5.3 Protocol 31: Unconscious / Fainting & Protocol 32: Unknown Problem (Man Down)

5.3 Protocol 31: Unconscious / Fainting & Protocol 32: Unknown Problem (Man Down)

Quick Answer: Protocol 31 governs patients with decreased levels of consciousness, separating self-limiting syncope (fainting) from life-threatening sustained coma. Because unconsciousness abolishes protective laryngeal reflexes and pharyngeal tone, the dispatcher's primary focus is verifying effective breathing and guarding against the deadly agonal breathing trap. In contrast, Protocol 32 manages Unknown Problem (Man Down) calls from third parties who cannot see or safely assess the subject. Protocol 32 enforces strict caller safety warnings against approaching unknown individuals or hazardous roadways while assigning conservative, high-acuity default determinants to safeguard unverified patients.

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Protocol 31: Syncope vs. Sustained Coma

Unconsciousness is a priority symptom in emergency medical dispatch that spans a broad clinical continuum, ranging from benign, self-reversing syncopal episodes to profound structural comas caused by catastrophic intracranial catastrophe:

1. Syncope (Fainting / Near-Syncope)

Syncope is defined as a sudden, temporary loss of consciousness and postural muscle tone resulting from acute, transient global cerebral hypoperfusion. It is characterized by three core criteria:

• Rapid Onset: The patient loses consciousness swiftly, often preceded by prodromal autonomic symptoms (lightheadedness, tunnel vision, diaphoresis, pallor, nausea, yawning).
• Brief Duration: The blackout is self-limiting, typically lasting less than 60 seconds (and rarely exceeding 2 minutes).
• Spontaneous, Complete Recovery: Upon assuming a horizontal position (which eliminates gravitational pooling and restores cerebral perfusion), the patient awakens fully oriented without prolonged focal neurological deficits.

Common etiologies include vasovagal neurocardiogenic syncope, orthostatic hypotension, situational syncope (cough, micturition), and dangerous cardiac syncope (ventricular arrhythmias, aortic stenosis, complete heart block), which requires immediate ALS evaluation.

2. Sustained Coma / Unconsciousness

Coma is a state of sustained unresponsiveness where the patient cannot be aroused even by vigorous external noxious stimuli. The patient remains unresponsive with eyes closed, lacking purposeful interaction with the environment:

• Etiologies: Intracranial hemorrhage, massive hemispheric stroke, severe traumatic brain injury (TBI), severe hypoglycemia (blood glucose < 40 mg/dL), acute opioid or sedative intoxication, severe septic shock, status epilepticus, or anoxic brain injury.
• Dispatch Urgency: Sustained unconsciousness is a DELTA-level emergency. The breathing quality picks the code: 31-D-1 Unconscious — agonal/ineffective breathing (which in practice means shunting to Protocol 9), 31-D-2 Unconscious — effective breathing, 31-D-3 Not alert, and 31-D-4 Changing color. Completely ineffective breathing is the ECHO code 31-E-1.

+-------------------------------------------------------------------------+
|                   SYNCOPE VS. SUSTAINED UNCONSCIOUSNESS                 |
|                                                                         |
|   Parameter:      Syncope (Fainting)       Sustained Coma               |
|   Duration:       Seconds (< 2 minutes)    Persistent (> 2 minutes)     |
|   Recovery:       Spontaneous & Complete   Requires Medical Intervention|
|   Arousal:        Alert upon awakening     Unresponsive to stimuli      |
|   Determinant:    31-A-1 / 31-C-2          31-D-2 or 31-D-3 (ALS Hot)   |
+-------------------------------------------------------------------------+

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Airway Assessment & The Agonal Breathing Trap

In the unconscious patient, the loss of consciousness produces profound neuromuscular relaxation throughout the hypopharynx:

• Anatomical Airway Obstruction: The tongue falls posteriorly against the posterior pharyngeal wall, completely occluding the airway. Flaccid epiglottic and pharyngeal tissues vibrate or collapse on inspiration.
• Loss of Protective Airway Reflexes: The cough, gag, and swallowing reflexes are extinguished, leaving the lungs completely unprotected against silent aspiration of gastric acid, saliva, and blood.

The Agonal Breathing Trap on Protocol 31

The most lethal failure in emergency medical dispatch occurs when an unconscious patient in early sudden cardiac arrest is incorrectly handled under Protocol 31 instead of Protocol 9:

• During the first 2 to 4 minutes of cardiac arrest, 40% to 60% of patients exhibit agonal respirations—intermittent, reflex brainstem gasps characterized by snorting, snoring, groaning, or periodic jerking mouth movements.
• Callers routinely tell the EMD: "He passed out, but he's breathing... he's making a heavy snoring sound."
• The Cardinal Protocol Rule: Stertorous snoring, gasping, snorting, or irregular breathing in an unresponsive patient is CARDIAC ARREST until proven otherwise by the Agonal Breathing Detector or immediate chest compression coaching. If breathing is abnormal, irregular, or agonal, the EMD must immediately shunt to Protocol 9.

                     THE AGONAL BREATHING DISPATCH TRAP:
    "Unconscious + Snoring / Gasping / Groaning = CARDIAC ARREST!"
         Do NOT treat as simple fainting. Shunt instantly to CPR!

Recovery Position Instructions

If the caller confirms the patient is unconscious but definitively breathing normally, rhythmically, and easily, and there is no suspicion of cervical spine trauma:

"Put them on their side with their top knee bent to keep them from rolling. Tilt their head back slightly to keep their airway open."

The Recovery Position uses gravity to prevent the tongue from falling back into the airway and ensures vomitus drains freely out of the oral cavity rather than into the trachea.

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Protocol 32: Unknown Problem (Man Down)

Protocol 32 addresses calls where the caller reports a person down or in medical distress but has little or no specific clinical information:

• Common Call Profiles: Motorists driving past an individual lying on a highway shoulder; pedestrians viewing an unmoving person across a four-lane boulevard; security guards viewing grainy closed-circuit television (CCTV) monitors; third-party callers relaying secondhand reports from distant acquaintances.

The Dilemma of the Information Void

In Protocol 32, the EMD cannot determine Case Entry vital signs:

• Is the patient awake? "I don't know, I'm driving past at 60 miles an hour."
• Is the patient breathing? "I can't tell, they're just lying on the grass."
• Are they bleeding? "I couldn't see from that far away."

                          PROTOCOL 32 TRIAGE DILEMMA
                                      |
                     CALLER CANNOT SEE OR ASSESS PATIENT
                                      |
         +----------------------------+---------------------------+
         |                                                        |
  SCENE SAFETY RISK                                      INFORMATION VOID
"Do not approach unknown persons"                     Cannot verify breathing/pulse
"Stay in your vehicle / safe zone"                   High risk of cardiac arrest / OD
         |                                                        |
         +----------------------------+---------------------------+
                                      |
                      MANDATORY HIGH-ACUITY DEFAULT
                     (32-D-1 Life status questionable)

Universal Caller Safety Warnings

Because the caller is at or near an unverified scene, the EMD's primary legal and operational duty is bystander preservation. Approaching an unknown prone person carries extreme risks:

• Violent Altercations & Weapons: The subject may be experiencing violent excited delirium, acute paranoid psychosis, or feigning injury to commit an ambush assault.
• Environmental & Toxic Hazards: The person may have collapsed from concentrated hydrogen sulfide, carbon monoxide in a confined space, downed high-voltage power lines, or active chemical exposure.
• Traffic Fatalities: Motorists who exit their vehicles on high-speed freeways to check on individuals face catastrophic pedestrian-vehicle strike hazards.

[!CAUTION] Non-Discretionary Protocol 32 Safety Directive: The EMD must explicitly instruct third-party callers: "Do not approach the person. Stay in a safe location (or keep driving) and do not put yourself in danger."

Triage Defaults and High-Risk Assumptions

When essential medical information is entirely unobtainable, the MPDS enforces a fail-safe default philosophy:

• Never Assume Benign Conditions: An unknown person lying motionless on the ground must never be assumed to be simply "sleeping off alcohol intoxication" or resting.
• Default Determinants: Protocol 32 is deliberately tiny — one DELTA code and four BRAVO codes. 32-D-1 (Life status questionable) is used when the caller cannot confirm that the person is alive. The BRAVO codes cover the less alarming reports: 32-B-1 Standing, sitting, moving, or talking, 32-B-2 Medical alarm (no patient information), 32-B-3 Unknown status / other codes not applicable, and 32-B-4 Caller's language not understood (no interpreter in center). If the caller can see the patient from a safe distance and confirms motionless unresponsiveness, it is treated as a suspected cardiac arrest or severe overdose until field responders arrive.
• Landmark Extraction: The EMD must extract precise geographical coordinates: mile markers, highway overpasses, compass directions, prominent storefronts, clothing colors, and caller contact details for follow-up.