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Panic Attack, Emergency Medicine


Basics


Description


  • Characteristic, acute episodes of physical symptoms and intense fear that rapidly peak within 10 min and resolve in ó ł ╝20 min
  • There may be a nonfearful variant in medical patients.

Panic Disorder
  • Recurrent, unexpected panic attacks with ≥1 mo of persistence:
    • Concerns about having another attack
    • Worry about the implications or consequences of the attacks
    • Behavioral change, such as phobic avoidance, related to the attacks
    • With or without agoraphobia = anxiety related to fear of escape
  • Episodic, recurrent, or chronic attacks
  • Frequently comorbid with depression, substance abuse, disability, suicidal tendency

Genetics
  • Probably genetic
  • Family history of panic or anxiety is common
  • Altered serotonin- and benzodiazepine-receptor function

Etiology


Mechanism
Limbic system, norepinephrine release, other neurotransmitters (e.g., serotonin) implicated, leading to "fight-or-flight " Ł response é á

Risk Factors


  • Major life events in the year preceding onset
  • Family history of panic or anxiety
  • Childhood shyness or separation anxiety
  • May develop in the course of predisposing physical illness or cocaine abuse:
    • May persist after the illness or substance use has resolved
  • Twice as common in women

Diagnosis


Signs and Symptoms


  • Multiple systems suggest autonomic arousal
  • Cardiac:
    • Palpitations
    • Tachycardia
    • Chest pain or discomfort
  • Respiratory:
    • Shortness of breath
    • Smothering
    • Feeling of choking
  • Neurologic:
    • Tremor
    • Dizziness
    • Lightheadedness
    • Feeling faint
    • Numbness
    • Tingling
    • Sweating
    • Chills
    • Flushing
    • Feelings of unreality or detachment
  • Gl:
    • Nausea
    • Cramps
    • Abdominal pain
  • Intense fears:
    • Automatic, stereotypic
    • Imminent death
    • Having a heart attack
    • Humiliation
    • Loss of control " ö " Łgoing crazy " Ł

History
  • Known medical conditions
  • All medications, including over the counter
  • Herbal supplements
  • Recreational drugs/alcohol use
  • Caffeine consumption
  • Age at onset
  • Initiating life events or stressors
  • Childhood antecedents
  • Resultant avoidance
  • Response to previous medication trials
  • Family history of panic, anxiety
  • Family history of drugs/alcohol use

Physical Exam
  • Thorough physical and neurologic exam
  • Guided by particular symptoms

Essential Workup


Detailed history, appropriate physical exam: é á
  • Guided by presentation and initial findings
  • May be minimal, depending on presentation

Diagnosis Tests & Interpretation


Lab
  • Toxicology screen
  • Consider tricyclic antidepressant (TCA) level
  • CBC
  • Electrolytes, BUN/creatinine, glucose
  • Thyroid-stimulating hormone
  • Pulse oximetry or arterial blood gases

Diagnostic Procedures/Surgery
  • ECG for suspected mitral valve prolapse (MVP), to exclude underlying cardiac disease, or to monitor for QRS widening in patients on TCA:
    • Age >40 yr
    • Cardiac symptoms
  • Holter monitor:
    • If palpitations, near-syncope
  • Sleep-deprived EEG if seizure suspected

Differential Diagnosis


  • Consider organic causes if:
    • Panic presents late in life (>50 yr)
    • No childhood antecedents or family history
    • No initiating or major life events
    • Without avoidance or significant fear
    • With a history of poor response to anxiolytic or antidepressant medication
  • Medications:
    • Neuroleptics (akathisia)
    • Bronchodilators
    • Digitalis
    • Anticholinergic agents
    • Psychostimulants
    • Diet pills
    • Herbal supplements
  • Respiratory:
    • Asthma
    • Hyperventilation
    • Chronic obstructive pulmonary disease
    • Pulmonary embolus
    • Bacterial pneumonia
    • Costochondritis
  • Cardiovascular:
    • Angina
    • Myocardial infarction
    • Arrhythmia
    • Anemia
    • MVP
  • Substances:
    • Stimulant abuse
    • Withdrawal (alcohol, sedative " ôhypnotics)
    • Antidepressant discontinuation syndrome (with interruption, dose decrease, or discontinuation of SSRI or SNRI)
    • Excessive caffeine intake
  • Endocrine:
    • Hyperthyroidism
    • Hypoglycemia
    • Hypoparathyroidism
    • Pheochromocytoma
  • Other metabolic derangements:
    • Hypokalemia
    • Hypomagnesemia
    • Hypophosphatemia
  • Neurologic:
    • Complex partial or limbic seizures (fear, physical symptoms, perceptual distortions)
    • Transient ischemic attack
    • Labyrinthitis
    • Benign positional vertigo
  • Psychiatric:
    • Obsessive-compulsive disorder
    • Post-traumatic stress disorder
    • Specific phobia or social phobia
    • Somatoform disorder
    • Factitious disorder
    • Acute grief
  • Domestic violence

Tachycardia é á

Treatment


Pre-Hospital


  • If diagnosis is supported by previous events, history and workup:
    • Reassurance and diversion
    • Does not require emergent care
  • If 1st episode, treat and transport as appropriate to presentation

Initial Stabilization/Therapy


  • Be calm and reassuring.
  • Most panic attacks resolve within 20 " ô30 min without any treatment.
  • Fear may trigger another panic attack.

Ed Treatment/Procedures


  • Patient education, new cognitions:
    • Normal response to abnormal alarm
    • Physiologic explanations for symptoms
  • High-potency benzodiazepines (drugs of choice):
    • Clonazepam:
      • Slow for emergency use
      • Long-acting without rapid onset/offset phenomena
      • Best choice in this class for maintenance therapy of recurrent panic attacks
    • Alprazolam:
      • Rapid onset
      • Rebound anxiety occurs due to short duration and rapid offset.
      • May lead to escalating doses with continued use
    • Lorazepam:
      • Quick onset
      • Advantage of sublingual (SL) use
      • Longer effect and less abrupt offset than alprazolam
  • Avoid low-potency benzodiazepines:
    • Diazepam
    • Chlordiazepoxide
  • Treat recurrent panic attacks and panic disorder with selective serotonin reuptake inhibitors (SSRIs) (or TCAs), with or without clonazepam:
    • Will not work immediately
    • Do not need to be started emergently, especially if there is no clear, established access to follow-up management
  • There are a few small studies on the efficacy of atypical antipsychotics (e.g., olanzapine, risperidone) for treatment-resistant panic disorder. However, data to support this use is limited.
  • Discharge therapy:
    • Several clonazepam tablets in case of repeated attacks

Rapid offset (withdrawal) of alprazolam may trigger further attacks. é á

Medication


First Line
  • Clonazepam: 0.5 mg PO in the ED; 0.25 " ô0.5 mg PO BID for initial outpatient therapy
  • SSRI:
    • To be started as an outpatient
    • May require higher doses and longer time to therapeutic response for panic than for depression

Second Line
  • Lorazepam: 1 mg PO or SL
  • TCA:
    • To be started as an outpatient

  • Limit use of benzodiazepines.
  • Risk/benefit discussion about the relative safety of SSRIs and less anticholinergic TCAs (e.g., nortriptyline, desipramine)
  • Physiologic and autonomic effects of pregnancy and postpartum period may trigger attacks in predisposed women.

Follow-Up


Disposition


Admission Criteria
  • As medically indicated to rule out organic cause
  • Meets criteria for psychiatric admission (suicidal, homicidal)

Discharge Criteria
Most panic attacks do not require inpatient level of care. é á
Issues for Referral
  • Managed care mental health carve-outs
  • Psychopharmacologic and cognitive behavioral therapy evaluation for repeated attacks, or interepisode fear or avoidance
  • Stigma
  • Primary care follow-up may be an acceptable alternative to specialty, mental health/psychiatry referral.

Follow-Up Recommendations


  • Appointment with primary care physician or referral to mental health specialty treatment
  • Avoid precipitants, e.g., caffeine, stimulants, alcohol.

Pearls and Pitfalls


  • Panic is "contagious. " Ł Try not to be infected by the patients sense of urgency to stop the symptoms; they will resolve spontaneously.
  • Be calm so as not to add to the patient's alarm, but diligent, so patient feels attended to and reassured.
  • Cognitive " ôbehavioral therapy (CBT) can start in the ED with brief explanation of the physiologic cause of symptoms.
  • Be cautious not to start adolescents and young adults on a lifetime course of benzodiazepines; CBT ( é ▒SSRI therapy) is associated with good outcomes and fewer deleterious side effects.
  • Avoid the use of alprazolam, especially for ongoing treatment.

Additional Reading


  • Lader é áM. Management of panic disorder. Expert Rev Neurother.  2005;5(2):259 " ô266.
  • Lessard é áMJ, Marchand é áA, Pelland é áM â ł, et al. Comparing two brief psychological interventions to usual care in panic disorder patients presenting to the emergency department with chest pain. Behav Cogn Psychother.  2012;40(2):129 " ô147.
  • Marchesi é áC. Pharmacological management of panic disorder. Neuropsychiatr Dis Treat.  2008;4(1):93 " ô106.
  • Pelland é áM â ł, Marchand é áA, Lessard é áMJ, et al. Efficacy of 2 interventions for panic disorder in patients presenting to the ED with chest pain. Am J Emerg Med.  2011;29(9):1051 " ô1061.
  • Susman é áJ, Klee é áB. The Role of High-Potency Benzodiazepines in the Treatment of Panic Disorder. Prim Care Companion J Clin Psychiatry.  2005;7(1):5 " ô11.

See Also (Topic, Algorithm, Electronic Media Element)


  • Psychosis, Medical vs. Psychiatric
  • Withdrawal, Drug

Codes


ICD9


  • 300.01 Panic disorder without agoraphobia
  • 300.21 Agoraphobia with panic disorder

ICD10


  • F40.01 Agoraphobia with panic disorder
  • F41.0 Panic disorder without agoraphobia

SNOMED


  • 225624000 Panic attack (finding)
  • 35607004 Panic disorder with agoraphobia (disorder)
  • 371631005 Panic disorder (disorder)
  • 56576003 Panic disorder without agoraphobia (disorder)
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