of them go from a 10 to an 8. They seem to gain a better understanding of the pain scale when they have something tangible to associate it with."

Explain that an accurate assessment means that pain can be treated appropriately, advises Donnahie. "The number does not guarantee them a different medicine, or a higher dose of a medication," she adds. "It is a guideline which assists us in their treatment."

Ultimately, nurses accept whatever score the patient gives, says Donnahie. "Accepting the patient's report of pain is the whole goal of asking, and we write it down even if they say their pain is a 20," she says. "We try to tell all the patients that we are not going to be able to get rid of their pain, but we will make it more manageable. This helps eliminate any false preconceptions they may hold."


  1. Marco CA, Plewa MC, Buderer N, et al. Self-reported pain scores in the ED: Lack of association with vital signs. Acad Emerg Med 2006; 13:974-979.


For more information on pain and vital signs, contact:

  • Karen Donnahie, RN, Emergency Department, St. Mary's Hospital, 2635 N. Seventh St., P.O. Box 1628, Grand Junction, CO 81502-1628. E-mail:
  • Catherine A. Marco, MD, Department of Emergency Medicine, St. Vincent Mercy Medical Center, 2213 Cherry St., Toledo, OH 43608-2691. Fax: (419) 251-4211. E-mail: