How should an acute panic attack be evaluated and treated in the emergency department, including exclusion of medical emergencies and first‑line medication dosing?

Management of Panic Attacks in the Emergency Department

Panic attacks presenting to the ED require systematic exclusion of life-threatening medical emergencies before psychiatric diagnosis, followed by acute symptom management with benzodiazepines and arrangement for outpatient psychiatric follow-up rather than initiation of long-term pharmacotherapy. 1

Initial Evaluation: Medical Clearance

Exclude Medical Emergencies First

The primary task is distinguishing panic attacks from medical emergencies that mimic panic symptoms. Do not diagnose panic disorder until cardiac, pulmonary, metabolic, and toxicologic causes are excluded. 1, 2

Key differentiating features to assess:

• Vital signs must be normal - abnormal vital signs mandate medical workup, not psychiatric diagnosis 1
• Cardiac symptoms - chest pain, palpitations, diaphoresis require ECG and cardiac biomarkers to exclude acute coronary syndrome or arrhythmia 1
• Respiratory symptoms - dyspnea, chest tightness require pulse oximetry and consideration of pulmonary embolism, pneumothorax, or asthma 1
• Neurological symptoms - altered mental status, focal deficits, or confusion suggest delirium or stroke rather than panic 1

Focused History and Physical Examination

Obtain specific panic attack characteristics: 1, 3, 4

• Rapid onset - symptoms peak within 10 minutes 5
• Associated symptoms - trembling, dizziness, derealization, paresthesias, chills or hot flushes distinguish panic from cardiac disease 1
• Multiple body systems involved - racing heart, sweating, shaking, breathlessness, churning stomach, faintness 5
• Fearful cognitions - fear of dying, going mad, or losing control 5
• Age and demographics - panic disorder typically affects young adults, predominantly women 4

Laboratory and Diagnostic Testing

For alert, cooperative patients with normal vital signs and noncontributory physical examination, routine laboratory testing is not necessary. 1

However, obtain targeted testing when clinical features suggest specific medical conditions: 1

• Fingerstick glucose - exclude hypoglycemia if altered mental status present 6
• ECG - if chest pain or palpitations present 1
• Electrolytes - if history suggests metabolic derangement 7
• Urine drug screen - does not typically change acute management in cooperative patients with normal vital signs 1

Common pitfall: Ordering extensive "medical clearance" laboratory panels delays psychiatric care without improving outcomes in patients with classic panic presentations and normal vital signs. 1

Acute Symptom Management

First-Line Pharmacologic Treatment

Benzodiazepines are the treatment of choice for acute panic attacks in the ED. 6, 5

Specific dosing recommendations:

• Alprazolam - ranked highest for both efficacy and tolerability; associated with lower dropout rates than placebo 5
• Diazepam - ranked among most effective with lowest dropout rates 5
• Lorazepam 2-4 mg IV or PO - preferred in many EDs due to predictable absorption and intermediate duration 6

Benzodiazepines demonstrate superior tolerability compared to all antidepressant classes and are associated with lower dropout rates than SSRIs, SNRIs, and TCAs. 5

Supportive Measures

Provide reassurance and environmental modification: 3, 2

• Explain symptoms - educate that physical sensations are anxiety-related, not life-threatening medical emergency 3, 2
• Calm environment - reduce stimulation, provide quiet space 2
• Breathing techniques - slow, controlled breathing may help reduce hyperventilation symptoms 2

Disposition and Follow-Up

Do Not Initiate Long-Term Antidepressants in the ED

Emergency physicians should not start SSRIs, SNRIs, or TCAs for panic disorder. 8, 5

Rationale:

• Panic disorder is a chronic illness requiring maintenance treatment and longitudinal management 8
• Antidepressants take 2-4 weeks to achieve therapeutic effect, providing no acute benefit 5
• Therapeutic gains are lost when treatment is stopped after short-term therapy, necessitating ongoing psychiatric care 8
• Optimal treatment selection (medication vs. cognitive-behavioral therapy vs. combination) requires psychiatric evaluation 8

Discharge Planning

Arrange outpatient psychiatric follow-up within 48-72 hours for all patients diagnosed with panic attacks. 3, 2

Provide limited benzodiazepine prescription (3-7 days maximum) to bridge to psychiatric care, with clear instructions about dependence risk. 2, 5

Educate patients about: 3, 2

• Nature of panic disorder - recurrent attacks are common but treatable 8
• Avoid self-medication with alcohol or illicit substances 2
• Return precautions - new symptoms (chest pain, focal weakness, fever) require re-evaluation 2

Admission Criteria

Admit patients with panic attacks only if: 1

• Medical emergency is identified during workup 1
• Suicidal ideation or intent is present 1
• Inability to care for self or lack of social support 1

Panic attacks alone, even if severe or recurrent, do not require hospital admission if the patient has returned to baseline and has appropriate outpatient follow-up arranged. 1

Special Considerations

Alcohol Intoxication

Elevated alcohol levels do not preclude psychiatric evaluation in alert, cooperative patients with normal vital signs. 1

However, defer definitive psychiatric diagnosis until patient is sober if intoxication impairs assessment. 1

Substance-Induced Panic

Consider withdrawal syndromes (alcohol, benzodiazepines, opioids) and intoxication (cocaine, amphetamines, cannabis) as panic mimics. 7

Obtain detailed substance use history including prescription medications that lower seizure threshold (tramadol) or cause serotonin syndrome. 7

Recurrent ED Visits

Patients with frequent panic-related ED visits require enhanced outpatient coordination. 1, 2

Contact the patient's primary care physician or psychiatrist during the ED visit to facilitate care continuity and prevent repeated emergency presentations. 1, 2