What is the most appropriate next step in management for a patient with symptoms suggestive of a panic attack, including shortness of breath, chest pain, dizziness, and a fear of dying?

Management of Panic Attack in Emergency Department Setting

Lorazepam is the most appropriate next step in management for this patient presenting with symptoms of a panic attack.

Clinical Assessment

This 45-year-old woman presents with classic symptoms of a panic attack:

• Shortness of breath, chest pain, dizziness, and perioral paresthesias
• Feeling of impending doom ("feels like she is going to die")
• Similar episodes in the past, first triggered in an anxiety-provoking situation (crossing a narrow bridge)
• Normal glucose level (120 mg/dL)
• ECG showing only sinus tachycardia
• Failure to respond to nitroglycerin (which actually worsened symptoms with headache)

Treatment Algorithm

1. First-line treatment: Benzodiazepines

   • Lorazepam 0.5-1 mg orally or sublingually is the treatment of choice 1
   • For patients with anxiety or agitation who can swallow, lorazepam 0.5-1 mg orally four times a day as required (maximum 4 mg in 24 hours) is recommended
   • Dose should be reduced to 0.25-0.5 mg in elderly or debilitated patients

2. Supportive measures

   • Reassurance about the benign nature of panic attacks
   • Explanation of the physiological mechanisms of hyperventilation
   • Oxygen therapy is not indicated in the absence of hypoxia

3. Avoid inappropriate treatments

   • Haloperidol (antipsychotic) is not first-line for uncomplicated panic attacks
   • Sumatriptan is for migraine treatment and could worsen cardiovascular symptoms
   • Verapamil adjustment would not address the acute symptoms
   • Oxygen is unnecessary without evidence of hypoxia

Rationale for Lorazepam Selection

Benzodiazepines are the medication of choice for acute panic attacks due to their:

• Rapid onset of action
• Effectiveness in reducing anxiety symptoms
• Ability to break the cycle of sympathetic activation
• Safety profile in the absence of respiratory depression or substance abuse

Guidelines specifically recommend lorazepam for managing anxiety and agitation 1, making it the most appropriate choice for this patient experiencing an acute panic attack with prominent physical symptoms.

Important Clinical Considerations

• Rule out medical causes first: The patient's normal glucose, ECG showing only sinus tachycardia, and lack of response to nitroglycerin help rule out cardiac and metabolic causes.

• Pattern recognition: The recurrent nature of episodes, first triggered in an anxiety-provoking situation (crossing a bridge), strongly suggests panic disorder.

• Common pitfalls to avoid:

  • Overtreatment with unnecessary medications (antipsychotics, oxygen)
  • Underrecognition of panic disorder, leading to excessive cardiac testing
  • Failure to provide appropriate anxiolytic therapy

• Follow-up considerations: After acute management, the patient should be evaluated for ongoing treatment of panic disorder, which may include SSRIs and cognitive-behavioral therapy.

Lorazepam provides rapid symptom relief while avoiding potential side effects of inappropriate medications, making it the optimal choice for this patient presenting with an acute panic attack in the emergency department.