health & wellness
A few years ago, I was at a dress rehearsal of the Peninsula Symphony and Stanford Community Chorus at Stanford Memorial Church when there was an unexpected commotion from the choir.
“We need a doctor!” someone shouted. I handed my violin to my music stand partner, threaded my way through the orchestra to the risers of the choir and discovered a young woman lying down with a dazed expression, circled by worried onlookers. I suspected she had fainted, but why?
Fainting, or the medical term syncope (pronounced SIN-ko-pee), is common in younger individuals, and after the age of 70 there is another sharp rise in the incidence. Fainting is twice as common in women as men. The most common cause of syncope is vasovagal syncope, which occurs when something triggers the vagal nerve, a long nerve from the abdomen to the brain. This can result in symptoms like nausea and sweating followed by decreased heart rate, low blood pressure and transient loss of consciousness due to reduced blood flow to the brain.
Prolonged standing, especially when combined with crowds and heat, can trigger syncope. There may also be underlying factors such as lack of sleep, or illness, especially if accompanied by fever, coughing, hyperventilation or standing up too quickly.
In about one-third of cases, people, especially older adults, suffer some type of trauma because of fainting, such as cuts, broken limbs or worse if it occurs while driving. This is why California DMV requires a doctor to report anyone who faints. I know of one unfortunate case where a doctor did not report a truck driver who had passed out at home due to a coughing fit. Subsequently, the driver had a second occurrence behind the wheel and a serious accident occurred.
Many studies have tried to determine the cause of syncope, but as a physician I find the patient’s medical history is most important. What happened immediately before the event? Are there underlying medical conditions such as diabetes or Parkinson’s disease that increase the risk of fainting? In older adults, a reaction due to medication is a common problem, especially with heart or blood pressure pills. A prescription dose of a blood pressure medication prescribed for a 60-year-old may be excessive for an 80-year-old due to slower drug metabolism. This is why I always check standing blood pressures in my older patients who are taking anti-hypertensive medications.
The timing of when a person last ate is also relevant. After a meal, blood pools in the stomach and intestines, so when a person gets up quickly, there isn’t enough time for it to reach the brain. Other common triggers include standing in the sun too long, acute pain, the sight of blood, anxiety, fear or panic, alcohol use and dehydration.
Most people experience some warning signs before they faint such as lightheadedness, feeling hot, nausea or weakness. But as people age, there may not be any warning signs. In addition, some symptoms may indicate a cardiac condition, including chest tightness, palpitations or shortness of breath.
It is often frightening for bystanders to witness someone passing out, but most victims recover in a few minutes. Too often I observe well-wishers trying to get a victim to stand up and walk around, but this is the wrong thing to do. The first most important step is to make sure the victim is breathing. If not, check the airway, call 911 and initiate CPR. When the victim regains consciousness, try to keep them lying down for 10-15 minutes with legs elevated. Try to loosen tight clothing, and have them rest in a cool, quiet place.
Treatment and prevention of syncope is dependent on the underlying cause. In many older patients, reducing the dose of diuretics or blood pressure medication may help prevent recurrence. Some people need expansion of blood volume by increasing salt and fluid intake. Others are helped by wearing compression stockings. Some people who sense when they are about to faint can prevent an incident by crossing their legs and squeezing them together, gripping both hands together hard, or by squatting or lying down. If standing for long periods, you can also flex your leg muscles, which helps prevent blood pooling in the leg veins.
Taking these precautions may help prevent syncope. You never want the upsetting experience of finding yourself lying flat on the ground in a daze. Because waking up to find 20 pairs of eyes staring down at you is enough to — well — make you faint.
Jerry Saliman, M.D. is a volunteer internist at Samaritan House Medical Clinic in San Mateo and a contributing medical blogger for the Peninsula Jewish Community Center (www.pjcc.org) in Foster City. He retired from Kaiser South San Francisco after a 30-year career.