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!)



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