Breathing but not awake

Lesson 2 taught you the pair of signs that mean cardiac arrest: the person won't respond, and they aren't breathing normally. This lesson is about the person who won't respond, and what their breathing tells you to do next. A friend on the bathroom floor after a party, who won't wake when you shake him. A stranger slumped in a stairwell, barely breathing, with pinpoint pupils. A colleague who went grey in a queue and slid down the wall. The first may only need turning onto his side and watching, if his breathing is normal. The second may already need CPR, and a spray that can bring her breathing back. The third is usually awake again within a minute, and the question is whether that is the end of it.

The recovery position comes first, and who it is not for. Then opioid overdose, where breathing is the whole problem and a spray can reverse it, though not once the heart has stopped. Then the ordinary faint.

Before you move anyone

Once you have made sure it is safe, checked for a response and made the call as lesson 2 taught, two questions come before the recovery position, in this order.

Are they breathing normally? This is lesson 2's test, and it decides everything. RCUK's 2025 adult guideline is specific about what fails it: "Slow, laboured breathing, as well as other abnormal patterns such as agonal gasping or panting, must be recognised as signs of cardiac arrest."¹ The AHA's list of the words bystanders use for agonal breathing is "abnormal breathing, snoring respirations, and gasping."² So if the person is not breathing, or the breathing is slow, laboured or noisy, a snore, a gurgle, a gasp, or you can't tell, they are treated as being in cardiac arrest and they go on their back for CPR. RCUK 2025: "If there is any doubt, assume cardiac arrest and start CPR."¹ The AHA's 2025 adult guideline: "If an adult is unconscious/unresponsive, with absent or abnormal breathing (ie, only gasping), the lay rescuer should assume the person is in cardiac arrest" (AHA 2025, COR 1, LOE C-LD).² Normal breathing, then, is breathing that none of those words describe: regular, quiet and unlaboured, at an ordinary pace. Nothing in this lesson's recovery-position sections applies to anyone else.

Are they injured? A fall, a crash, a blow to the head, anything that could have hurt the neck or back. If so, they are not rolled onto their side either, as the next section explains.

Only when the answers are yes and no does the recovery position come in. The flow below puts the decisions in order, and the rest of the lesson fills in each box.

The order of decisions for someone who won't respond. The outlined boxes are shared by both countries' guidance; the three shaded boxes are the outcomes, and the two at the bottom both lead on to decision 4. This course drew it from the guidelines named in each box.

The recovery position

Who it's for

The European and UK guidelines say it in one sentence. The ERC's 2025 first aid guideline, which RCUK's 2025 first aid guideline repeats almost word for word: "Place adults and children with decreased level of responsiveness who do NOT meet the criteria for CPR into a lateral (side-lying) recovery position" (ERC 2025; RCUK 2025).³⁴

The American guidance agrees, with a grade. The AHA and American Red Cross 2024 first aid guideline: "It is reasonable to position a person with decreased alertness of nontraumatic cause who is breathing normally in a recovery (side-lying) position." (AHA/Red Cross 2024, COR 2a, LOE C-LD).⁵ The recommendation above it in the same table settles the other case: "If a person requires CPR or rescue breathing (ie, is unresponsive with absent or abnormal breathing), the first aid provider should position the person supine and follow the CPR algorithm." (AHA/Red Cross 2024, COR 1, LOE C-LD).⁵ Supine means on the back. Lesson 4 taught you what a 2a means: benefit judged to outweigh risk, "is reasonable", one step below the class that says "should".

So both sides put the same person on their side: someone who won't respond properly, is breathing normally, and is not injured. Where they differ is in how they describe the arms, which comes below.

Who it isn't for

The ERC and RCUK give two exclusions in one line: "In cases of agonal breathing or trauma, do NOT move the person into the recovery position." (ERC 2025; RCUK 2025).³⁴

Agonal breathing is the gasping you met in lesson 2. The AHA describes it: "Agonal breathing is characterized by slow, irregular gasping respirations that are ineffective for ventilation."² A person doing that is in cardiac arrest, and the recovery position is one in which they can't be given CPR. The AHA's 2025 special circumstances guideline puts it flatly: "Effective CPR cannot be performed in the recovery (lateral decubitus) position."⁶ Lesson 2's five-a-side game had friends roll a man onto his side because "he's breathing", when the loud slow gasps were the arrest itself. That is the mistake this exclusion exists for.

Trauma. Neither the ERC nor RCUK says in the text this course read why an injured person is not rolled, so this lesson gives their instruction and not a reason. The ERC's evidence section adds what to do instead: "Persons with a known trauma should be kept in supine position."³ The AHA/Red Cross guideline comes at it from three sides. Its recovery-position recommendation is scoped to decreased alertness "of nontraumatic cause". Its background says the position "may not be ideal if there are injuries to the spine, hip, or pelvis; if breathing is abnormal; or if CPR is needed." And a separate line, written for an injured person who is responsive and breathing normally, says that one whose injury suggests a neck, back, hip or pelvic injury should be left in the position they were found in, unless the area is unsafe (AHA/Red Cross 2024, COR 1, LOE C-EO).⁵ Its supporting text gives the reason for that one: moving them risks "worsening hemorrhage or neurological injury".⁵ None of its graded lines is written for an injured person who won't respond. Lesson 11 takes up injuries to the head and spine. One line holds whatever the injury: the AHA/Red Cross guideline puts anyone who needs CPR on their back (COR 1, LOE C-LD).⁵

Why the side

An unresponsive person on their back is at risk from their own body. The British Red Cross explains the first part, in its page on someone who is not breathing: "When a person is unresponsive, their muscles relax and their tongue can block their airway so they can no longer breathe."⁷ The AHA/Red Cross guideline's supporting text gives the fuller list: "The recovery position may reduce the risk for airway obstruction, facilitate drainage of airway secretions, and reduce the risk of aspiration in a person with a decreased level of responsiveness, particularly if the airway cannot be closely monitored by a first aid provider."⁵ Aspiration is breathing in something that shouldn't be there: saliva, vomit, blood. The head tilt deals with the tongue: "Tilting their head back opens the airway by pulling the tongue forward," in the British Red Cross's words.⁷ And the ERC's steps keep the head "facing downwards to the side to allow liquid material to drain from the mouth."³

Then the same AHA/Red Cross guideline says something the leaflets leave out: "However, the recovery position is associated with delayed recognition of respiratory arrest and delayed initiation of chest compressions."⁵ A person on their side, facing away from you, with a coat over them, can stop breathing without anyone noticing. That is why the position is not a thing you do and walk away from. The ERC's last two steps are to check regularly for normal breathing and not to leave the person unless you have to go for help.³ RCUK's paediatric guideline gives a number for children, continuously or at least every minute.⁸ The ERC gives adults no number, and nothing read here gives them a longer gap, so stay where you can see the chest and hear the breath.

How, step by step

The ERC's 2025 first aid guideline gives the method. RCUK's page carries the who and the two exclusions and no method of its own, so the steps are the ERC's.³⁴ In its order:

1. Make sure their legs are straight.
2. Place the arm nearest you out at a right angle to the body. Straight or bent at the elbow: the ERC says a randomised trial in volunteers found no difference between the two, so either.³
3. Bring the far arm across the chest and hold the back of that hand against the cheek nearest you.
4. With your other hand, take hold of the far leg just above the knee and gently lift the knee up, keeping the foot on the ground.
5. Keeping the hand pressed against the cheek, pull on the far, bent leg to roll the person carefully towards you, onto their side.
6. Adjust the upper leg so the hip and the knee are both bent at right angles.
7. Carefully tilt the head back so the airway stays open, and adjust the hand under the cheek if needed to keep the head tilted and facing down to the side, so that anything in the mouth can drain out.
8. Check regularly for normal breathing.
9. Don't leave them unless you have to go for help.

The steps are this course's plain-language version of the ERC's list, not a quotation.³

The American guidance describes the finished position rather than the roll. The AHA/Red Cross 2024 guideline gives no step-by-step technique; its one figure shows a person on their side with the lower arm stretched out beyond the head, the upper hand under the cheek, and the upper leg bent at the hip and knee.⁵

AHA/Red Cross 2024, Figure 1 and Table 14;⁵ ERC 2025 First Aid.³ RCUK 2025 First aid gives the who and the who-not and prints no technique.⁴

Neither is wrong. The ERC's reason for allowing either arm position is the volunteer trial that found no difference; the AHA gives no reason for its arm placement in the text read, and this course won't supply one. Both put the person on their side with the head supported and the airway open, and the upper leg bent so the body stays put.

Which side? The ERC text says to roll the person "towards you", and gives no preference for left or right.³ The one exception in the sources is pregnancy. The AHA/Red Cross supporting text says a side-lying position may be preferred for comfort by pregnant people, people with breathing difficulties and people with larger or smaller bodies, and that lying on the left side improves circulation in the later stages of pregnancy.⁵ The NHS fainting page says of someone who has fainted and is breathing normally that if they are pregnant, especially more than 28 weeks, it's better to lay them on their side.⁹ So for a pregnant woman, the left side; for everyone else, whichever side you rolled them towards.

How much is known

Less than you'd guess for something taught in every first aid class. The ERC reports that ILCOR's scoping review found 34 studies, mostly in healthy volunteers; in children, the position was associated with fewer hospital admissions; and one observational study in opioid overdose favoured a semi-recumbent position, sitting half up, over lying on the side.³ That is the evidence base: volunteers, one association in children, and one study pointing another way in one condition. The AHA's C-LD label says the same thing in its own alphabet. The position rests on the airway reasoning above and on long practice, which is a reasonable basis for a manoeuvre that costs nothing, and it is also why the guideline's caution about missed arrests deserves its full weight.

The bathroom floor

Now the common case, in one country's words and then the other's.

Your flatmate went out for a friend's birthday. At two in the morning you find him on the bathroom floor, on his back, one arm across his face. You say his name. Nothing. You kneel, shake his shoulders and shout it. Nothing, though he groans once and does not open his eyes. Lesson 2 told you what to make of a groan that has nothing to do with what you said: it does not count as responding.

In England. He is unresponsive, so you call 999 on speaker at once and put the phone on the floor by his head (RCUK 2025).¹ While it connects you watch his chest and listen. It rises and falls regularly, at an ordinary pace, and it is quiet: no snore, no gurgle, no gasp. You tell the call handler what you see and hear, and they agree it sounds like normal breathing. He hasn't fallen from anything, and there's no blood or bruise. He does not meet the criteria for CPR, so he goes into the recovery position (RCUK 2025), by the ERC's method:⁴³ you straighten his legs, put his near arm out, bring the far hand to his cheek, lift the far knee and roll him towards you, tilt his head back. Then you sit on the floor where you can see his chest and hear him, and you keep the call going.

In Ohio. The same floor, the same groan. Under the AHA's adult guideline you look at his breathing first: regular, quiet, at an ordinary pace, no gasping.² That is not the picture the AHA tells you to treat as arrest, so this is not a CPR call. A person you can't wake is still a 911 call, as lesson 2 gave it from the American Red Cross's steps, and the AHA/Red Cross 2024 guideline gives the reason: calling "leads to the arrival of rescuers who are trained and equipped to manage medical emergencies".⁵ So you make it, on speaker. Then, since his decreased alertness has no traumatic cause and he is breathing normally, the recovery position is the reasonable choice (AHA/Red Cross 2024, COR 2a, LOE C-LD).⁵ You roll him onto his side with his upper hand under his cheek and his upper leg bent, and watch.

Putting him on his side is the part you can rehearse at the end of this lesson. Watching him afterwards is the part the AHA/Red Cross caution about delayed recognition is aimed at.

Who lies flat, who lies on their side, and whose feet go up

The AHA/Red Cross 2024 guideline sets out positioning in two tables, and the rows a bystander needs fit on one card. Lesson 9 comes back to the rows about shock and bleeding.

AHA/Red Cross 2024, Tables 14 and 15, read from the publisher's images.⁵

The UK and European answer for the first two rows is the pair of ERC and RCUK sentences you've already read, and for an injured person their answer is not to roll them. For the fourth row, RCUK's 2025 first aid guideline has nothing on fainting, because the ERC dropped presyncope from the scope of its 2025 chapter, and the NHS page carries the UK advice: lay a person who has fainted and is breathing normally on their back and raise their legs.¹⁰⁹ Both sides raise the legs after a simple faint. The AHA grades it 2b and says why the grade is low: the evidence for raising the feet comes from studies outside first aid, the improvements seen were temporary, and not every study found them.⁵

Opioid overdose

This section teaches a medical emergency in the terms the public health bodies use. It says nothing about drug use itself; Habits and Addiction, later on the Core, owns that. The person on the floor is a person who has stopped breathing properly, and that is all a bystander needs to know about them.

What you'd see

RCUK's 2025 first aid guideline says to suspect an opiate or opioid overdose when the person is breathing slowly, the breathing is irregular or absent, the person is extremely drowsy or unresponsive, or their pupils are very small (RCUK 2025).⁴ The ERC's 2025 first aid guideline lists the same three signs: slow, irregular or absent breathing, extreme drowsiness, and pinpoint pupils (ERC 2025).³ Notice the first sign on both lists. Slow breathing in someone who won't respond is the overdose picture as well as a sign of arrest, which is one more reason it never counts as normal. Opioids include heroin, methadone, morphine and fentanyl, and the UK government's naloxone guidance names them.¹¹

You often won't know. The AHA's 2025 special circumstances guideline says that telling an opioid overdose from other causes of arrest can be difficult without an accurate history, which is often unavailable, and that most opioid deaths involve other substances that also slow the breathing.⁶ That matters less than it sounds, because the first response is the same as for anyone who is unresponsive and not breathing normally: call, and CPR. Naloxone is the one extra step, and the sources are clear about where it fits.

What's happening, as the sources give it

The UK Department of Health and Social Care puts the mechanism in two lines, in its guidance on supplying naloxone: the main life-threatening effect of heroin and other opiates is to slow down and stop breathing, and naloxone blocks that effect and reverses the breathing difficulty.¹¹ The AHA's 2025 guideline describes the sequence: an opioid overdose depresses the nervous system and breathing, progresses to respiratory arrest, where breathing stops, and then to cardiac arrest.⁶

Set that beside lesson 4's two kinds of arrest. In the sudden adult kind, the blood is still full of oxygen when the heart stops, which is why compressions come first. An overdose is the other kind: the breathing fails first, the oxygen runs out, and only then does the heart stop. That is a hypoxic arrest, like drowning in lesson 6, and it is why the AHA asks lay rescuers for CPR with breaths here, and trained rescuers who find a pulse for breaths (both COR 1, LOE B-NR).⁶ RCUK and the ERC say start CPR, which under RCUK's adult guideline means 30:2 if you're trained and compressions if you're not; neither gives overdose a breathing rule of its own in the text read.⁴³¹ The AHA's estimate for the United States is that "An estimated 1 in 6 to 1 in 3 OHCAs are related to an overdose, most commonly involving opioids."¹² (OHCA is out-of-hospital cardiac arrest.) The AHA scopes that sentence to the US, and this course has no equivalent UK figure.

The two columns

AHA 2025 Part 10, section 21.11 and Top 10;⁶ RCUK 2025 First aid;⁴ ERC 2025 First Aid and Special Circumstances.³¹³

Read the naloxone row twice; it's where the three differ most. The AHA says plainly that "Trained rescuers, lay rescuers, and members of the general public can all administer naloxone."⁶ Its strong COR 1 recommendation is narrower: it is written for trained rescuers who have found a pulse, and lesson 2 taught you that lay rescuers don't check one. For anyone in cardiac arrest, lay or trained, its grade is 2b, for adults on B-NR evidence and for children on C-EO.⁶ RCUK adds a condition, "if you are trained", and gives no reason for it in the text read, so this course offers none. The ERC's first aid chapter words it differently again: "Administer intra-nasal naloxone, or if you are trained, use an intramuscular naloxone autoinjector."³

The sentence to remember

The AHA's supporting text has the line that organises everything else: "Opioid antagonists are extremely unlikely to benefit an adult or child in cardiac arrest who is not receiving CPR and do not reverse VF."⁶ Naloxone is an opioid antagonist, a drug that blocks what the opioid does; VF is ventricular fibrillation, the rhythm lesson 5 taught you a defibrillator treats. The AHA's own explanation is that the drug is unlikely to work in the absence of cardiac output, that is, when no blood is moving to carry it, and that proven interventions, high-quality CPR with breaths, come before ones without established benefit in arrest.⁶

The AHA then says something unusual for a guideline: its instruction to start CPR before naloxone "differs from that of the prescribing information for naloxone or nalmefene."⁶ (Nalmefene is another opioid antagonist available in the US.) The leaflet in the box may tell you to give the spray first. The AHA puts CPR first while saying openly that the leaflet does not.

The European texts land close by, and one of them corrected itself on the way. The ERC's 2025 first aid chapter originally said naloxone is not effective once cardiac arrest has occurred; a correction published in September 2026 softened it to "Naloxone is probably not effective once cardiac arrest occurred. However, this should be investigated in a large clinical trial."³ So the honest version is "probably". The AHA and the ERC read the same thin evidence differently: the AHA's 2b says naloxone "may be reasonable" in arrest alongside CPR, and the ERC's special circumstances chapter says the evidence is "not sufficient to recommend" it.⁶¹³

After they wake

Naloxone wears off. The AHA's supporting text says the drug may take several minutes and repeated doses to reverse respiratory arrest, especially by nose or by injection into muscle, and its recommendation for adults who respond is observation in a health care setting (AHA 2025, COR 1, LOE C-LD), because the breathing can slow again once the naloxone fades and the opioid has not.⁶ RCUK's 2025 first aid guideline says to follow the packaging instructions on when to give another dose, and that the person should remain under observation until emergency assistance arrives.⁴ So a person who wakes is a person you stay with, on the line to the call handler, watching the breathing, with the second dose ready if the packaging says so.

This course did not read a product leaflet, so it does not teach how to use any spray or injector. The packaging carries the steps, and RCUK's instruction to follow it is the one to hold on to.

The law, in both countries

In the US, naloxone is sold without a prescription. On March 29, 2023 the Food and Drug Administration approved "Narcan, 4 milligram (mg) naloxone hydrochloride nasal spray for over-the-counter (OTC), nonprescription, use", the first naloxone product approved for use without a prescription.¹⁴ The AHA's 2025 systems-of-care guideline recommends that policies allow lay people to possess and use naloxone with immunity from liability (AHA 2025 Part 4, COR 1, LOE B-NR), and calls community distribution programmes beneficial (COR 2a, LOE B-NR).¹²

In the UK, the position is different and easy to misstate. Naloxone is a prescription-only medicine, so, in the Department of Health and Social Care's words, "pharmacies cannot sell it over the counter".¹¹ But since 2015 people working for drug treatment services have been able to supply it without a prescription; "The regulations were amended in February 2019 to include nasal naloxone"; and regulations made in December 2024 widened supply to a longer list including police, prisons, probation services, nurses, midwives, pharmacists and paramedics, with a registration route for others that, at the September 2025 update, was still being set up.¹¹ The products the guidance names are Nyxoid, a nasal spray licensed from age 14, and Prenoxad, an injection, and a 1.26 mg nasal spray, both licensed from 18.¹¹ And whoever supplied it, the guidance's line for the moment itself is plain: "Anyone can use available naloxone to save a life in an emergency."¹¹

A second kind of protection. Lesson 1 dealt with being sued for helping. Overdoses raise a different fear: that the person who calls for help will be charged with a drug offence. A 2021 report by the US Government Accountability Office, Drug Misuse: Most States Have Good Samaritan Laws and Research Indicates They May Have Positive Effects, found that "48 jurisdictions (47 states and D.C.) have enacted both Good Samaritan and Naloxone Access laws."¹⁵ In its words, "These laws protect people from certain criminal penalties if they call 911 to save an overdose victim", and they "vary in the types of drug offenses that are exempt from prosecution".¹⁵ It named "Kansas, Texas and Wyoming" as then having a naloxone access law but no overdose Good Samaritan law.¹⁵ That count is as of 2021 and will have changed; this course read the report's summary page and not the report. It read nothing on a UK equivalent, so it makes no claim about one. General information, not legal advice.

The stairwell

The harder case, with a gap for you to fill.

A shopping centre, late afternoon. A young woman is sitting slumped in a stairwell, chin on her chest. You say hello and get nothing. You shake her shoulder and say it louder, and she does not respond. Her lips look bluish. She takes a breath, and then nothing for what feels like a long time, then another, shallow and slow. When you gently lift one eyelid with your thumb, her pupils are tiny. On the wall by the fire door is a small red box marked "Naloxone", and a man on the stairs has stopped to help.

Take it in steps.

1. Danger. Lesson 2's check: nothing on the stairs, nobody threatening, the door propped open.

2. Response. None.

3. Breathing. A shallow breath, then a gap of eight or ten seconds, then another. Slow and irregular. That fails lesson 2's test in both countries: not breathing normally.

4. She responds. A few minutes in, after the spray, her breathing picks up, she coughs, and her eyes open. She is confused and wants to get up. Lesson 3's signs of life apply: she is breathing normally and coming round, so the compressions stop. The AHA's line is that resuscitation continues "until the adult or child is awake and breathing normally."⁶

What you watch for now is her breathing slowing again, for the reasons given under After they wake. So you stay, you keep the call handler on the line, you keep looking at her chest, and the box stays open beside you. If she drifts back to drowsy and won't respond but her breathing stays normal, she is this lesson's recovery-position case. If her breathing goes slow or irregular again, you're back at step 3.

Fainting

The third case is usually the least serious. The NHS describes fainting as passing out for a short time, and says it's not usually a sign of something serious, but that anyone who has fainted should see a GP.⁹ This section is about the minute before, the minute after, and the short list that turns a faint into an emergency call.

The minute before

Most faints announce themselves. The AHA/Red Cross 2024 guideline lists the signs of presyncope, the feeling of a faint coming on: pallor, sweating, lightheadedness, visual changes and weakness (AHA/Red Cross 2024).⁵ The NHS list is dizziness, sweating, feeling warm or hot, feeling sick and changes to vision.⁹

The first move is not a manoeuvre. It is a safe position. The AHA/Red Cross guideline says a person with those symptoms from a vasovagal or orthostatic cause should get into or be helped into a safe position such as assisted sitting or lying down (AHA/Red Cross 2024, COR 1, LOE C-LD), and its supporting text gives the reason: injuries are frequent complications of fainting, in about 30% of people admitted to emergency departments after one, and about 5% of those have severe trauma.⁵ Orthostatic is the faint that comes from standing up too quickly, which the NHS lists among the causes of fainting, along with being too hot and being very upset or in severe pain.⁹ The texts read here don't define vasovagal, and this course won't supply a definition; what matters for you is the other side of the line, below, where the guideline says the manoeuvres are not for a faint that comes with signs of a heart attack or stroke. The NHS gives the position the plain way: lie down with your legs raised, or if you can't, sit with your head lowered between your knees.⁹

Then, and this is the part most people have never heard of, tense your muscles. ILCOR's 2025 first aid review: "We recommend the use of any type of physical counter-pressure maneuver by individuals with acute symptoms of presyncope due to vasovagal or orthostatic causes in the first aid setting (strong recommendation, low-certainty and very low–certainty evidence)."¹⁶ That is a strong recommendation, the top grade lesson 4 taught you, unusual in first aid. The manoeuvres are things you do with your own body: the NHS gives crossing your legs while standing, rocking up and down on your toes, and clenching your fists.⁹ ILCOR adds a weaker preference for the lower body over the arms and abdomen (weak recommendation, very low certainty).¹⁶ The AHA/Red Cross guideline grades the manoeuvres as beneficial once the person is in a safe position (COR 2a, LOE C-LD) and lower-body ones as possibly preferable (COR 2b, LOE C-LD).⁵

Why does tensing the legs work? The AHA/Red Cross background gives the short answer: contracting the muscles of the legs, arms, abdomen or neck causes "a rise in blood pressure", which relieves the symptoms of a faint coming on.⁵ It does not go further than that, so neither does this course.

One limit matters more than the mechanism. The manoeuvres are for the common faint. The AHA/Red Cross guideline says their use "is not recommended when symptoms of a heart attack or stroke accompany presyncope" (AHA/Red Cross 2024, COR 3: No Benefit, LOE C-EO), and its text says they have not been advocated for cardiac causes and may delay care.⁵ Lesson 12 teaches those symptoms. And if the feeling does not lift within a minute or two, or the person faints anyway, or it gets worse or comes back, the guideline says to call the emergency services (COR 2b, LOE C-EO).⁵

The minute after

If they've fainted, the NHS page gives a sequence for a bystander: check whether they respond by shaking their shoulders and asking loudly if they are OK; if not, shout for help, gently tilt the head back and lift the chin, and check breathing for at least 10 seconds; if they are breathing normally, lay them on their back and raise their legs; if pregnant, especially past 28 weeks, on their side.⁹ The page says the person will usually wake within 30 seconds.⁹ One thing to notice: this NHS page checks breathing before calling, which is the pre-2025 UK order lesson 2 described, and RCUK's 2025 guideline now says to call 999 for anyone unresponsive and check while it connects.¹ For a faint the difference is seconds, because they are usually awake before you'd finish dialling.

The American guidance for the same moment is the leg raise you met in the positioning table: raising the feet about 6 to 12 in (15 to 30 cm) while waiting for the ambulance may be reasonable for a faint without trauma (AHA/Red Cross 2024, COR 2b, LOE C-LD), and they go back to flat if it hurts or makes things worse (COR 2b, LOE C-EO).⁵ Both sides agree on the position: on the back, legs up, breathing watched. They don't agree on the call, which comes next.

When a faint is an emergency call

The NHS page's default after a faint is a GP appointment. It says to call 999 if the person is not breathing, "cannot be woken up within 1 minute", "has not fully recovered or has difficulty with speech or movement", has chest pain or a pounding, fluttering or irregular heartbeat, "has seriously hurt themselves before or after fainting", is shaking or jerking as in a seizure, fainted while exercising, or fainted while lying down.⁹ If none of those applies, the page's advice is "See a GP if: you have fainted".⁹

The AHA/Red Cross guideline draws the line lower. Its trigger, from the presyncope table, includes the faint itself: "If no improvement occurs within 1 to 2 minutes, if syncope occurs, or if symptoms worsen or reoccur, the first aid provider should activate emergency services" (COR 2b, LOE C-EO).⁵ Syncope is the faint.

AHA/Red Cross 2024, Table 25;⁵ NHS, Fainting.⁹

Neither is wrong, and neither text read here says why it draws the line where it does for a faint that has already happened. This course read no US public page on fainting, so the US column is the guideline's alone.

Three of the NHS reasons connect to other lessons. Not breathing is lesson 2's arrest. Difficulty with speech or movement is a stroke sign, and lesson 12 teaches FAST. Fainting while exercising, or with chest pain or palpitations, is the symptom list Strength and Fitness told you to stop for; lesson 12 picks up the heart attack, and the NHS puts the call at 999 whatever the person says afterwards.

What people get wrong

"Put anyone who's unconscious in the recovery position." Not someone gasping, and not someone injured: those are the two exclusions you read earlier in this lesson.³⁴ A gasping person needs CPR, and the AHA says CPR can't be done on the side.⁶

"Snoring means they're sleeping it off." In someone who won't respond, snoring is one of the words bystanders use for agonal breathing (AHA 2025),² and RCUK counts slow, laboured breathing as a sign of cardiac arrest.¹ Slow breathing is also the first sign RCUK gives for an opioid overdose.⁴ If what you hear is noisy or slow, say so to the call handler, and if there is any doubt, start CPR (RCUK 2025).¹

"Once they're on their side, they're safe." The AHA/Red Cross guideline links the position with arrests noticed late, as you read under Why the side.⁵ Check the breathing, and keep checking.

"Naloxone first, then CPR." The AHA: don't delay CPR or the call for naloxone (COR 1, LOE C-EO), and it notes that this order differs from the drug's prescribing information.⁶ RCUK and the ERC both put "start CPR" before the naloxone line.⁴³

"Naloxone will restart the heart." The AHA: opioid antagonists "do not reverse VF" and are extremely unlikely to benefit someone in arrest who is not getting CPR; the ERC's corrected text says naloxone is "probably not effective once cardiac arrest occurred".⁶³

"Naloxone is dangerous if it turns out not to be an overdose." The ERC calls it "a safe and effective antidote" and says it works only on opioid overdoses.³ The AHA says "Major complications are rare and dose related."⁶ The UK guidance lists rare side effects, including a very small risk of heart problems in susceptible people, and says that because naloxone is given to someone already facing a fatal overdose, that risk "is not a reason to avoid using it".¹¹

"Once they wake up, they're fine." The opioid can outlast the naloxone, which is why the AHA wants adults who respond observed in a health care setting and RCUK keeps them under observation until help arrives.⁶⁴

"Sit a fainting person up so they get some air." The NHS says lie down with the legs raised, or sit with the head between the knees, and the AHA/Red Cross guideline's first recommendation for presyncope is a safe position, because the injuries come from the fall.⁹⁵

"A faint is never serious." Usually it is not, and the NHS still wants a GP to check. Its 999 list includes chest pain, palpitations, a seizure, difficulty with speech or movement, and fainting while exercising or lying down, and in the US the AHA/Red Cross guideline calls for help if someone who felt a faint coming on goes on to faint.⁹⁵

Practice

Where to learn with your hands

The recovery position is the one skill in this course you can rehearse on a willing adult at home, slowly and for placement only. The judgement around it, telling normal breathing from the slow or noisy kind and knowing the moment to roll someone back, is what a class with a manikin and an instructor adds. For CPR itself, the two free tools this course points to are the BHF's RevivR and RCUK's Lifesaver, neither of which replaces a class.¹⁷ Lesson 16 has the full list of where to train.

Connections

Lesson 2's test, breathing normally or not, was the hinge of this whole lesson: pass it and the recovery position applies, fail it and nothing here does, and slow or snoring breathing fails it. Lesson 4's contrast between an arrest that starts with oxygenated blood and one that starts without it returned as the reason the AHA wants breaths in an overdose. Lesson 5's ventricular fibrillation is what the AHA says naloxone does not reverse. This lesson gave lesson 6's children the same recovery position, with RCUK's stricter check for them: continuously, or at least every minute. Lesson 1's law gained a second kind of protection, for the person who calls. And lesson 4's grading key did its hardest work on the counter-pressure manoeuvres, where ILCOR's strong recommendation rests on low and very low certainty evidence.

Lesson 9 takes the positioning table further into shock and bleeding. Lesson 11 explains what a suspected spinal injury changes. Lesson 12 teaches the chest pain and stroke signs that turn a faint into something else. Lesson 14 covers the seizure that is not an arrest, and the person with low blood sugar who can't be woken. Habits and Addiction, later on the Core, can assume you can recognise an opioid overdose and know naloxone's status in both countries.

Go deeper

• RCUK, 2025 Resuscitation Guidelines: First aid, the "Recovery position" and "Opiate/Opioid poisoning" sections. Free and short: the UK's who, who-not and overdose steps in a few lines each.
• Djärv and colleagues, European Resuscitation Council Guidelines 2025 First Aid, Resuscitation, 2025, free to read at the publisher. The full recovery-position method with its figures, and the evidence section where the 34 studies and the volunteer trial live.
• Department of Health and Social Care, Supplying take home naloxone without a prescription (first published as "Widening the availability of naloxone"), updated September 2025. Free. The UK legal position on naloxone in plain English, including who may supply it, the line that anyone may use it, and what its side effects are.
• Hewett Brumberg and colleagues, 2024 AHA and American Red Cross Guidelines for First Aid, Circulation, 2024, free. The two positioning tables and the presyncope section are short, and they are where the US grades in this lesson come from.
• St John Ambulance's 2016 recovery-position video is not embedded here, because the arm and hand placement it teaches couldn't be checked against the 2025 guidance from its pictures alone, and a 30-second US CDC video on a naloxone nasal spray shows one US product only.

Sources

1. Resuscitation Council UK, 2025 Resuscitation Guidelines: Adult basic life support, 27 October 2025 . Read level: full, direct, checked again on 2026-09-25 for this lesson. "Suspect cardiac arrest in any person who is unresponsive", "Slow, laboured breathing", "If you are uncertain", "If there is any doubt", the call for anyone unresponsive, the seizure-like onset, and 30:2 for the trained.
2. M. E. Kleinman, J. E. Buick, N. Huber and colleagues, "Part 7: Adult Basic Life Support: 2025 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care", Circulation 152 (suppl 2), 2025 . Read level: full, from the Internet Archive capture 20251026225858. The lay recognition recommendation (COR 1, LOE C-LD) and the definition and lay words for agonal breathing.
3. T. Djärv, J. Rogers, F. Semeraro and colleagues, "European Resuscitation Council Guidelines 2025 First Aid", Resuscitation 215 (suppl 1), 2025, 110752, and its corrigendum, Resuscitation 228, 2026, 111316 . Read level: full, direct, on the publisher's page, where every passage quoted here was found word for word, the recovery position and opioid sections checked again on 2026-09-25; the corrigendum read in full. The recovery position sentences, the step-by-step method (paraphrased here), the drainage and "kept in supine position" sentences, the volunteer trial, the 34 studies and the semi-recumbent study, the changes table that drops presyncope from its scope, the overdose signs, both naloxone sentences, the safety sentence, and the corrected "probably" sentence.
4. Resuscitation Council UK, 2025 Resuscitation Guidelines: First aid, 27 October 2025 . Read level: partial (recovery position, opioid, hypoglycaemia, drowning and pregnancy sections), direct, the recovery position and opioid sections checked again on 2026-09-25 for this lesson. The recovery position sentences (no method is given), the overdose signs, "Call 999", "start CPR", "Administer naloxone if you are trained", the packaging line, the observation line, and the aspiration line on oral sugar.
5. E. K. Hewett Brumberg, M. J. Douma and colleagues, "2024 American Heart Association and American Red Cross Guidelines for First Aid", Circulation 150, 2024, e519 to e579 . Read level: full, direct, from the Internet Archive capture 20260329073336 for all prose; the recommendation tables are images, and Tables 14 (positioning), 15 (shock) and 25 (presyncope) were read from the publisher's full-size images. Every AHA/Red Cross 2024 recommendation here with its COR and LOE, Figure 1's description, the positioning background and supporting text, the airway and delayed-recognition sentences, the pregnancy and comfort sentences, the injury figures, the manoeuvres' mechanism, the 11-trial meta-analysis, the 27-person study and the harms review, and the leg-raise evidence.
6. D. Cao, A. M. Arens, S. L. Chow and colleagues, "Part 10: Adult and Pediatric Special Circumstances of Resuscitation: 2025 American Heart Association Guidelines", Circulation 152 (suppl 2), 2025 . Read level: partial, from the Internet Archive capture 20251027153841: the Top 10, cough CPR, drowning, respiratory pathogen, pregnancy and opioid overdose (21.11) sections, plus the recovery-position sentence in the gas embolism section; the opioid section and the Top 10 checked again on 2026-09-25 for this lesson. The six opioid recommendations with their COR and LOE, the observation recommendation, the Top 10 line on who can give naloxone, the "extremely unlikely" and "prescribing information" sentences, the synopsis on how overdose progresses, and the supporting text on doses, other substances, complications, cardiac output and continuing until the person is awake.
7. British Red Cross, Unresponsive and not breathing, undated . Read level: full, direct. The tongue sentence and the head-tilt sentence.
8. Resuscitation Council UK, 2025 Resuscitation Guidelines: Paediatric basic life support, 27 October 2025 . Read level: full, direct for key points, PBLS, AED and drowning sections. Checking breathing continuously or at least every minute.
9. NHS, Fainting, page last reviewed 17 August 2026. **Read level: full, direct**, checked again on 2026-09-25 for this lesson. Every NHS instruction and quotation here: the causes, the symptoms, the positions, the manoeuvres, the bystander sequence, the side for pregnancy, the eight reasons to call 999, and "See a GP".
10. European Resuscitation Council Guidelines 2025 First Aid (as source 3), Table 1, the topics "Not included" . Read level: direct, on the publisher's page. Presyncope's absence from the ERC's 2025 scope, and so from RCUK's.
11. Department of Health and Social Care, Supplying take home naloxone without a prescription (formerly "Widening the availability of naloxone"), published 23 April 2025, updated 12 September 2025 . Read level: full, direct, checked again on 2026-09-25. Prescription-only status, the 2015, 2019 and 2024 regulations and the registration route, the products and their ages, the opioid names, the two-line mechanism, the side effects, and "Anyone can use available naloxone".
12. C. Dezfulian, J. G. Cabañas, J. R. Buckley and colleagues, "Part 4: Systems of Care: 2025 AHA Guidelines", Circulation 152 (suppl 2), 2025 . Read level: partial, from the Internet Archive capture 20260208194135 (the public access naloxone section among others). The 1 in 6 to 1 in 3 estimate, scoped to the United States, and the two public access naloxone recommendations with their grades.
13. C. Lott, V. Karageorgos, C. Abelairas-Gomez and colleagues, "European Resuscitation Council Guidelines 2025 Special Circumstances in Resuscitation", Resuscitation 215 (suppl 1), 2025, 110753 . Read level: partial (the drowning, opioid and hypothermia passages), direct, on the publisher's page. "Existing evidence is not sufficient to recommend".
14. US Food and Drug Administration, "FDA Approves First Over-the-Counter Naloxone Nasal Spray", press release, March 29, 2023 . Read level: full, direct.
15. US Government Accountability Office, Drug Misuse: Most States Have Good Samaritan Laws and Research Indicates They May Have Positive Effects, GAO-21-248, 29 March 2021 . Read level: the product page's Fast Facts and Highlights in full, direct; the 57-page report not opened. The count as of 2021, the three states, and what the laws do.
16. T. Djärv, M. J. Douma and colleagues for the ILCOR First Aid Task Force, "2025 International Consensus on First Aid Science With Treatment Recommendations", Circulation 152, 2025. **Read level: full, direct, from the accepted manuscript on ilcor.org; the presyncope recommendation quoted here checked word for word against the typeset text.** The counter-pressure recommendation and the lower-body preference.
17. British Heart Foundation, RevivR, and Resuscitation Council UK, Lifesaver. **Read level: both pages full, direct**; neither course was taken.