Management of Acute Panic Attack
For an acute panic attack, immediately implement psychological first aid with reassurance that symptoms are not life-threatening, guide the patient through slow diaphragmatic breathing (inhale through nose, hold briefly, exhale slowly through pursed lips), and position them comfortably in a seated position with upper body elevated. 1
Immediate Non-Pharmacological Interventions
First-line management should focus on rapid de-escalation through specific techniques:
- Apply cooling to the face using a cold compress or cool air to reduce physiological arousal 1
- Guide controlled breathing: Instruct the patient to take slow, deep breaths through the nose, hold briefly, and exhale slowly through pursed lips to interrupt catastrophic thinking 1
- Position optimally: Place the patient in a "coachman's seat" position (seated, leaning forward slightly with elbows on knees) to optimize breathing mechanics 1
- Provide firm reassurance that despite the intense physical symptoms (palpitations, chest pain, dyspnea, dizziness), they are experiencing a panic attack and are not dying or having a heart attack 2, 1
Critical Differential Diagnosis
Before treating as panic attack, you must exclude life-threatening conditions:
- Rule out acute coronary syndrome in patients with chest pain, especially those over 30 years old or with cardiac risk factors, as the likelihood of angina increases dramatically with age (67% in men aged 30-39 to 94% in men aged 60-69) 2
- Key distinguishing features of panic: Look for trembling, dizziness, de-realization, paresthesias, chills or hot flushes, and abrupt onset building to a peak within minutes 2
- Against cardiac etiology: Pain affected by palpation, breathing, turning, twisting or bending, or pain from multiple sites argues against angina 2
Acute Pharmacological Management (When Needed)
For severe, refractory acute panic attacks that do not respond to psychological interventions:
- Benzodiazepines are effective for immediate symptom relief but should be used cautiously 3
- Alprazolam dosing for panic: Start with 0.5 mg orally three times daily, which can be increased in increments of no more than 1 mg per day every 3-4 days if needed 4
- Important caveat: Benzodiazepines are less effective than antidepressants and cognitive behavioral therapy for long-term management and carry risks of dependence 3
- Reduce dose by half when used with ritonavir or other strong CYP3A inhibitors 4
What NOT to Do
Avoid psychological debriefing (formal structured interventions where patients are asked to ventilate emotions and relive the trauma), as this may worsen outcomes 2, 1
Post-Attack Management Plan
After stabilizing the acute episode:
- Educate the patient that panic attacks, while terrifying, are benign and not life-threatening despite intense physical symptoms 1
- Develop a written action plan for managing future episodes, teaching patients to recognize early warning signs (racing heart, tight chest, sense of impending doom) so they can implement coping strategies before symptoms escalate 2, 1
- Teach sensory grounding techniques for use at warning signs: noticing environmental details (colors, textures, sounds), cognitive distractions (word games, counting backwards), or sensory-based distractors (flicking rubber band on wrist) 2
- Refer for cognitive behavioral therapy (CBT), which has strong evidence for treating panic disorder and is equally effective as antidepressants 1, 3
Long-Term Considerations
For recurrent panic attacks (panic disorder):
- SSRIs are first-line pharmacotherapy with favorable side-effect profiles, safety in overdose, and no physical dependency, recommended for 12-24 months minimum 5
- Combined treatment with both SSRI and CBT may provide optimal outcomes 5, 3
- Monitor for comorbidities: Depression occurs commonly with panic disorder, and untreated depression can influence end-of-life preferences 2