Should a patient who ingested 30mg of Vyvanse (lisdexamfetamine) and experienced a panic attack treated with lorazepam (Ativan) 1mg orally be kept overnight for observation?

Management of Panic Attack After Vyvanse Ingestion Treated with Lorazepam

The patient who experienced a panic attack after ingesting 30mg of Vyvanse (lisdexamfetamine) and was treated with lorazepam 1mg should not require overnight observation and can be safely discharged if symptoms have resolved.

Rationale for Discharge vs. Observation

Assessment of Current Situation

• The patient has experienced a panic attack, which is a recognized adverse effect of stimulant medications like Vyvanse
• The patient has been treated with lorazepam 1mg, which is an appropriate intervention for acute anxiety/panic
• Lorazepam has a duration of effect of 6-8 hours, with a half-life of approximately 10-20 hours in adults 1

Key Considerations

Stimulant Toxicity Profile

• Vyvanse (lisdexamfetamine) is an amphetamine-class stimulant that can cause tachycardia, hypertension, and CNS stimulation 1
• The 30mg dose is within the therapeutic range and not considered a toxic overdose
• Panic attacks are a recognized adverse effect of therapeutic doses of stimulants
• The American Heart Association guidelines classify amphetamines under the "tachycardia and/or hypertension" toxidrome, not requiring extended observation after symptom resolution 1

Benzodiazepine Considerations

• Lorazepam 1mg is a standard therapeutic dose for acute anxiety/panic
• Unlike opioid reversal with naloxone, there is no risk of "resedation" after benzodiazepine treatment for panic 1
• The American Heart Association guidelines do not recommend extended observation periods for patients treated with benzodiazepines for acute anxiety, unlike patients treated with naloxone for opioid overdose 1, 2

Decision Algorithm

1. If the patient's vital signs have normalized:

   • Heart rate and blood pressure returned to normal range
   • No respiratory depression
   • Normal oxygen saturation

2. If mental status has returned to baseline:

   • Alert and oriented
   • No confusion or sedation
   • Normal neurological examination

3. If panic symptoms have resolved:

   • No persistent anxiety
   • No chest pain or shortness of breath
   • Patient feels comfortable

4. If no other concerning symptoms are present:

   • No signs of serotonin syndrome
   • No cardiac arrhythmias
   • No seizure activity

→ Then discharge is appropriate with proper follow-up instructions

Important Caveats and Pitfalls

• Polysubstance use: If there is concern for additional substance use beyond the reported Vyvanse, more caution may be warranted
• Underlying cardiac conditions: Patients with pre-existing cardiac conditions may require more monitoring after stimulant-induced tachycardia
• Psychiatric comorbidities: Patients with severe underlying psychiatric conditions may benefit from psychiatric evaluation before discharge
• Recurrent symptoms: If panic symptoms recur after lorazepam effect begins to wane, this may indicate need for further evaluation

Discharge Instructions

• Avoid further stimulant use until follow-up with prescribing physician
• Return if symptoms recur or worsen
• Follow up with primary care or psychiatrist regarding stimulant medication management
• Consider temporary dose reduction or medication change if panic attacks are recurrent

Conclusion

Based on current guidelines and evidence, a patient who has experienced a panic attack after taking a therapeutic dose of Vyvanse and has responded well to lorazepam treatment does not require overnight observation if vital signs and symptoms have normalized. The American Heart Association guidelines support this approach, as there is no indication for extended monitoring in this clinical scenario 1, 2.