What is the treatment for a patient with a panic attack in the emergency room (ER)?

Treatment of Panic Attack in the Emergency Room

The immediate treatment of panic attacks in the ER centers on psychological first aid with reassurance, breathing control techniques, and physical comfort measures—benzodiazepines should be reserved for severe cases that don't respond to non-pharmacological interventions, as they carry significant dependence risks. 1

Immediate Non-Pharmacological Management (First-Line)

The priority is applying psychological first aid principles with reassurance that symptoms are not life-threatening, combined with specific relaxation techniques. 1

Breathing Control Techniques

• Guide the patient to take slow, deep breaths through the nose, hold briefly, and exhale slowly through pursed lips—this interrupts catastrophic thinking and is the cornerstone of acute management. 1
• Position the patient in a "coachman's seat" (seated with upper body elevated) to optimize breathing mechanics. 1
• Avoid rebreathing from a paper bag as it may cause dangerous hypoxemia. 1

Physical Interventions

• Apply cooling to the face using a cold compress or cool air to reduce physiological arousal. 1
• Use small ventilators to help with breathlessness if available. 1
• Ensure the patient is positioned comfortably in a seated position with upper body elevated. 1

Environmental Management

• Place the patient in a private room when possible to minimize anxiety-provoking stimuli. 2
• Create a calming environment—even in general EDs, a dedicated area with colorful walls and distraction equipment can reduce distress. 2

Critical Differential Diagnosis (Must Rule Out First)

Before attributing symptoms to panic, you must exclude acute coronary syndrome, especially in patients over 30 years old or with cardiac risk factors—the likelihood of angina increases dramatically with age (67% in men aged 30-39 to 94% in men aged 60-69). 1

Key Distinguishing Features of Panic vs. Cardiac Emergency

• Panic is suggested by: trembling, dizziness, de-realization, paresthesias, chills or hot flushes, and abrupt onset building to peak within minutes. 1
• Angina is less likely if: pain is affected by palpation, breathing, turning, twisting or bending, or pain originates from multiple sites. 1

Other Medical Conditions to Exclude

• Hyperthyroidism, cardiac arrhythmias, and hypoglycemia can mimic panic attacks. 3
• Substance-induced presentations from caffeine excess or stimulant medications can directly provoke panic-like symptoms. 3

Pharmacological Management (Second-Line)

Medications should only be considered when non-pharmacological interventions fail or in severe cases with significant distress.

Benzodiazepines for Acute Management

• Alprazolam is the most effective and best-tolerated benzodiazepine for panic attacks, with the strongest evidence for rapid symptom control and lowest dropout rates. 4
• For acute panic in the ER, alprazolam 0.25-0.5 mg orally can be given, with effects typically within 30-60 minutes. 5
• Diazepam and clonazepam also show strong efficacy and high tolerability rankings, with diazepam and clonazepam demonstrating the strongest reduction in panic attack frequency. 4

Critical Warnings About Benzodiazepines

• The risk of dependence increases with dose and duration of treatment—benzodiazepines should be used cautiously and only for short-term management in the ER setting. 5
• Elderly patients and those with liver disease require lower starting doses (0.25 mg). 5
• Abrupt discontinuation must be avoided due to withdrawal risks. 5

When NOT to Use Benzodiazepines Immediately

• If the patient responds to breathing techniques and reassurance within the first 10-15 minutes, pharmacological intervention may be unnecessary. 1
• Pure hyperventilation due to anxiety does not require medication—only provide oxygen if the patient is actually hypoxemic (oxygen saturation <90%). 1

What NOT to Do

• Never perform psychological debriefing (formal structured interventions where patients ventilate emotions and relive the trauma)—this may worsen outcomes. 1
• Never encourage rebreathing from a paper bag as it may cause hypoxemia. 1
• Avoid providing oxygen therapy unless the patient is truly hypoxemic, as patients with pure hyperventilation are unlikely to require it. 1

Post-Attack Management Before Discharge

Patient Education

• Educate the patient that panic attacks, despite intense physical symptoms, are benign and not life-threatening. 1
• Explain the physiological process of anxiety to normalize symptoms and reduce catastrophic thinking. 6

Written Action Plan

• 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. 1
• Teach sensory grounding techniques: noticing environmental details (colors, textures, sounds), cognitive distractions (word games, counting backwards), or sensory-based distractors (flicking rubber band on wrist). 1

Follow-Up Recommendations

• Consider referral for cognitive behavioral therapy (CBT), which has the strongest evidence for treating panic disorder long-term. 1, 7
• Screen for major depressive disorder, as it co-occurs in 50-60% of panic disorder cases and significantly increases suicide risk. 3
• Assess for substance use disorders, as patients often attempt to self-medicate panic symptoms with alcohol or benzodiazepines. 3

Long-Term Pharmacological Considerations (If Recurrent)

If the patient has recurrent panic attacks requiring ongoing treatment:

• SSRIs (particularly paroxetine and fluoxetine) are first-line for long-term management, with TCAs, SNRIs (venlafaxine), and MAOIs also showing efficacy. 4, 8, 7
• Benzodiazepines may be used adjunctively for rapid control while starting antidepressants, but long-term benzodiazepine monotherapy carries significant dependence risks. 9, 8
• Treatment duration for panic disorder often requires several months to years, as relapse is frequent with premature discontinuation. 7