Panic Attack, Emergency Medicine

Basics

Description

- Respiratory: - Shortness of breath - Smothering - Feeling of choking

- Gl: - Nausea - Cramps - Abdominal pain

- Intense fears: - Automatic, stereotypic - Imminent death - Having a heart attack - Humiliation - Loss of control " ö " Łgoing crazy " Ł

- 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

- If diagnosis is supported by previous events, history and workup: - Reassurance and diversion - Does not require emergent care

- 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

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 attackWorry about the implications or consequences of the attacksBehavioral change, such as phobic avoidance, related to the attacksWith 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:PalpitationsTachycardiaChest pain or discomfort
Respiratory:Shortness of breathSmotheringFeeling of choking
Neurologic:TremorDizzinessLightheadednessFeeling faintNumbnessTinglingSweatingChillsFlushingFeelings of unreality or detachment
Gl:NauseaCrampsAbdominal pain
Intense fears:Automatic, stereotypicImminent deathHaving a heart attackHumiliationLoss 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 yrCardiac 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 historyNo initiating or major life eventsWithout avoidance or significant fearWith a history of poor response to anxiolytic or antidepressant medication
Medications:Neuroleptics (akathisia)BronchodilatorsDigitalisAnticholinergic agentsPsychostimulantsDiet pillsHerbal supplements
Respiratory:AsthmaHyperventilationChronic obstructive pulmonary diseasePulmonary embolusBacterial pneumoniaCostochondritis
Cardiovascular:AnginaMyocardial infarctionArrhythmiaAnemiaMVP
Substances:Stimulant abuseWithdrawal (alcohol, sedative " ôhypnotics)Antidepressant discontinuation syndrome (with interruption, dose decrease, or discontinuation of SSRI or SNRI)Excessive caffeine intake
Endocrine:HyperthyroidismHypoglycemiaHypoparathyroidismPheochromocytoma
Other metabolic derangements:HypokalemiaHypomagnesemiaHypophosphatemia
Neurologic:Complex partial or limbic seizures (fear, physical symptoms, perceptual distortions)Transient ischemic attackLabyrinthitisBenign positional vertigo
Psychiatric:Obsessive-compulsive disorderPost-traumatic stress disorderSpecific phobia or social phobiaSomatoform disorderFactitious disorderAcute grief
Domestic violence

Tachycardia é á

Treatment

Pre-Hospital

If diagnosis is supported by previous events, history and workup:Reassurance and diversionDoes 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 alarmPhysiologic explanations for symptoms
High-potency benzodiazepines (drugs of choice):Clonazepam:Slow for emergency useLong-acting without rapid onset/offset phenomenaBest choice in this class for maintenance therapy of recurrent panic attacksAlprazolam:Rapid onsetRebound anxiety occurs due to short duration and rapid offset.May lead to escalating doses with continued useLorazepam:Quick onsetAdvantage of sublingual (SL) useLonger effect and less abrupt offset than alprazolam
Avoid low-potency benzodiazepines:
Treat recurrent panic attacks and panic disorder with selective serotonin reuptake inhibitors (SSRIs) (or TCAs), with or without clonazepam:Will not work immediatelyDo 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 outpatientMay 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.

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)