What is the best initial medication for a 39kg girl experiencing a panic attack with dyspnea (difficulty breathing) in the Emergency Room (ER)?

Best Medication for Panic Attack in a 39kg Girl in the ER

For a 39kg girl experiencing a panic attack with dyspnea in the Emergency Room, a benzodiazepine such as diazepam at an appropriate weight-based dose is the best initial medication choice.

Initial Assessment and Intervention

When treating a panic attack in a pediatric patient presenting with dyspnea, it's crucial to:

1. First rule out organic causes of dyspnea (respiratory distress, cardiac issues)
2. Confirm diagnosis of panic attack based on symptoms (acute onset of fear, dyspnea, palpitations)
3. Initiate pharmacological intervention promptly

Medication Selection Algorithm

First-line Treatment: Benzodiazepines

Benzodiazepines are the medication of choice for acute panic attacks in the emergency setting due to:

• Rapid onset of action
• Effective anxiolysis
• Safety profile when properly dosed

For a 39kg child, the appropriate dosing would be:

• Diazepam: 0.04-0.2 mg/kg IV/IO 1
  • For this patient: 1.5-2 mg IV initially
  • Maximum single dose should not exceed 5 mg

Alternative Options

If benzodiazepines are contraindicated or unavailable:

• Lorazepam: 0.02-0.04 mg/kg IV/IO 1
  • For this patient: 0.8-1.5 mg IV
  • Maximum single dose: 2 mg

Administration Considerations

• Administer IV medication slowly to minimize respiratory depression
• Monitor vital signs continuously, especially respiratory rate and oxygen saturation
• Have resuscitation equipment readily available, though serious adverse events are rare with appropriate dosing

Monitoring After Administration

After administering the benzodiazepine:

• Assess response within 5-10 minutes
• Monitor for respiratory depression
• If inadequate response after 15-20 minutes, consider a second dose at 50% of the initial dose

Common Pitfalls to Avoid

1. Misdiagnosis: Failing to rule out organic causes of dyspnea before attributing symptoms to panic
2. Overdosing: Using adult doses in pediatric patients can lead to excessive sedation
3. Underdosing: Insufficient dosing may fail to relieve symptoms and require repeated administration
4. Delayed treatment: Prolonged panic attacks can worsen anxiety and potentially lead to respiratory compromise

Special Considerations

• For patients with recurrent panic attacks, consider psychiatric consultation for long-term management
• If the patient has comorbid asthma, ensure proper asthma management is also addressed
• Document response to treatment to guide future management if recurrent episodes occur

While other medications like SSRIs are effective for long-term management of panic disorder 2, they are not appropriate for acute management in the emergency setting due to delayed onset of action.