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Clinical Case 060: Panic? Don’t Panic! .. don’t forget your towel

One of my favourite discoveries in recent months has been Joe Lex’s awesome “Free Emergency Talks” podcast.  This is a wonderful resource – you can listen to hand-picked lectures from a range of eminent speakers – all selected by a guy who has been to more conferences than I have had stale sandwiches in the theatre tea room!

Anyway I was listening to a talk this week called “I Feel Anxious and Panicky” – acute behavioural disorders in the ED by Dr Michael Wilson MD.  A topic close to my heart – I am one of those unusual docs who loves to see the psych presentations.  Why? I reckon we do more good here than in most groups – simple interventions can make a big difference to our patients.

Listening to this talk I got the feeling that our management of acute anxiety disorders & panic in Australia is a bit different to the US of A.  But I work in a small ED on my own so I thought I would put up a case and see how you guys would manage it.  Here we go:

27 yo woman presents to the ED complaining of dyspnoea.  The triage nurse has taken a history: sudden onset SOB about half an hour ago associated with tightness in the throat, a sense of pre-syncope and then some tingling in the hands.  Her boyfriend thought she might have had an ‘asthma attack’ though she has no history of asthma.  She states a similar thing happened last week and it passed after ~ 40 minutes.

PMHx:  overweight (BMI = 39), smoker, no pregnancy or surgical history.

At triage her obs are as follows: pulse 95 reg, BP 145/90, RR 24/min, SPo2 = 99%, afebrile.

On examination:  ENT normal, clear chest – no wheeze, HS dual, not clinically anaemic, reflexes are normal, no signs of thyroid disease / masses.

Resting ECG = sinus tachycardia with normal complexes / intervals.  A random BSL = 5.7 mmol.

OK, now here are my questions…

Q1:  What investigations (if any) would you do in the ED?  Or as an outpatient for follow-up?

Q2:  What medications (if any) would you prescribe in the ED?  Or on discharge?

Q3:  What is your disposition plan / referral options?

Q4:  Outline what discussion / counselling you will have with this patient…

After seeing a few comments from over the globe Katrin in Sweden, Javier in ?, Tim on KI, Australia – I will tell you how I manage patients with typical panic symptoms in general.

Take the history fully – then ask for other ‘classic’ features of panic – globus pharyngeus, “sense of impending doom” usually they say “I feel like someting really bad is about to happen”, abrupt onset and peaks over 20 – 30 minutes then resolves. Symptoms of hypocapnea are common – perioral, peripheral tingles, presyncope.  A sense of detachment / out of body sensation or a “loss of control” are less common but typical.

If your patient is describing most or all of these then you have nailed down the phenomena – not much else in medicine causes these transiently.  Sure they might have a phaechromocytoma or thyrotoxicosis – but they are rare and you cannot get a clear “rule out today” done.

My experience of these patients – when they present initially – it that they are really quite open to the concept that this is “panic disorder”. If you describe the usual symptoms there is usually a lot of head nodding and they agree it is exactly their experience. Often hey then admit to having previous episodes.

I usually tell them that it can happen “out of the blue” but can occur in periods of stress.  “so have you been under much pressure at work?”, or explore their close interpersonal relationships. Personally my hit rate on finding a significant, new stressor is pretty high in my practice.

If you feel that some tests are needed – then do them quickly – ECG, BSL, VBG, postural BP etc depending on the symptoms. Examine them thoroughly for reassurance and so you don’t miss the subtle eye signs of Grave’s etc….

Here is the problem though – if you don’t do a good job of reassuring them with normal tests, and leave it open then you are going to make them more anxious. If you think a TSH and urinary catecholamine check are needed then explain it: “I am sure this is a panic episode, but these tests will be useful for your GP / psychologist. Don’t send them out saying you are not sure and need to wait for further tests – that will result in increased anxiety and a rapid representation!

I never prescribe benzos – there is plenty of evidence hey are unhelpful and likely harmful in this situation. I make sure they are not taking any “uppers” – caffeine, amphetamines, diet pills etc. If they are on an SSRI then I tell them to stay on it and see their GP for review. In Australia they can get great cheap counselling by entering into a mental health care plan with a GP and psychologist. Bring on the socialised health care (taunting the Americans!)

 

Comments

  1. Katrin Hruska says:

    I look forward to seeing the different answers to this question.

    Q1. I would make sure that the patient and I were both convinced that this is a panic attack, by getting a better history. If the patient had special concerns I would address them, ie explain why I don’t think this is a myocardial infarction. I always try to explain the symptoms of a panic attack and stress how extremely scary an experience it can be. If the patient had fully recovered and there were no alarming signs of other pathology, I wouldn’t order any more investigations.
    Q2. I wouldn’t prescribe any medicine.
    Q3. If there were signs of an underlying depression I would refer the patient to primary care. The councelor/social worker in our ED can offer these patients a few CBT sessions, so if it seemed uncomplicated I would recommend the patient to follow up with her.
    Q4. Making the patient understand that this is unpleasant but harmless is crucial. I encourage them to plan a strategy for handling the situation if it happens again, eg drink a glass of water, get some fresh air, call a friend. For a single episode I don’t think every patient necessarily needs follow-up, but I make sure that they know where to get help if needed (primary care) and that they always feel welcome back to the ED. We had a patient with a history of panic disorder wait an hour for an ambulance when he had his VT. It is not easy for neither us nor the patient to know the difference between life-threatening symptoms and a panic attack, which I try to remind myself every time I go to see a patient like this.

  2. I love psych in the ED – can often make a meaningful difference to a patient’s life, provided one has the time to do so.

    (i) clarify the history. No tests per se although may consider a depression-anxiety score if I am concerned or need to explor stressors/life events

    (ii) & (iii) no meds. Patient education and perhaps on referral for CBT. Excellent resources at moodgym.anu.edu.au etc

    (iv) as above, plus an explanation of relationship of various health domains (physical-mental-sexual-financial-social/family-spiritual) and exploring the classic stressor/response mechanisms and identifying her triggers. Takes 45 mins all up.

    End result – patient educated, happy and empowered

    I love these interventions in ED…it is such a contrast to chest pain, fracture-dislocations, MVCs etc

  3. Javier Benítez says:

    Q1: What investigations (if any) would you do in the ED? Or as an outpatient for follow-up?

    The main role of an emergency physician is to rule out life/limb-threatening diagnosis. With this presentation although anxiety is highly suspected you should risk stratify the patient for pulmonary embolism, especially this patient with a high BMI, smoker, of reproductive age, shortness of breath and tachycardic. I would ask her about use of oral contraceptives, any history of PE or DVT, history of coagulopathy in the family, menstrual history as well.

    Other diagnosis that go in hand with the presentation of anxiety, shortness of breath, tachycardia, throat tightening (chest pain equivalent?) are pregnancy, hyperthyroidism, anemia, electrolyte imbalance, spousal/partner abuse, substance abuse as well, psychiatric history, infection.

    According to PERC she would benefit from a d-dimer at least.
    I would also get a pregnancy test.
    CBC to assess for anemia,
    Basic metabolic panel to assess for electrolytes imbalance
    TSH for hyperthyroidism
    Chest xray

    Assess for life stressors, any suicidal ideations or attempts, wanting to hurt others. If positive, need to assess for substance abuse and clear her for behavioral assessment. Any previous psychiatric hisotry, family history of psychiatric diagnosis.

    If everything is negative I would refer her to a primary care physician who can assess her more thoroughly.

    Q2: What medications (if any) would you prescribe in the ED? Or on discharge?

    I would treat the tachycardia with some fluids, then repeat vitals after fluids. Reassess patient and see how she feels.

    If everything points to anxiety, I would try a short acting benzo in the department, but not on discharge. I would refer her to a primary care doctor who can evaluate her for medications if necessary.

    Q3: What is your disposition plan / referral options?

    If no suicidal/homicidal, I would refer her to a primary care doctor.

    Q4: Outline what discussion / counselling you will have with this patient…

    Talk to her about life stressors, sometimes patients only need to heard and give her some techniques on how to deal with the symptoms. If there is social services in the ED I would have them talk to the patient and provide some resources, and literature.

    Thanks for providing this case

    Javier

    • Hi Javier
      You say she is PERC positive
      I thought she was negative and low risk on Well’s
      Please explain your scoring?
      Casey

      • Javier Benítez says:

        Javier Benítez
        (Your comment is awaiting moderation…)
        July 20th, 2012 at 10:40 pm
        Hi Casey, thanks for posting my answer and these cases which help our education a great deal.
        Here is the PERC rule PERC Rule
        Age < 50 years
        Pulse 94%
        No unilateral leg swelling
        No hemoptysis
        No recent trauma or surgery
        No prior PE or DVT
        No hormone use
        Although the vital signs reported state that her HR was normal, the electrocardiogram showed that she was tachycardic. Other findings that concern me about PE are her symptoms, the fact that she’s of reproductive age and might be using oral contraceptives, also her obesity, I’m not sure how much of a factor her smoking plays a role, but it’s definitely not a good thing.
        Thanks,
        Javier
        http://www.mdcalc.com/perc-rule-for-pulmonary-embolism/
        Reply

  4. Seriously hoopy discussion.

    Nearest D-dimer test from me is 150km to the mainland and a plane trip (either send the patient or send the blood).

    Sending the blood means probably a 12-24 hr wait for results.

    Sending the patient seems like overkill.

    I’d treat the tachycardia with reassurance not fluids.

    I guess this case highlights the inherent difficulty in medicine – frequency gambling and pattern recognition suggest this is anxiety. Medicolegal concerns mean we don’t want to miss a PE. So do we do a barrage of tests for $$$ (which, in some locations may mean transfer of a patient at worst, an overnight admission or protracted ED stay at best)…

    Casey, you are the cool frood – what would you do?

  5. Tim
    See my updated answers. In this case – a good hx and exam. Refer to GP for mhcp – lots of education less investigation

  6. Well exactly.

  7. Katrin Hruska says:

    I feel fortunate to work in a country (Sweden) where I never have to worry about medicolegal implications and can choose to do what I believe is in the interest of the patient.
    Clinical decision aids (they are not rules!) don’t perform better than the judgement of an experienced doctor. My fear is that doctors spend to much time ticking boxes and too little time trying to understand the patient’s current problem.

  8. Javier Benítez says:

    One of the things I love the most about the internet is that you can voice your opinion and read other’s and learn from each other. With this in my mind, I feel inclined to write my opinion and not sit on the sidelines as other people probably do.

    First of all, this is how I would approach this patient. I am sure that other people would approach it differently in the country I live, so this has nothing to do with where you live. I don’t have the patient in front of me which is a huge deal when taking into account your clinical gestalt. This post is just that, one digital clinical picture. Can you really go to an abandoned island and learn medicine with just books? I have to say no. So, there is a lot of information missing when you don’t have the patient in front of you. Things in medicine are not black or white, that’s why they call it the art of medicine. We need the textbook foundation, pass exams to prove to other people we can do this work, and most important of all we need the clinical experience. During the clinical experience you learn how multiple people approach the same problem and then you modify it and make your own way of approaching the same problem.

    I am very appreciative of your postings and letting me know how you all approach this patient. It only broadens my learning and appreciation for the art of medicine no matter what part of the world we live in.

    Thanks,

    Javier

  9. Katrin Hruska says:

    I fully agree with you, Javier. There is no correct answer to this case, the discussion itself is the goal. I believe that doctors who take the time to reflect on their own and other’s practice are great doctors. Discussing why we do certain things is more interesting than what we do.
    Social media offers a much deeper understanding than textbooks, where there are often just one correct answer, usually the one applicable to a university hospital setting. If you have the resources readily available, it should lower the threshold for further investigations. If you are far away from a CT scanner, getting a d-dimer is only indicated if you are prepared to transport the patient in case it’s positive. Using different approaches for different circumstances doesn’t mean one of them is wrong.

  10. Absolutely

    Casey should be commended for bunging up these cases and kudos to everone who writes in with suggestions…

    Clearly the approach in a tertiary ED will differ from someone in Dingo Woop-Woop with limited facilities…which makes the practice of medicine that much more interesting

    Safety first of course – if the patient NEEDS X. Y or Z doing, then they need it – regardless of whether in Toronto or Timbuktu

    ..and these cases make us think about not just the medicine, but the decisions and justification for “doing what we do”

    Peace

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