Can a 39kg girl with dyspnea receive Vistaril (hydroxyzine) in the Emergency Room (ER) for a panic attack?

Hydroxyzine Use for Panic Attack with Dyspnea in a 39 kg Child

Hydroxyzine can be safely administered to a 39 kg child experiencing a panic attack with dyspnea in the emergency room setting, with a recommended starting dose of 0.5-1 mg/kg (approximately 20-40 mg). 1

Medication Selection and Dosing

Hydroxyzine is FDA-approved for the symptomatic relief of anxiety and tension associated with psychoneurosis, making it appropriate for panic attacks 1. For pediatric patients:

• Weight-based dosing: 0.5-1 mg/kg per dose
• For a 39 kg child: 20-40 mg would be appropriate
• Route: Oral administration is preferred
• Onset of action: 15-30 minutes for oral administration

Clinical Assessment Before Administration

Before administering hydroxyzine, assess:

1. Respiratory status: Ensure dyspnea is due to panic/anxiety rather than a primary respiratory cause
2. Cardiovascular status: Check heart rate and blood pressure
3. Current medications: Assess for potential drug interactions
4. Cardiac history: Hydroxyzine can prolong QT interval 2

Management Algorithm

1. Rule out organic causes of dyspnea

   • Assess vital signs, oxygen saturation, and respiratory effort
   • Consider physical signs of respiratory distress versus anxiety-induced dyspnea

2. First-line interventions for panic-induced dyspnea

   • Non-pharmacological approaches: Positioning (sitting upright), cooling the face, opening windows, using small ventilators 3
   • Relaxation techniques and emotional support 3

3. Pharmacological intervention

   • If non-pharmacological measures are insufficient, proceed with hydroxyzine
   • Start with 0.5 mg/kg (approximately 20 mg for a 39 kg child)
   • Monitor for response and side effects

Special Considerations

• Sedation: Hydroxyzine may cause sedation, which should be monitored in the emergency setting 4
• Respiratory monitoring: Although hydroxyzine is generally safe, monitor respiratory status as the patient has presented with dyspnea
• QT prolongation: Be cautious in patients with known cardiac conditions 2
• Avoid rapid IV administration: If IV route is necessary (though oral is preferred), administer slowly to prevent potential adverse effects 3

Alternative Approaches

If hydroxyzine is contraindicated or ineffective:

• For severe anxiety with dyspnea: Consider low-dose benzodiazepines (e.g., lorazepam 0.5-1 mg) 3
• For persistent dyspnea: If dyspnea persists and is determined to be primarily anxiety-related, consider consultation with pediatric psychiatry for ongoing management

Monitoring After Administration

• Vital signs every 15-30 minutes
• Observe for sedation and respiratory status
• Monitor for resolution of panic symptoms and dyspnea
• Assess for common side effects: drowsiness, dry mouth, headache

Discharge Considerations

• Ensure complete resolution of symptoms before discharge
• Provide education about panic attacks and breathing techniques
• Consider referral for outpatient mental health follow-up if this is a recurrent issue

Hydroxyzine has demonstrated efficacy for anxiety disorders 4, 5 and is generally well-tolerated in the pediatric population when appropriately dosed. Its antihistamine properties make it a reasonable choice for managing anxiety-induced dyspnea in a child without the risks associated with benzodiazepines.