Fainting, how to manage the emergency related to loss of consciousness

By Cristiano Antonino On Jan 19, 2023

Loss of consciousness and fainting are the sixth most common emergency to which emergency room professionals respond, accounting for almost 8% of all calls

These are emergencies that should by no means be downplayed, by the rescuer: firstly because of the psychological impact these events have on the patient’s bystanders, and secondly because loss of consciousness can be indicative of a truly serious clinical picture.

It is a good idea for the rescuer to take them seriously, and not to classify them superficially as ‘low blood pressure’.

Fainting, also known as syncope, affects up to 6 out of every 1,000 people annually. Up to half of women over the age of 80 have experienced at least one fainting event at some point in their lives. Among patients presenting with syncope to an emergency department, about 4% died in the next 30 days. The risk to a patient’s health due to fainting greatly depends on what caused the condition.

Loss of Consciousness or Fainting Definition

What Is Fainting?

Fainting is a loss of consciousness and muscle strength characterized by a fast onset, short duration, and spontaneous recovery.

It is caused by a decrease in blood flow to the brain, typically from low blood pressure.

In some cases, there are symptoms before the loss of consciousness such as lightheadedness, sweating, pale skin, blurred vision, nausea, vomiting, or feeling warm.

Syncope may also be associated with a short episode of muscle twitching. When consciousness and muscle strength are not entirely lost, it is called a presyncope.

It is recommended that presyncope be treated the same as syncope.

Causes of Fainting Definition

Fainting can be triggered by any of the following:

Fear or emotional trauma
Severe pain
A sudden drop in blood pressure
Low blood sugar due to diabetes or going too long without eating
Hyperventilation (rapid, shallow breathing)
Dehydration
Standing in one position for too long
Standing up too quickly
Physical exertion in hot temperatures
Coughing too hard
Straining during a bowel movement
Seizures
Consuming drugs or alcohol

Causes range from non-serious to potentially fatal. There are three broad categories of causes: heart or blood vessel-related, vasovagal (also known as a reflex), and orthostatic hypotension.

Heart or Blood-Related Syncope

Heart-related causes of syncope may include an abnormal heart rhythm, problems with the heart valves or heart muscle, or blockages of blood vessels from a pulmonary embolism or aortic dissection.

The most common cause of heart-related syncope is cardiac arrhythmia (abnormal heart rhythm), wherein the heart beats too slowly, too rapidly, or too irregularly to pump enough blood to the brain. Some arrhythmias can be life-threatening. Heart disease or dysfunctions that reduce blood flow to the brain increase the risk for syncope.

The most common heart-related condition associated with fainting is an acute myocardial infarction or ischemic event. Women are significantly more likely to experience syncope as a presenting symptom of myocardial infarction. In general, faints caused by structural disease of the heart or blood vessels are particularly important to recognize, as they are warning of potentially life-threatening conditions.

Vasovagal Syncope

Vasovagal syncope, also referred to as reflex syncope, is one of the most common types of fainting.

It may occur in response to various triggers, such as scary, embarrassing, or uneasy situations, during blood drawing, or moments of sudden high stress.

It can also be triggered by a specific activity, such as urination, vomiting, or coughing.

With vasovagal syncope, the patient is usually predisposed to low blood pressure by various environmental factors.

For example, a lower-than-expected blood volume from a low-salt diet or heat causing vasodilation worsens the effect of an insufficient blood volume.

If there is underlying fear or anxiety (e.g., social situation), or acute fear (e.g., potentially dangerous or painful event), it can trigger the body’s flight-or-fight response.

During the flight-or-fight response, the brain increases the heart’s pumping action.

If the heart cannot deliver enough volume of blood—because of low blood pressure—a feedback response slows the heart rate excessively, resulting in loss of blood to the brain.

Associated symptoms may be felt in the minutes leading up to a vasovagal episode and are referred to as the prodrome.

These consist of lightheadedness, confusion, pallor, nausea, salivation, sweating, tachycardia, blurred vision, and sudden urge to defecate, among other symptoms.

Types of Vasovagal Syncope

Isolated fainting: A fainting episode can occur suddenly with only brief warning symptoms if any. This type of fainting tends to occur among adolescents and may be associated with fasting, exercise, abdominal straining, or circumstances promoting vasodilation (e.g., heat, alcohol). The subject is invariably upright. The tilt-table test, if performed, is generally negative.

Recurrent fainting: Recurrent fainting typically presents with complex associated symptoms. It is associated with sleepiness, preceding visual disturbance (“spots before the eyes”), sweating, lightheadedness. The subject is usually but not always upright. The tilt-table test, if performed, is generally positive. It is relatively uncommon.

Orthostatic Hypotensive Syncope

Orthostatic hypotensive syncope is primarily caused by an excessive drop in blood pressure when a person stands up from either a lying or sitting position.

When the head is elevated above the feet, gravity causes blood pressure in the head to drop.

This triggers a sympathetic nervous response to compensate and redistribute blood back into the brain.

The sympathetic response causes peripheral vasoconstriction and increased heart rate to raise blood pressure back to baseline.

Healthy people may experience minor symptoms (e.g., lightheadedness or graying-out) as they stand up if blood pressure is slow to respond to the upright posture.

If the blood pressure is not adequately maintained during standing, faints may occur.

Transient orthostatic hypotension is quite common and does not necessarily signal a severe underlying disease.

Orthostatic hypotension may be due to medications, dehydration, significant bleeding, or infection.

The most susceptible to orthostatic hypotension are elderly and frail individuals or those who are dehydrated.

More serious orthostatic hypotension is often the result of certain commonly prescribed medications, including beta-blockers, anti-hypertensives, and nitroglycerin.

How to Treat Fainting Emergencies

The most effective ways to determine the underlying cause of fainting are medical history, physical examination, and electrocardiogram (ECG).

The ECG is useful to detect an abnormal heart rhythm, poor blood flow to the heart muscle, and other electrical issues.

Heart-related causes also often have little history of early signs or symptoms.

Low blood pressure and a fast heart rate after the event may indicate blood loss or dehydration, while low blood oxygen levels may be seen following the event in those with pulmonary embolism.

More specific tests such as implantable loop recorders, tilt table testing, or carotid sinus massage may be useful in uncertain cases.

The tilt-table test (TTT) is a medical procedure often used to diagnose syncope or fainting

A tilt table test can be done in different ways. In some cases, the patient will be strapped to a tilt table lying flat and then tilted or suspended completely or almost completely upright (as if standing).

Most of the time, the patient is suspended at an angle of 60 to 80 degrees.

Sometimes, the patient will be given a drug, such as nitroglycerin or isoproterenol, to create greater susceptibility to the test.

In all cases, the patient is instructed not to move.

The patients’ symptoms, blood pressure, pulse, electrocardiogram, and blood oxygen saturation is recorded.

The test either ends when the patient faints or develops other significant symptoms or after a set period (usually from 20 to 45 minutes, depending on the facility or individualized protocol).

A computed tomography scan (CT scan) is typically not required unless specific concerns are present.

Other causes that should be considered include seizure, stroke, concussion, low blood oxygen, low blood sugar, drug intoxication, and some psychiatric disorders.

Treatment depends on the underlying cause.

Those who are considered at high risk following investigation may be admitted to the hospital for further heart monitoring.

How to Treat Fainting

If you see someone faint, call Emergency Number immediately.

Though fainting often has no medical significance, you can’t know if it’s a symptom of a more serious condition, like a seizure or heart attack.

The dispatcher will ask whether the person who fainted is now conscious and awake and then provide appropriate instructions.

You should always treat fainting as a medical emergency until the signs and symptoms are relieved and the cause is known.

Talk to your doctor if you faint more than once.

If you feel faint:

Lie down or sit down. To reduce the chance of fainting again, get up slowly.
If you sit down, place your head between your knees.

If someone else faints:

Position the person on their back. If there are no injuries and the person is breathing, raise the person’s legs above heart level — about 12 inches (30 centimeters) — if possible. Loosen belts, collars, or other constrictive clothing. To reduce the chance of fainting again, don’t get the person up too quickly. If the person doesn’t regain consciousness within one minute, call 911 or your local emergency number.
Check for breathing. If the person isn’t breathing, begin CPR. Call 911 or your local emergency number. Continue CPR until help arrives or the person starts to breathe. If the person was injured in a fall associated with a faint, treat bumps, bruises, or cuts appropriately—control bleeding with direct pressure.

How Do EMTs & Paramedics Treat Fainting

For all clinical emergencies, the first step is a rapid and systematic assessment of the patient.

For this assessment, most EMS providers will use the ABCDE approach.

The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach is applicable in all clinical emergencies for immediate assessment and treatment.

It can be used in the street with or without any equipment.

It can also be used in a more advanced form where emergency medical services are available, including emergency rooms, hospitals, or intensive care units.

Treatment Guidelines & Resources for Medical First Responders

Treatment guidelines for loss of consciousness (syncope) can be found on page 23 of the National Model EMS Clinical Guidelines by the National Association of State EMT Officials (NASEMSO).

NASEMSO maintains these guidelines to facilitate the creation of state and local EMS system clinical guidelines, protocols, and operating procedures.

These guidelines are either evidence-based or consensus-based and have been formatted for use by EMS professionals.

The guidelines include the following treatment and interventions:

Treatment and interventions should be directed at abnormalities in the physical exam or on additional examination and may include management of cardiac dysrhythmias, cardiac ischemia/infarct, hemorrhage, shock, and the like.

Manage airway as indicated
Oxygen as appropriate
Evaluate for hemorrhage and treat for shock if indicated
Establish IV access
Fluid bolus if appropriate
Cardiac monitor
12-lead EKG
Monitor for and treat arrhythmias (if present, refer to the appropriate guideline)

EMS Protocol for Fainting or Syncope Emergencies

Protocols for pre-hospital treatment of fainting or syncope vary by EMS provider and can also depend on the patient’s symptoms or medical history.

A typical protocol might follow these initial steps after a careful patient assessment:

Routine medical care
Gently lower the patient to a supine position or Trendelenburg position if hypotensive
Oxygen as appropriate
Obtain blood glucose if approved. If < 60, refer to Hypoglycemia Guidelines.
Initiate IV/IO NS @ TKO, if approved
If the patient is hypotensive or shows signs of dehydration, administer 500ml fluid bolus

Syncope: Symptoms, Diagnosis And Treatment

How Healthcare Providers Define Whether You’re Really Unconscious

Cardiac Syncope: What It Is, How It Is Diagnosed And Who It Affects

New Epilepsy Warning Device Could Save Thousands Of Lives

Understanding Seizures And Epilepsy

First Aid And Epilepsy: How To Recognise A Seizure And Help A Patient

Neurology, Difference Between Epilepsy And Syncope

First Aid And Emergency Interventions: Syncope

Epilepsy Surgery: Routes To Remove Or Isolate Brain Areas Responsible For Seizures

Trendelenburg (Anti-Shock) Position: What It Is And When It Is Recommended

Head Up Tilt Test, How The Test That Investigates The Causes Of Vagal Syncope Works

Positioning The Patient On The Stretcher: Differences Between Fowler Position, Semi-Fowler, High Fowler, Low Fowler