From the Guidelines
If a patient pushes down with their opposite heel after experiencing syncope, the most appropriate action is to place them in a safe position, such as sitting or lying down, and consider using physical counter-pressure maneuvers (PCMs) to improve blood flow and prevent further episodes. This approach is based on the latest guidelines from the American Heart Association and American Red Cross, which recommend the use of PCMs, such as leg crossing or squatting, to increase blood pressure and prevent syncope in patients with vasovagal or orthostatic syncope 1. The patient's behavior of pushing down with their opposite heel may be an attempt to improve blood flow to the brain, and using PCMs can help to achieve this goal. It is also important to monitor the patient's vital signs and collect information about the events leading up to the syncope, including any preceding symptoms, to share with healthcare providers. According to the 2019 American Heart Association and American Red Cross guidelines, lower-body PCMs are preferable to upper-body and abdominal PCMs, and the use of PCMs is not suggested when symptoms of a heart attack or stroke accompany presyncope 1. In addition to using PCMs, it is essential to ensure the patient's airway, breathing, and circulation are stable, and to prevent them from standing up quickly, which may trigger another syncopal episode. Overall, the goal is to prioritize the patient's safety and prevent further complications while waiting for emergency medical services to arrive. The 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope also recommends the use of physical counter-pressure maneuvers, such as leg crossing, to increase blood pressure and improve orthostatic tolerance in patients with neurogenic orthostatic hypotension 1. However, the 2019 guideline provides more specific recommendations on the use of PCMs in patients with presyncope, making it the most relevant and up-to-date guidance for this scenario.
From the Research
Response to Patient Pushing Down with Opposite Heel After Fainting
If a patient pushes down with their opposite heel after experiencing syncope, it may be a physical counterpressure maneuver.
- This maneuver is taught to patients to help manage vasovagal syncope 2.
- The patient should be encouraged to liberalize their fluid and salt intake, unless they have contraindications such as hypertension 2.
- Midodrine is the first-line therapy for patients having frequent presyncope or syncope or for those with brief or no prodromes 2.
- Other treatments for syncope modulate other neurotransmitters or affect heart rate, such as fludrocortisone, β blockers, and norepinephrine transport inhibitors 3.
Management of Vasovagal Syncope
Vasovagal syncope is not generally associated with cardiovascular, neurological, or other diseases, and therefore represents an isolated manifestation 4.
- Isolated vasovagal syncope cannot be regarded as a disease for several reasons, including the fact that spontaneous syncope occurs in about half of individuals during their lives 4.
- The unidentified neural pathways involved in the vasovagal response are probably present in all healthy humans, with individual differences in susceptibility 4.
- Patients with vasovagal syncope should be distinguished from those with other forms of syncope that start in old age and are often associated with cardiovascular or neurological disorders 4.
Treatment Options
Treatment options for vasovagal syncope include conservative measures, midodrine, fludrocortisone, and β blockers 2, 3.
- The most recent trials evaluating established and novel therapies are reviewed, and randomized placebo-controlled data evaluating fludrocortisone, midodrine, and β blockers in older patients are awaited 3.
- Because of the significance of the placebo effect in this condition, any treatment must be evaluated in a randomized double-blind placebo-controlled trial before being accepted as effective 3.