Panic attack: Difference between revisions
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==Background== | ==Background== | ||
*Can occur de novo or in setting of psychiatric disorder (most commonly panic disorder)<ref name="Foldes" /> | |||
==Clinical Features== | ==Clinical Features== | ||
*Discrete period of intense fear or discomfort that peaks within a few minutes '''plus'' at least four of the following:<ref name="Foldes">Foldes-Busque G, Denis I, Poitras J, Fleet RP, Archambault P, Dionne CE. A prospective cohort study to refine and validate the Panic Screening Score for identifying panic attacks associated with unexplained chest pain in the emergency department. BMJ Open. 2013;3(10):e003877. doi:10.1136/bmjopen-2013-003877.</ref> | |||
**[[Chest pain]], [[palpitations]] | |||
**[[Dyspnea]], feeling of suffocation | |||
**Diaphoresis, hot or cold flashes | |||
**[[Nausea]] | |||
**Trembling | |||
**Flexor spasm of hands and feet (carpopedal spasm) | |||
**Paresthesias | |||
**Fear of death, fear of losing control | |||
**Depersonalization | |||
*May feel the "urge to flee" or "sense of impending doom" | |||
*The acute respiratory alkalosis can cause a transient imbalance of calcium, potassium and other ions, with the net effect of increasing the irritability of excitable muscles and nerves | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{SOB DDX}} | {{SOB DDX}} | ||
== | ==Evaluation== | ||
*Diagnosis of exclusion: must rule out organic causes of symptoms (see [[chest pain]], [[palpitations]], [[shortness of breath]], etc.) | |||
*Clinical diagnosis, based on history and physical exam. | |||
==Management== | ==Management== | ||
*1-2mg [[ | *Reassurance and patient education | ||
*Consider anxiolytic (e.g. 1-2mg [[Lorazepam]] (Ativan) IV/IM/PO or 50-100mg [[Hydroxyzine]] IM) | |||
*Use of a brown paper bag or face mask for rebreathing has been a traditionally described treatment<ref>Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients. Annals of Emergency Medicine. June 1989. 18(6): 62-628.</ref> | |||
**Was thought to increase the re-ventilation of expired CO2<ref>Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients. Annals of Emergency Medicine. June 1989. 18(6): 62-628.</ref> | |||
**However, may result in morbidity and even death if erroneously applied to patients who were hypoxic or have other underlying disorder (e.g. [[myocardial ischemia]]) <ref>Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients. Annals of Emergency Medicine. June 1989. 18(6): 62-628.</ref> | |||
**Any benefit provided is the result of the reassurance of “instructional manipulation” and patient belief in the treatment, rather than the elevated FiCO2.<ref>van den Hout MA, et al. Rebreathing to cope with hyperventilation: Experimental tests of the paper bag method. Journal of Behavioral Medicine. 1988. 11:303–310</ref> | |||
==Disposition== | ==Disposition== | ||
*Discharge | |||
==See Also== | ==See Also== | ||
*[[Shortness of breath]] | |||
== | ==References== | ||
<references/> | <references/> | ||
[[Category: | [[Category:Psychiatry]] | ||
Latest revision as of 21:11, 12 May 2022
Background
- Can occur de novo or in setting of psychiatric disorder (most commonly panic disorder)[1]
Clinical Features
- Discrete period of intense fear or discomfort that peaks within a few minutes 'plus at least four of the following:[1]
- Chest pain, palpitations
- Dyspnea, feeling of suffocation
- Diaphoresis, hot or cold flashes
- Nausea
- Trembling
- Flexor spasm of hands and feet (carpopedal spasm)
- Paresthesias
- Fear of death, fear of losing control
- Depersonalization
- May feel the "urge to flee" or "sense of impending doom"
- The acute respiratory alkalosis can cause a transient imbalance of calcium, potassium and other ions, with the net effect of increasing the irritability of excitable muscles and nerves
Differential Diagnosis
Acute dyspnea
Emergent
- Pulmonary
- Airway obstruction
- Anaphylaxis
- Angioedema
- Aspiration
- Asthma
- Cor pulmonale
- Inhalation exposure
- Noncardiogenic pulmonary edema
- Pneumonia
- Pneumocystis Pneumonia (PCP)
- Pulmonary embolism
- Pulmonary hypertension
- Tension pneumothorax
- Idiopathic pulmonary fibrosis acute exacerbation
- Cystic fibrosis exacerbation
- Cardiac
- Other Associated with Normal/↑ Respiratory Effort
- Other Associated with ↓ Respiratory Effort
Non-Emergent
- ALS
- Ascites
- Uncorrected ASD
- Congenital heart disease
- COPD exacerbation
- Fever
- Hyperventilation
- Interstitial lung disease
- Neoplasm
- Obesity
- Panic attack
- Pleural effusion
- Polymyositis
- Porphyria
- Pregnancy
- Rib fracture
- Spontaneous pneumothorax
- Thyroid Disease
- URI
Evaluation
- Diagnosis of exclusion: must rule out organic causes of symptoms (see chest pain, palpitations, shortness of breath, etc.)
- Clinical diagnosis, based on history and physical exam.
Management
- Reassurance and patient education
- Consider anxiolytic (e.g. 1-2mg Lorazepam (Ativan) IV/IM/PO or 50-100mg Hydroxyzine IM)
- Use of a brown paper bag or face mask for rebreathing has been a traditionally described treatment[2]
- Was thought to increase the re-ventilation of expired CO2[3]
- However, may result in morbidity and even death if erroneously applied to patients who were hypoxic or have other underlying disorder (e.g. myocardial ischemia) [4]
- Any benefit provided is the result of the reassurance of “instructional manipulation” and patient belief in the treatment, rather than the elevated FiCO2.[5]
Disposition
- Discharge
See Also
References
- ↑ 1.0 1.1 Foldes-Busque G, Denis I, Poitras J, Fleet RP, Archambault P, Dionne CE. A prospective cohort study to refine and validate the Panic Screening Score for identifying panic attacks associated with unexplained chest pain in the emergency department. BMJ Open. 2013;3(10):e003877. doi:10.1136/bmjopen-2013-003877.
- ↑ Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients. Annals of Emergency Medicine. June 1989. 18(6): 62-628.
- ↑ Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients. Annals of Emergency Medicine. June 1989. 18(6): 62-628.
- ↑ Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients. Annals of Emergency Medicine. June 1989. 18(6): 62-628.
- ↑ van den Hout MA, et al. Rebreathing to cope with hyperventilation: Experimental tests of the paper bag method. Journal of Behavioral Medicine. 1988. 11:303–310