St Emlyn’s Lesson Plans
Assessing a blackout or unexplained fall
Build a witness-based blackout history, recognise cardiovascular red flags and avoid reassuring labels that hide risk.
Medical Students · 45-minute session
For learners
Before: Allow about 12 minutes in total.
When we meet: We will reconstruct an unwitnessed fall and an exertional blackout, using the history and ECG to decide who needs urgent cardiovascular assessment.
Practise: use the practice card with a partner.
For facilitators
Send: the learner preparation link before teaching.
Bring: Before/during/after history sheet and NICE red-flag list.
Run: 45-minute session plan · 30-minute option
Practise: use the card for observed practice and feedback. Allow time for both turns, or arrange a follow-on practice session.
Before the session
If you are attending this session, complete the core preparation below before you come. Allow about 12 minutes in total.
Core preparation
NICE CG109 transient loss of consciousness · About 10 minutes
Read 1.1.1–1.1.2 on event history, examination and ECG, then 1.1.4.1–1.1.4.3 on urgent assessment and uncomplicated faint. Finish with 1.3.2.1, which distinguishes collapse during exercise from collapse after stopping.
https://www.nice.org.uk/guidance/cg109/chapter/Recommendations
Think about (allow 2 minutes): What would you ask a witness before accepting that an unexplained fall was a simple trip?
Picture the scene
A person is sitting up and feels well after a brief collapse. They say, ‘It was just a faint. Can I go?’
By the end of the session
- Describe what happened before, during and after a transient loss of consciousness.
- Identify cardiovascular red flags that need urgent assessment.
- Explain why an ECG or a history label must be interpreted alongside the full event.
After the session
- In the next fall history, ask whether the patient remembers the entire event and seek a witness account where appropriate.
Facilitator guide
Send learners the preparation link several days before teaching. Allow about 12 minutes in total.
Before learners arrive
- Find the local blackout/cardiology pathway and how an abnormal ECG receives urgent review.
- Have a current ECG teaching example with provenance, or use the written description provided.
Equipment: Before/during/after history sheet and NICE red-flag list.
Setup: One learner acts as witness and one takes the history; a third notes which answer changed risk.
If the preparation has not been completed
Use five minutes in place of “Establish the essentials”. On paper, give pairs the headings before, during and after. Allow two minutes to add witness questions, two to compare the questions with the case history, and one to check the cardiovascular red flags in NICE 1.1.4.2. The written ECG description is sufficient for the cases.
Suggested session plan
- 0–5 min — Explore. Ask what ‘just a faint’ fails to tell us.
- 5–10 min — Establish the essentials. Build a witness-history structure.
- 10–32 min — Discuss & Apply. Use 11 minutes per case, ending with a referral statement.
- 32–40 min — Consolidate. Ask pairs to reconstruct the event, explain why a normal ECG does not settle the exertional case and identify the referral route.
- 40–45 min — Reflect & Transfer. Ask learners where they will add a question about recollection and witnesses to their next fall history.
Start the discussion
Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.
Cases and discussion
Use these cases, or invite an anonymised case from the group that addresses the same questions.
An unexplained fall
An 80-year-old has facial injuries after an apparent trip. They cannot clearly remember the fall and no witness is initially available.
Add this information as the discussion develops:
- A relative describes sudden collapse without a protective response and rapid recovery.
- The ECG report describes bundle-branch conduction disease; the patient is taking several medicines.
Ask the group:
- What makes loss of consciousness possible rather than certain?
- Which aspects of injury, medication and cardiac assessment matter?
- What should happen with an abnormal ECG?
Discussion notes
Points to draw out:
- Reconstruct the event and assess injuries; facial injury or absent recollection alone is not proof of syncope.
- Obtain observations, relevant lying/standing blood pressure when appropriate, medication history, cardiac examination and a 12-lead ECG reviewed by someone competent.
- An abnormal ECG with possible blackout warrants prompt senior assessment and an appropriate cardiovascular pathway; monitoring and admission depend on the whole presentation.
- Do not diagnose the mechanism from the label ‘trifascicular block’. Describe the actual ECG findings and recognise the concern.
Common misconceptions:
- Accepting ‘tripped’ without exploring recollection.
- Assuming an automated ECG label is a final diagnosis.
- Ignoring bleeding, pregnancy-related or neurological alternatives when the history suggests them.
For a more experienced group: Ask what would make postural hypotension plausible and why it might coexist with other disease.
Collapse during football
A 35-year-old loses consciousness while running during a match. They recover quickly. A relative died suddenly at a young age.
Add this information as the discussion develops:
- The initial ECG is not obviously abnormal.
- Contrast with a person who feels warm and nauseated after standing for a long time, with a clear provoking factor and recovery on lying down.
Ask the group:
- Which history feature remains a red flag despite the ECG?
- How would you communicate the need for cardiovascular assessment?
- What makes a reflex faint more plausible in the contrast case?
Discussion notes
Points to draw out:
- Syncope during exertion and a relevant family history need urgent cardiovascular assessment; a normal snapshot ECG does not eliminate intermittent rhythm or structural problems.
- Under NICE, relevant red flags call for specialist cardiovascular review prioritised within 24 hours; a deteriorating or unstable patient needs immediate care.
- Posture, provoking factors and prodromal symptoms support uncomplicated faint when the full assessment fits. They are not a checklist that overrides contradictory findings.
- Discuss driving and exercise restrictions with the supervising clinician using the current applicable guidance rather than inventing a universal interval.
Common misconceptions:
- Diagnosing hypertrophic cardiomyopathy from age or one tracing alone.
- Confusing collapse during exercise with a typical post-exercise faint.
- Calling all brief jerking epilepsy.
For a more experienced group: Ask why the frequency and circumstances of events influence selection of ambulatory ECG monitoring.
Important clinical points
- Assess injuries alongside the cause of the blackout or fall.
- An abnormal ECG, exertional syncope, significant cardiac findings or relevant family history requires escalation.
- Students should not give unverified driving-clearance advice.
Practise with a partner
Use the card to rehearse the skill together. One learner performs. One learner checks the key steps and gives feedback. Then swap roles.
Cardiovascular examination · MLA
Practise with a partnerRead the observer setup and allow time for both turns. Use the card alongside the lesson activity or in a follow-on practice session.
Closing the session
Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.
- Give three witness questions that distinguish different causes.
- Explain why a normal ECG does not settle the exertional case.
- State the local urgent cardiovascular referral route.
Key teaching points:
- Establish what happened before, during and after the event.
- Interpret the ECG alongside the history and examination.
- Exertional events and relevant cardiac findings change the urgency of assessment.
Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.
Adapting the discussion
Uncertainty and local practice
Syncope is a transient reduction in cerebral perfusion, but the exact cause may remain uncertain after the first visit. Investigation and safety advice must reflect that uncertainty.
If the discussion drifts
Which event detail changes our level of concern?
For a more experienced group
Compare monitoring choices for frequent versus rare unexplained events; leave device decisions to the specialist pathway.
A 30-minute version
30 minutes: opening 3, witness structure 5, cases 15, consolidation 5, reflection 2.
Evidence and guidance
- NICE CG109 — Initial assessment, cardiovascular red flags and investigations.https://www.nice.org.uk/guidance/cg109/chapter/Recommendations
- GMC Outcomes for graduates — Safe assessment and seeking supervision.https://www.gmc-uk.org/education/standards-guidance-and-curricula/standards-and-outcomes/outcomes-for-graduates/
Suggested curriculum links
GMC Outcomes for graduates / MLA 2026: Transient loss of consciousness; falls and cardiovascular assessment
The lesson develops event reconstruction, ECG escalation and safe onward care.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
First published 2020-09-22 · Iain Beardsell.