Can I use a Pain Response?


Occasional comments from delegates revolve around a lay responder’s use of painful stimuli in determining the responsive level of a casualty.

The first question to be asked is does the responder have permission to lay hands on? In the same way one assumes that a drowning man would like dragging from a pond there is an implied consent that the unresponsive individual in this case requires similar assistance. It then follows in law that providing you behave as a reasonable individual (operating within the realms of your experience and training) you can use such stimuli to gain a response.


Acceptable painful stimulation can be achieved in several ways.

NAIL BED PRESSURE is easy to perform and less painful to the patient.  A pen is firmly pressed onto the nail.
PINCH TO THE INNER ASPECT OF THE ARM OR THIGH.  This pinch is most sensitive to elicit a response.
PINCH TO THE EAR LOBE. Effective, however the responder should be aware of the impression this may give to observers

Unacceptable pain responses are the sternal rub (rubbing a knuckle into the breastbone) supraorbital pressure (pressing the thumb into the small notch located at the 12 O’clock position of the eye socket), and nipple pinching; these types of stimuli should be avoided.  Frequent rubbing of the sternum (breastbone) can cause damage to the area and opening of the skin which may lead to infection.  Supraorbital pressure should always be avoided as it can cause increased chance of damage or fractures with the facial trauma patient, or patients with frontal craniotomies or facial surgery.


Not perhaps ideal for the lay responder but used widely in the professional trauma care world. Its principle being, that one can express in numerical terms (a maximum of 15 and minimum of 3) the responsiveness of a casualty from scene to hospital and through the casualty care chain. Its problem in the rare users’ case is that it is easy to forget if you are not using it frequently, though we know of some First Aiders who have it printed on a card inside their First Aid Kit.


4 – Spontaneous
3 – To Speech
2 – To Pain
1 – No response


5 – Oriented
4 – Confused
3 – Inappropriate Words
2 – Incomprehensible Sounds
1 – No response


6 – Obeys Commands
5 – Localizes to Pain
4 – Withdraws to Pain
3 – Abnormal Flexion
2 – Extension
1 – No response/Flaccid

It is possible to have a GCS of 3 and be dead!