What is the appropriate emergency department management for a patient presenting with an acute panic attack, including assessment for medical emergencies and first‑line pharmacologic treatment?

Emergency Department Management of Panic Attacks

For patients presenting to the ED with suspected panic attacks, first exclude life-threatening medical emergencies—particularly acute coronary syndrome, pulmonary embolism, and metabolic crises—then treat acute symptoms with benzodiazepines (lorazepam 2-4 mg IV/PO) and arrange outpatient psychiatric follow-up rather than admitting stable patients. 1

Initial Assessment: Rule Out Medical Emergencies

The primary task is distinguishing panic from conditions that mimic it:

• Obtain an ECG in any patient reporting chest pain or palpitations to exclude acute coronary syndrome or arrhythmia, as these symptoms overlap significantly with panic presentations 1
• Check pulse oximetry and consider imaging for patients with dyspnea or chest tightness to rule out pulmonary embolism, pneumothorax, or acute asthma exacerbation 1
• Perform finger-stick glucose if any altered mental status is present to exclude hypoglycemia 1
• Assess for focal neurological deficits, confusion, or altered consciousness, which suggest stroke or delirium rather than panic 2

Key distinguishing features favoring panic over cardiac disease include trembling, dizziness, derealization, paresthesias, temperature sensations (chills/hot flushes), and abrupt symptom onset peaking within minutes 3. Pain worsened by palpation, breathing, or positional changes argues against angina 3.

Diagnostic Testing Strategy

In alert, cooperative patients with normal vital signs and unremarkable physical examination, routine laboratory panels are unnecessary and delay psychiatric care without improving outcomes 2, 1. This represents a critical practice point—extensive "medical clearance" workups are not indicated.

Targeted testing only when specific clinical clues exist:

• ECG for chest pain/palpitations 1
• Glucose for altered mental status 1
• Urine drug screens generally do not alter acute management in cooperative patients with normal vitals 2

Acute Pharmacologic Management

Benzodiazepines are first-line treatment for acute panic attacks in the ED 1. Specifically:

• Lorazepam 2-4 mg IV or PO is preferred due to predictable absorption and intermediate duration 1
• Alternative: Diazepam 5-10 mg IV or IM, which can be repeated in 3-4 hours if necessary 4

Critical pitfall: Do not use benzodiazepines for chronic management after ED discharge, as they carry risks of tolerance, dependence, and may paradoxically worsen long-term outcomes 5.

Non-Pharmacologic Acute Interventions

While awaiting medication effect:

• Place patient in a private room to minimize anxiety-provoking stimuli 3
• Guide box breathing (4-4-4-4 pattern): inhale 4 seconds, hold 4 seconds, exhale 4 seconds, hold 4 seconds, with patient seated upright and slight forward lean 3
• Apply cooling to the face (cold compress or cool air) to reduce physiological arousal 3
• Provide explicit reassurance that symptoms are not life-threatening, as this addresses the catastrophic thinking that fuels panic 3

Do NOT use paper bag rebreathing—this may cause hypoxemia 3. Oxygen therapy is only indicated if actual hypoxemia (SpO2 <90%) is documented 3.

Disposition Decisions

Hospital admission is reserved for:

• Medical emergency identified during workup 1
• Suicidal ideation or intent 1
• Inability to care for self or insufficient social support 1

Patients whose panic resolves to baseline and who have arranged outpatient follow-up do NOT require admission 2, 1. This is a key cost-saving and resource-utilization point.

Special Populations

Alcohol-Related Presentations

• Elevated blood alcohol does not preclude psychiatric evaluation in alert, cooperative patients with normal vitals 2
• Defer definitive psychiatric diagnosis until sobriety if intoxication impairs assessment 2
• Consider alcohol withdrawal syndrome (which can mimic panic) in appropriate clinical context 4

Substance-Induced Presentations

• Obtain thorough substance-use history including stimulants, cannabis, and withdrawal syndromes (alcohol, benzodiazepines, opioids) that can mimic panic 1

Discharge Planning and Follow-Up

For discharged patients:

• Contact the patient's primary care physician or psychiatrist during the ED visit to facilitate continuity of care 1
• Provide written action plan for managing future episodes, teaching recognition of early warning signs (racing heart, tight chest, sense of impending doom) 3
• Teach sensory grounding techniques: noticing environmental details (colors, textures, sounds), cognitive distractions (word games, counting backwards), or sensory-based distractors 3
• Arrange outpatient psychiatric follow-up within 1-2 weeks 1

Avoid psychological debriefing (formal structured interventions asking patients to ventilate emotions and relive trauma), as this may worsen outcomes 3.

Long-Term Treatment Considerations (For Outpatient Provider)

While not initiated in the ED, patients should be counseled that:

• SSRIs (sertraline 25-50 mg daily initially, target 50-200 mg/day) combined with cognitive behavioral therapy represent first-line chronic treatment 5, 6
• Improvement begins by week 2, with maximal benefit by week 12 5
• Treatment should continue 9-12 months after remission 5

Common Pitfalls to Avoid

• Do not perform extensive laboratory "clearance" panels in patients with classic panic presentation and normal vitals—this delays psychiatric care 2
• Do not prescribe benzodiazepines for chronic use at ED discharge—refer for SSRI initiation instead 5
• Do not dismiss recurrent ED visitors—these patients need enhanced outpatient coordination, not repeated ED workups 1, 7
• Do not miss bipolar disorder—screen before referring for SSRI initiation, as these patients require mood stabilization first 5