Fainting / Syncope

In high school I first learned about syncope after waking up next to a toilet in an ophthalmologist’s office. He’d just removed some metal from my eye. When I stood up, the room went dim, and somehow my body found itself next to the toilet. I still remember the smell of ammonia and pushing someone away. Luckily, those were the days before syncope… 911… ER.

Later during my residency, I recall standing on one side of a gurney talking with a patient while a nurse was placing an IV on the other, with some young woman behind her. In the corner of my eye I saw what looked like a tree falling… the young woman. It gave me a bit of vertigo, not knowing if I was moving or she. When patient (#2) awoke, she gathered her wits, had a seat, some water, a laugh and recovered just fine.

If you think of your brain as a light bulb and red blood cells as electrons, then “near syncope” = brownout and syncope = blackout. For whatever reason, the electrons just aren’t getting through the bulb. In both cases above, the causes were pretty clear and no call for alarm. Usually the change in position to splayed out flat is therapeutic, as long as it’s a padded landing.

Red Flags:

• Underlying heart disease
• Pacemaker
• Sudden onset during exercise
• No preceding symptoms
• Onset while seated or supine
• Associated worst headache ever
• Prolonged duration, even after supine
• Pregnant +/- bleeding
• Recent bloody vomit/diarrhea
• Diabetic
• Frail/elderly
• Taking warfarin (Coumadin)
• “He was racing down the basketball court and suddenly just dropped.”
• “My implanted defibrillator keeps firing.”
• “Papa was eating and talking, and next we knew, his face was in the pasta.”

Happy Words

• Stood up fast, then hit the deck
• Missed lunch
• Sleepless
• Upset
• Longer than usual church services
• Happened while peeing (called micturition syncope)
• “Standing for an hour in the hot sun
• … on graduation day during a boring speech
• … after being awake all night partying”
• “Drank a 5th of JD” (btw – Mortality jumps if you speak in 5ths.)
• “Was screaming at a Beatles concert”
• “Woke up with diarrhea, then rode the centrifuge at the state fair”

Unless the cause is clearly positional, emotional or alcohol, most folks who pass out and land in an ER get an EKG and are placed on a monitor. If they have a pacemaker, we try to have it “interrogated.” If suspicion for brain bleed, then likely a head CT. If suspicion for electrolyte imbalance, then we check electrolytes. If bleeding from anywhere, then blood counts and maybe coagulation tests. If female, maybe a pregnancy test. If diabetic, we check the glucose. For the elderly or for athletes who collapse without warning, expect echocardiograms +/- carotid dopplers. Often we’ll check blood pressures supine, sitting and standing (orthostatics) to help assess whether the tank needs filling.

Despite all those considerations, the large majority of patients I see who pass out recover without a hitch. Head low, legs up, cool air and hydration very often do the trick. If your bulb went dim, or you “done fell out,” and want to chat about next steps, feel free to give Pre-R a call.

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