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==Background==
==Background==
*Can occur de novo or in setting of psychiatric disorder (most commonly panic disorder)<ref name="Foldes" />


==Clinical Features==
==Clinical Features==
*Discrete period of intense fear or discomfort that peaks within a few minutes '''plus'' at least four of the following:<ref name="Foldes">Foldes-Busque G, Denis I, Poitras J, Fleet RP, Archambault P, Dionne CE. A prospective cohort study to refine and validate the Panic Screening Score for identifying panic attacks associated with unexplained chest pain in the emergency department. BMJ Open. 2013;3(10):e003877. doi:10.1136/bmjopen-2013-003877.</ref>
**[[Chest pain]], [[palpitations]]
**[[Dyspnea]], feeling of suffocation
**Diaphoresis, hot or cold flashes
**[[Nausea]]
**Trembling
**Flexor spasm of hands and feet (carpopedal spasm)
**Paresthesias
**Fear of death, fear of losing control
**Depersonalization
*May feel the "urge to flee" or "sense of impending doom"
*The acute respiratory alkalosis can cause a transient imbalance of calcium, potassium and other ions, with the net effect of increasing the irritability of excitable muscles and nerves


==Differential Diagnosis==
==Differential Diagnosis==
{{SOB DDX}}
{{SOB DDX}}


==Workup==
==Evaluation==
*Diagnosis of exclusion: must rule out organic causes of symptoms (see [[chest pain]], [[palpitations]], [[shortness of breath]], etc.)
*Clinical diagnosis, based on history and physical exam.


==Management==
==Management==
*1-2mg [[lorazepam]] (Ativan) IV
*Reassurance and patient education
*Consider anxiolytic (e.g. 1-2mg [[Lorazepam]] (Ativan) IV/IM/PO or 50-100mg [[Hydroxyzine]] IM)
*Use of a brown paper bag or face mask for rebreathing has been a traditionally described treatment<ref>Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients. Annals of Emergency Medicine. June 1989. 18(6): 62-628.</ref>
**Was thought to increase the re-ventilation of expired CO2<ref>Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients. Annals of Emergency Medicine. June 1989. 18(6): 62-628.</ref>
**However, may result in morbidity and even death if erroneously applied to patients who were hypoxic or have other underlying disorder (e.g. [[myocardial ischemia]]) <ref>Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients. Annals of Emergency Medicine. June 1989. 18(6): 62-628.</ref>
**Any benefit provided is the result of the reassurance of “instructional manipulation” and patient belief in the treatment, rather than the elevated FiCO2.<ref>van den Hout MA, et al. Rebreathing to cope with hyperventilation: Experimental tests of the paper bag method. Journal of Behavioral Medicine. 1988. 11:303–310</ref>


==Disposition==
==Disposition==
*Discharge
== Calculators ==
{{GAD7_Calculator}}


==See Also==
==See Also==
*[[Shortness of breath]]


==External Links==
==References==
 
==Sources==
<references/>
<references/>


[[Category:Psych]]
[[Category:Symptoms]]
[[Category:Psychiatry]]

Revisión actual - 09:41 22 mar 2026

Background

  • Can occur de novo or in setting of psychiatric disorder (most commonly panic disorder)[1]

Clinical Features

  • Discrete period of intense fear or discomfort that peaks within a few minutes 'plus at least four of the following:[1]
    • Chest pain, palpitations
    • Dyspnea, feeling of suffocation
    • Diaphoresis, hot or cold flashes
    • Nausea
    • Trembling
    • Flexor spasm of hands and feet (carpopedal spasm)
    • Paresthesias
    • Fear of death, fear of losing control
    • Depersonalization
  • May feel the "urge to flee" or "sense of impending doom"
  • The acute respiratory alkalosis can cause a transient imbalance of calcium, potassium and other ions, with the net effect of increasing the irritability of excitable muscles and nerves

Differential Diagnosis

Acute dyspnea

Emergent

Non-Emergent

Evaluation

Management

  • Reassurance and patient education
  • Consider anxiolytic (e.g. 1-2mg Lorazepam (Ativan) IV/IM/PO or 50-100mg Hydroxyzine IM)
  • Use of a brown paper bag or face mask for rebreathing has been a traditionally described treatment[2]
    • Was thought to increase the re-ventilation of expired CO2[3]
    • However, may result in morbidity and even death if erroneously applied to patients who were hypoxic or have other underlying disorder (e.g. myocardial ischemia) [4]
    • Any benefit provided is the result of the reassurance of “instructional manipulation” and patient belief in the treatment, rather than the elevated FiCO2.[5]

Disposition

  • Discharge

Calculators

GAD-7 Calculator

GAD-7 (Generalized Anxiety Disorder 7-item)
Over the last 2 weeks, how often have you been bothered by the following problems?
1. Feeling nervous, anxious, or on edge 0
2. Not being able to stop or control worrying 0
3. Worrying too much about different things 0
4. Trouble relaxing 0
5. Being so restless that it is hard to sit still 0
6. Becoming easily annoyed or irritable 0
7. Feeling afraid, as if something awful might happen 0
Result
GAD-7 Score
Interpretation
Score Anxiety Severity
0-4 Minimal anxiety
5-9 Mild anxiety
10-14 Moderate anxiety — consider treatment
15-21 Severe anxiety — active treatment recommended
References
  • Spitzer RL, Kroenke K, Williams JB, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097.
  • Kroenke K, Spitzer RL, Williams JB, Monahan PO, Löwe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007;146(5):317-325.

See Also

References

  1. ↑ 1.0 1.1 Foldes-Busque G, Denis I, Poitras J, Fleet RP, Archambault P, Dionne CE. A prospective cohort study to refine and validate the Panic Screening Score for identifying panic attacks associated with unexplained chest pain in the emergency department. BMJ Open. 2013;3(10):e003877. doi:10.1136/bmjopen-2013-003877.
  2. ↑ Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients. Annals of Emergency Medicine. June 1989. 18(6): 62-628.
  3. ↑ Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients. Annals of Emergency Medicine. June 1989. 18(6): 62-628.
  4. ↑ Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients. Annals of Emergency Medicine. June 1989. 18(6): 62-628.
  5. ↑ van den Hout MA, et al. Rebreathing to cope with hyperventilation: Experimental tests of the paper bag method. Journal of Behavioral Medicine. 1988. 11:303–310
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