Panic attack

Background

• Can occur de novo or in setting of psychiatric disorder (most commonly panic disorder)

Clinical Features

• Discrete period of intense fear or discomfort that peaks within a few minutes 'plus at least four of the following:
  • 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
  • Acute respiratory distress syndrome (ARDS)
  • Asthma
  • Cor pulmonale
  • Epiglottitis
  • Inhalation exposure
  • Noncardiogenic pulmonary edema
  • Pneumonia
  • Pneumocystis Pneumonia (PCP)
  • Pulmonary embolism
  • Pulmonary hypertension
  • Tension pneumothorax
  • Idiopathic pulmonary fibrosis acute exacerbation
  • Cystic fibrosis exacerbation
• Cardiac
  • Aortic dissection
  • Cardiac tamponade
  • Cardiogenic pulmonary edema (CHF)
  • Myocardial Infarction
  • Pericarditis
  • Myocarditis
• Other Associated with Normal/↑ Respiratory Effort
  • Abdominal distension
  • Anemia
  • CO Poisoning
  • Salicylate toxicity
  • Diabetic ketoacidosis (DKA)
  • Diaphragm injury
  • Electrolyte abnormalities
  • Flail chest
  • Hypotension
  • Metabolic acidosis
  • Pneumothorax/hemothorax
  • Renal Failure
  • Sepsis
  • Superior vena cava syndrome
  • Toxic ingestion
• Other Associated with ↓ Respiratory Effort
  • Guillain-Barre syndrome
  • Lambert-Eaton Syndrome
  • Multiple sclerosis
  • Myasthenia Gravis
  • Organophosphate toxicity
  • Stroke (Main)
  • Tick paralysis

Non-Emergent

• ALS
• Ascites
• Uncorrected ASD
• Congenital heart disease
• COPD exacerbation
• Deconditioning
• Fever
• Hyperventilation
• Interstitial lung disease
• Neoplasm
• Obesity
• Obstructive sleep apnea
• Panic attack
• Pleural effusion
• Polymyositis
• Porphyria
• Pregnancy
• Rib fracture
• Spontaneous pneumothorax
• Thyroid Disease
• URI
• Vocal cord dysfunction

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
  • Was thought to increase the re-ventilation of expired CO2
  • 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)
  • Any benefit provided is the result of the reassurance of “instructional manipulation” and patient belief in the treatment, rather than the elevated FiCO2.

Disposition

• Discharge

Calculators

GAD-7 Calculator

GAD-7 (Generalized Anxiety Disorder 7-item)
Over the last 2 weeks, how often have you been bothered by the following problems?
1. Feeling nervous, anxious, or on edge	0
2. Not being able to stop or control worrying	0
3. Worrying too much about different things	0
4. Trouble relaxing	0
5. Being so restless that it is hard to sit still	0
6. Becoming easily annoyed or irritable	0
7. Feeling afraid, as if something awful might happen	0
Result
GAD-7 Score

Interpretation
Score	Anxiety Severity
0-4	Minimal anxiety
5-9	Mild anxiety
10-14	Moderate anxiety — consider treatment
15-21	Severe anxiety — active treatment recommended

References
Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146(5):317-325.

See Also

• Shortness of breath