Once the patient falls to the ground, however, gravity no longer keeps the blood pooling in the legs. Blood returns to the heart, blood flow is restored, and the patient regains consciousness within several seconds. Vasomotor syncope is therefore “self correcting” - as long as well-meaning bystanders don't prop the victim up.
There are two general kinds of vasomotor syncope.
Normally, when a person stands up, the blood vessels in the legs constrict in order to support the blood pressure in the standing position. Orthostatic hypotension – a fairly common condition – occurs in patients whose blood vessels do not constrict normally when they stand, thus allowing the blood to pool in the legs, and the blood pressure to drop precipitously. This condition is most often caused by prescription drugs, but is also seen in diabetes, Parkinson’s disease, with dehydration, and in several other disorders. A modestly alert physician can easily diagnose orthostatic hypotension simply by taking the blood pressure while the patient is lying down, and again while the patient is standing.
Vasovagal syncope (also known as cardioneurogenic syncope) is the most common cause of syncope, probably accounting for more than 80% of all syncopal episodes. Since vasovagal syncope is simply an exaggeration of a normal neurological reflex, most individuals will experience at least one vasovagal episode in their lifetimes.
The reflex responsible for vasovagal syncope works like this: A person is exposed to some stimulus (such as a needle stick) that initiates the reflex. The “stimulated” nerves (the nerves of the stuck finger, for instance) send an electrical signal to the vasomotor center in the brainstem. (The vasomotor center determines the body’s vascular “tone.”) The vasomotor center, in turn, signals the blood vessels in the legs to dilate, causing the blood to pool in the legs, and producing syncope. This same reflex also causes a drop in the heart rate, but usually it is the pooling of blood in the legs – and not the slow heart rate – that produces loss of consciousness.
The “stimulus” that triggers a vasovagal episode can be any one of hundreds of things. As already noted, pain is a common cause of fainting. Other common triggering events include the sight of blood, receiving upsetting news, or standing motionless for long periods (such as with soldiers standing at parade rest).
Anyone can have vasovagal syncope given an adequate triggering event, but many people are particularly prone to these episodes, and often with relatively mild triggers. These individuals tend to relate histories of syncope dating back to adolescence, and frequently will describe several different of triggering events. While, as noted, there are scores of possible triggering events for vasovagal syncope, some are quite characteristic and almost always point to vasovagal syncope. Syncope occurring after urinating, defecating, coughing or swallowing, or syncope associated with pain, fright, the sight of blood, or other noxious stimuli, is almost always vasovagal.
In these and other ways, vasovagal syncope tends to be highly situational. It is more likely to occur after a viral illness, after exercise, after a warm shower, or early in the morning – any time that relative dehydration is present, and dilation of the blood vessels in the legs would be more likely to produce a significant drop in blood pressure. Furthermore, vasovagal syncope is often preceded by a few seconds or a few minutes of warning symptoms. Often, these symptoms include lightheadedness, ringing in the ears, visual disturbances, sweating and/or nausea. Because of such “warning symptoms,” people who have had one or two episodes of syncope are frequently able to tell when an event is about to occur. And importantly, if they recognize the warning symptoms, they are able to abort the blackout simply by lying down and elevating the legs. (“Aborting” syncope is not possible with most other forms of syncope.)
Given these characteristic features and the situational nature of this condition, doctors can make the correct diagnosis in the vast majority of patients with vasovagal syncope simply by asking right questions and listening carefully to the answers.
