Not Just a Nap: Syncope and What it Really Means

It starts like a routine call.

“Patient fainted.” "Man down." "Syncope." Could be a hot day, maybe a missed meal. But as EMS providers should know, syncope isn’t a diagnosis, it’s a symptom. And behind that momentary loss of consciousness could be anything from benign vasovagal response to life-threatening arrhythmias.

What is syncope?

Clinically, syncope is a sudden, temporary loss of consciousness due to a drop in cerebral perfusion, aka, your brain didn’t get enough blood. It’s typically brief and resolves on its own, but the causes are anything but simple. According to the American Heart Association, syncope accounts for 3–5% of emergency department visits and up to 6% of hospital admissions annually. And about one-third of syncopal episodes have no definitive cause on initial evaluation.

EMS translation: “Down goes the patient, no one saw it, vitals are fine, and now we all look confused.”

Types of Syncope

Most EMS providers categorize syncope into three primary buckets:

• Vasovagal (The Drama Queen Special): Often triggered by emotional stress, pain, or prolonged standing. This is your “benign” fainting, until it’s not.

• Orthostatic Hypotension (Grandpa Stood Up Too Fast): Seen in the elderly, dehydrated, or those on antihypertensives.

• Cardiac Syncope (The Oh Sh*t Kind): The one that keeps us awake. Caused by arrhythmias, structural defects, or ischemia. High risk, often no prodrome.

While your patient may wake up smiling and saying, “I’m fine,” you should stay sharp. According to the 2017 ACC/AHA Guidelines, these red flags demand a closer look:

• Syncope during exertion

• Family history of sudden cardiac death

• Abnormal ECG

• Chest pain or palpitations prior to the event

• Older adult with comorbidities (falls, fractures, anticoagulants = bad combo)

• Syncope with no warning (suggests arrhythmia)

The Prehospital Assessment:

This is our bread and butter... This is where we shine, or at least we're supposed to. Vital signs are step one, but orthostatic measurements are often skipped. Just don’t. An orthostatic drop of >20 mmHg systolic is significant. Cardiac monitoring is non-negotiable. If you catch a bradycardia or prolonged QT, you might prevent a second, more serious event. If available, a 12-lead ECG is critical—look for signs of ischemia, Brugada, WPW, or blocks. Blood glucose? Should be mandatory, hypoglycemia can mimic everything. Lastly, ask about medications, especially beta blockers, diuretics, or anything that says “may cause dizziness.” Spoiler: they do.

Transport or RMA?

I know you want that RMA, but just do your job. Refusals on syncope calls are tricky. If the cause is uncertain, or red flags are present, err on the side of transport. According to JEMS literature, 18% of syncopal patients released by EMS without ED evaluation were later found to have serious underlying conditions. So yeah. Transport. Or at least document like you tried.

What Can Help?

If your patient’s gonna collapse dramatically, the least you can do is be prepared.

• Pulse Ox: For those “they look fine but I’m sweating” moments

• G-Shock Watch: So you can actually track the 10 seconds of unconsciousness (instead of guessing)

• Syncope Checklist Cards: Yes, they exist. Yes, they make you look smart.

• Gloves That Fit: Because you’re not catching a falling adult with bare hands and optimism.

Check out all of this gear, and more, from out Amazon storefront!

References

American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. (2017). 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope. Circulation, 136(5), e60–e122. https://doi.org/10.1161/CIR.0000000000000499

Sun, B. C., Emond, J. A., & Camargo, C. A. Jr. (2004). Direct medical costs of syncope-related hospitalizations in the United States. The American Journal of Cardiology, 93(10), 1306–1308. https://doi.org/10.1016/j.amjcard.2004.01.049

Sivaramakrishnan, R., & Natarajan, P. (2020). Syncope in emergency medicine: A review. Journal of Family Medicine and Primary Care, 9(4), 1920–1925. https://doi.org/10.4103/jfmpc.jfmpc_1105_19

Sanders, M. J. (2019). Mosby’s Paramedic Textbook (5th ed.). Jones & Bartlett Learning.

National Institutes of Health. (2020). Syncope. MedlinePlus. https://medlineplus.gov/syncope.html