How to Treat Loss of Consciousness & Fainting Emergencies

Learn How EMTs & Paramedics Identify, Treat, and Care for Patients with Loss of Consciousness & Fainting Emergencies

Loss of consciousness (LOC) or fainting is one of the most common emergencies that EMS professionals respond to.

(Review our list of the 16 Most Common EMS Emergencies for EMTs and Paramedics).

According to the National Library of Medicine (NLM), fainting is also one of the most frequent causes for emergency room visits, accounting for approximately 1% to 3.5% of all visits to the Emergency Department (ED) and about 6% of hospital admissions in the United States.

Among patients presenting with syncope in an emergency department, the mortality rate within 30 days is estimated to be approximately 1.6%, which is significantly influenced by the underlying cause of the condition.

Let’s explore the various causes of fainting emergencies and the EMS protocol for their treatment.

Loss of Consciousness or Fainting Definition

What is Fainting?

Fainting can be defined as a temporary, sudden loss of consciousness (LOC) and muscle strength— characterized by a fast onset, short duration, and spontaneous recovery. It’s caused by a decrease in blood flow to the brain, typically triggered by various issues, such as low blood pressure, dehydration, or heart problems.

In some cases, symptoms may precede the loss of consciousness, including lightheadedness, sweating, pale skin, blurred vision, nausea, vomiting, or a feeling of warmth. Syncope can also be associated with a brief episode of muscle twitching.

Alternatively, when consciousness and muscle strength aren’t entirely lost, it’s called presyncope (near-fainting); however, it’s recommended that presyncope be treated the same as syncope.

Causes of Fainting

Emotional stress, physical factors, or underlying medical issues often trigger fainting.

Some of the most common causes of syncope include, but are not limited to:

• 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

Types of Syncope

Let’s delve into the three broad categories of fainting and their underlying causes: reflex syncope, orthostatic hypotension, and cardiac syncope—all of which can range from non-serious to potentially fatal.

Reflex Syncope

Also known as neurally mediated syncope (NMS), this prevalent type of fainting occurs when a trigger causes the nervous system to overreact, resulting in a rapid decrease in heart rate or blood pressure, which in turn reduces blood flow to the brain.

Subtypes and their associated triggers include:

• Vasovagal Syncope: Triggered by emotional distress, pain, extended periods of standing, or even the sight of blood
• Situational Syncope: Triggered by specific actions such as coughing, swallowing, urinating, or defecating
• Carotid Sinus Syncope: Triggered when pressure is applied to the carotid sinus (located in the neck), during activities like shaving or wearing a constructed collar

Orthostatic Hypotension

This occurs due to a sudden decrease in blood pressure when standing up (usually too quickly) from a seated or lying position. This is often related to dehydration, medications that lower blood pressure, or certain neurologic conditions such as Parkinson’s disease.

Cardiac Syncope

This is a result of a condition affecting the heart or blood vessels, such as arrhythmias (abnormal heart rhythms), structural heart disease, or heart failure. This form of syncope is considered the most serious and may have an increased risk of complications.

We’ll dive deeper into the serious nature and causes of heart and blood-related syncope in the next section.

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.

Cardiac Arrhythmia

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

Myocardial Infarction

Fainting can also be caused by an acute myocardial infarction (MI) or heart attack. Women are significantly more likely to experience syncope as a presenting symptom of myocardial infarction.

In general, fainting caused by structural disease of the heart or blood vessels is 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.

Additional prevalent triggers include:

• A predisposition to low blood pressure: Various environmental factors can trigger low blood pressure. For example, a lower-than-expected blood volume resulting from a low-sodium diet or heat-induced vasodilation can exacerbate the effect of an insufficient blood volume.
• An underlying fear or anxiety: This could be related to a social situation or an acute fear associated with a dangerous or painful event, which can trigger the body’s fight-or-flight response.

During this type of response, the brain increases the heart’s pumping action. If the heart is unable to supply an adequate volume of blood, due to low blood pressure, a feedback response slows the heart rate excessively, resulting in loss of blood to the brain.

Symptoms associated with a vasovagal episode may be experienced in the minutes preceding the event and are known as the prodrome (initial warning signs), which include:

• Lightheadedness
• Confusion
• Pallor (or a pale appearance)
• Nausea
• Salivation
• Sweating
• Tachycardia (heart palpitations)
• Blurred vision
• A sudden urge to defecate

Types of Vasovagal Syncope

Isolated Fainting

A fainting episode can occur suddenly with only brief warning symptoms, if any. This type of isolated fainting tends to occur among adolescents and may be associated with fasting, exercise, abdominal straining, or circumstances promoting vasodilation (e.g., heat or consuming alcohol).

In this scenario, the individual is typically in an upright position. If a tilt-table test is conducted, the results are usually negative (we’ll explore this type of test further in the next section of the article).

Recurrent Fainting

Recurrent fainting generally manifests with a range of complex symptoms. It’s often associated with sleepiness, preceding visual disturbance (such as seeing “spots before the eyes”), sweating, and lightheadedness.

The subject is usually, but not always, in an upright position. If conducted, the tilt-table test usually yields a positive result.

• Note: this condition is considered relatively rare.

Orthostatic Hypotension

Orthostatic hypotension (OH) 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 to the brain, causing peripheral vasoconstriction and increased heart rate, to raise blood pressure back to baseline.

Even healthy people may experience minor symptoms (e.g., lightheadedness or fainting) as they stand up if blood pressure is slow to respond to the upright posture. If the patient’s BP isn’t adequately maintained during standing, fainting may occur.

• Note: Transient orthostatic hypotension (TOH) is quite common and does not necessarily signal a severe underlying disease.

Orthostatic hypotension may also be due to medications, dehydration, significant bleeding, or infection. The most susceptible patients are typically 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 efficient methods for identifying the root cause of fainting include reviewing medical history, conducting a physical examination, and performing an electrocardiogram (ECG). An ECG is instrumental in identifying irregular heart rhythms, inadequate blood flow to the heart muscle, and other electrical issues.

Cardiac-related issues frequently exhibit minimal history of early signs or symptoms.

A decrease in blood pressure and an increased heart rate following the incident may suggest blood loss or dehydration, whereas low blood oxygen levels may be observed in individuals with pulmonary embolism after the event.

More targeted tests, such as an implantable loop recorder (a device that records the heartbeat nonstop for up to three years) or carotid sinus massage (CSM) (applying pressure to the carotid artery bifurcation in the neck), can both prove beneficial in ambiguous situations.

The Tilt-Table Test

One of the most common, non-invasive procedures used to diagnose the cause of fainting is the tilt-table test (TTT). Oftentimes, the patient is strapped to a tilt table, lying flat, and then tilted or suspended completely, or almost completely upright (as if standing).

This test can be done in a few different ways:

• Typically, the patient is positioned at an angle of 60 to 80 degrees. Occasionally, medication, such as nitroglycerin or isoproterenol, may be administered to enhance the patient’s responsiveness to the test.
• In all cases, the patient is instructed not to move while the patient’s symptoms, blood pressure, pulse, electrocardiogram, and blood oxygen saturation are recorded.
• The test either ends when the patient faints or develops other significant symptoms, or after a set period of time (usually anywhere 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.

Additional causes that should be considered include seizures, a stroke, a concussion, low blood oxygen, low blood sugar, drug intoxication, and various psychiatric disorders. Ultimately, the patient’s 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 witness an individual fainting, call 911 immediately. While often harmless, fainting still has significant medical importance—because it could be the first warning sign of a serious, potentially life-threatening condition.

It’s almost impossible to determine whether there’s a more severe underlying issue, such as a seizure or a heart attack, at the outset. Therefore, the dispatcher will inquire if the person who fainted is currently conscious and alert and will subsequently provide appropriate advice.

You should always treat fainting as a medical emergency until the signs and symptoms are relieved and the cause is known. Be sure to talk to your doctor if you’ve fainted more than once.

• Immediate actions if you feel faint: 
  • Sit or lie down. Make sure that you’re in a safe spot to prevent falling again. Once you start feeling better, get up very slowly and carefully.
  • Elevate legs. If you’re lying down, prop your legs up so they’re above heart level. If sitting, put your head between your knees to increase circulation to the brain.
  • Breathe deeply. Taking slow, deep breaths can help increase oxygen. 
• Immediate actions 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.
  • Check for breathing. If the person isn’t breathing, begin CPR (if you’re trained)—otherwise, 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 (if you’re trained).

How Do EMTs & Paramedics Treat Fainting

For all clinical emergencies, the first step is a rapid and systematic assessment of the patient. For this evaluation, most EMS providers will use the ABCDE approach.

The systematic Airway, Breathing, Circulation, Disability, and Exposure (ABCDE) method is relevant in all clinical emergencies for immediate assessment and treatment. The meaning of each letter is as follows:

• A = Airways
• B = Breathing
• C = Circulation
• D = Disability (Neurological)
• E = Exposure/Environment

This approach is applicable in outdoor settings, whether equipment is used. Additionally, it can be utilized in a more advanced form when emergency medical services are available, such as in emergency rooms, hospitals, or intensive care units.

Treatment Guidelines & Resources for Medical First Responders

Treatment guidelines for loss of consciousness/adult and pediatric syncope, and near syncope emergencies can be found in the National Model EMS Clinical Guidelines published by the National Association of State EMS 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 identified during the physical examination or through further assessments. This may include the management of cardiac dysrhythmias, cardiac ischemia or infarction, hemorrhage, shock, and similar conditions.

1. Manage airway as indicated.
2. Administer oxygen as appropriate.
3. Evaluate for a hemorrhage and treat for shock if indicated.
4. Establish IV access.
5. Administer a fluid bolus if appropriate.
6. Apply a cardiac monitor if needed.
7. Perform a 12-lead EKG if appropriate.
8. Monitor for and treat arrhythmias (if present, refer to the appropriate guidelines.)

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.

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

• Provide routine medical care.
• Gently lower the patient to a supine position (lying flat on their back with their face and torso upward) or the Trendelenburg position (lying flat on their back with the body tilted, so the head is lower than the feet), if hypotension (low blood pressure) is present.
• Administer oxygen as appropriate.
• Obtain blood glucose if approved. If < 60, refer to Unitek EMT’s Hypoglycemia Guidelines.
• Initiate an Intravenous (IV) or Intraosseous (IO) line using Normal Saline (NS) at a very slow “To Keep Open” (TKO) rate, if approved.
• If the patient is hypotensive or shows signs of dehydration, administer a 500 mL fluid bolus.

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