What to do if someone experiences syncope?

From the Guidelines

If someone experiences syncope, they should be laid down in a safe position, and if no improvement occurs within 1 to 2 minutes, or if symptoms worsen or reoccur, emergency services should be activated. According to the 2024 American Heart Association and American Red Cross guidelines for first aid 1, maintaining or assuming a safe position such as assisted sitting or lying down is recommended for individuals experiencing signs or symptoms of presyncope. Additionally, physical counterpressure maneuvers (PCMs) can be beneficial in avoiding syncope, with lower-body PCMs being preferable to upper-body and abdominal PCMs.

When a person faints, it is essential to check that they are breathing normally and loosen any tight clothing around their neck, chest, or waist. They should not be given anything to eat or drink until they are fully conscious. Most people regain consciousness within a minute or two, and once they wake up, they should be helped to sit up slowly to avoid another fainting episode. The use of PCMs is not recommended when symptoms of a heart attack or stroke accompany presyncope 1.

It is also crucial to note that if the person does not regain consciousness within a few minutes, is pregnant, has diabetes, experienced chest pain or shortness of breath before fainting, injured themselves when falling, or has repeated episodes of fainting, emergency services should be called immediately. Fainting typically occurs due to a temporary reduction in blood flow to the brain, often caused by dehydration, standing too long, emotional stress, or standing up too quickly. While most fainting episodes are harmless, some may indicate underlying medical conditions that require professional evaluation. Drinking around 2 L of fluid a day and not using salt sparingly, unless there are medical reasons not to, can also help prevent syncope 1.

In terms of specific actions to take to avoid an impending attack of reflex syncope, lying down or sitting down and doing counter maneuvers, such as tensing large muscles in the body, can be beneficial 1. However, the most recent and highest quality study, the 2024 American Heart Association and American Red Cross guidelines for first aid 1, should be prioritized when making a definitive recommendation. Therefore, laying the person down in a safe position and activating emergency services if necessary is the most appropriate course of action.

From the FDA Drug Label

Patients who experience any signs or symptoms suggesting bradycardia (pulse slowing, increased dizziness, syncope, cardiac awareness) should be advised to discontinue midodrine and should be re-evaluated. If someone experiences syncope while taking midodrine, they should be advised to:

• Discontinue midodrine immediately
• Be re-evaluated by a healthcare professional 2

From the Research

Immediate Response to Syncope

If someone experiences syncope, the following steps can be taken:

• Lay the person down in a cool, well-ventilated area, preferably on their back [no direct evidence from provided studies]
• Elevate the person's legs about 12 inches to improve blood flow to the brain [no direct evidence from provided studies]
• Loosen any tight clothing around the person's neck, chest, and arms [no direct evidence from provided studies]
• If the person is unresponsive, not breathing, or does not have a pulse, call for emergency medical help [no direct evidence from provided studies]

Medical Treatment for Syncope

For individuals experiencing recurrent vasovagal syncope, midodrine may be a potential treatment option:

• Midodrine has been shown to reduce the recurrence of syncope in healthy, younger patients with a high syncope burden 3
• A study found that midodrine can prevent hypotension and syncope during tilt tests in patients with vasovagal syncope 3
• Another study found that 95% of patients with vasovagal syncope had no inducible presyncope or syncope on repeated tilt table testing after midodrine treatment 4
• However, the effectiveness of midodrine treatment in patients with recurrent vasovagal syncope not responding to non-pharmacological treatment is less clear, with one study finding no significant difference in syncopal and pre-syncopal recurrences between midodrine and placebo treatment 5

Understanding Syncope

Syncope is a symptom characterized by transient loss of consciousness due to cerebral hypoperfusion:

• The pathophysiology of syncope involves complex interactions between vascular, humoral, and cardiac factors 6
• Identifying the cause of syncope can be challenging, as it may involve multiple etiologies operating in concert 6
• Reflex syncope syndromes are a common cause of syncope, and understanding the underlying mechanisms is essential for effective treatment 6