Syncope: The Role of Coughing

This type of syncope, at times, is lethal if not timely intervened. An informed bystander must place the patient flat on a bed or floor without any pillows and must elevate both legs at 45 degrees. Then he/she must advise the patient to cough continuously at a rate of 40-50 coughs per minute. A good cough produces a strong contraction of the diaphragm and the intercostal muscles, resulting in sudden elevation of intrathoracic pressure, as much as 60-80 mmHg. (Fig 5) This cough-assisted increase in the intrathoracic pressure is also reflected in the central aortic blood pressure (the most vital measure of blood pressure), resulting in better perfusion of the brain and heart. In fact, by coughing you are increasing the blood pressure of a hypotensive patient to achieve better levels of perfusion pressures. Coughing is an internal CPR. In many instances, this maneuver alone will bring a patient out of presyncope with restoration of color, heart rate, and blood pressure. However, these maneuvers must be considered only as a first aid and should not be substituted for other important steps, such as calling 911, etc.

Case Study

Cough - An Internal CPR

(Fig. 5) The figure above shows arterial pressure tracings and EKG tracings of an 80 year-old man while undergoing a left heart catheterization. The initial blood pressure was 180/94. A left coronary angiogram revealed multiple 90-95% blockages. During angiogram, the patient developed chest pain, shortness of breath, and diaphoresis. The systolic blood pressure dropped from 180 to 100 mmHg. The patient was asked to cough. With each cough, the central aortic and peripheral blood pressure increased to 165 mmHg, thereby improving critical perfusion to the brain and other vital organs. With additional medications, the patient’s blood pressure steadily improved and settled at 170/90.

When a patient is fainting with a cardiac cause such as slow heart rate, vasovagal attacks, or even ventricular fibrillation, the blood pressure precipitously drops resulting in poor or no perfusion to vital organs, particularly the brain and heart. In the very early phase of this critical moment, if the patient can cough, the central aortic pressure will instantaneously rise resulting in better perfusion of the brain, and can be lifesaving. However, the patient must be told to do so before completely passing out.

I herewith denote an incident that happened to me about a year ago. I am physically very healthy and active. Except for mild hypercholesterolemia and occasional discomfort from bursitis on my left shoulder, I have never had any other medical problems. I neither have any significant cardiac risk factors nor evidence of coronary artery disease.

I went to my physician’s office for a steroid injection on my left shoulder for bursitis. The initial vitals read as a pulse rate of 72 and blood pressure of 124/70. Soon after the injection I felt warm and broke into a heavy sweat. I felt somewhat lightheaded, “weightless” and things around me were just foggy. I felt for my pulse and there was none. I started to cough immediately and continuously; I lied down on the couch, and crouched my legs with my knees up. Within a few seconds, I felt “life” gushing into my brain and things started to clear up.

What I felt was a classical episode of vasovagal attack. What I did was exactly that had to be done, and needs to be done in similar situations. Such situations are not at all uncommon in daily life, particularly secondary to a pain reaction from trauma, needle injections, or pain from any of the visceral organs. It is my feeling that many of the “deaths on the dentist’s chair” are secondary to vasovagal attacks, and its poor management by ignorant caregivers.