A 22 year old man was rushed into the emergency department. He describes recurrent episodes of fearfulness, palpitations, with peri-oral tingling and cramping of the hands. His symptoms last 5 - 10 minutes. He is worried he may be having a heart attack. An ECG shows sinus tachycardia. He has a respiratory rate of 34 breaths/minute. What is the SINGLE most appropriate immediate intervention?
A. High flow oxygen
B. IV sedation
C. Rebreath into a paper bag
D. Alprazolam
E. Refer to cardiac team urgently
In panic attacks, perioral paresthesia, tingling and numbness in the hands can occur due to hyperventilation and CO2 washout leading to low ionic calcium. Rebreath into a paper bag will help to increase CO2 levels and resolve symptoms.
Panic attacks
Period of intense fear characterized by a constellation of symptoms that develop rapidly, reach a peak of intensity in about 10min, and generally do not last longer than 20–30min (rarely over 1 hour). Attacks may be either spontaneous (‘out of the blue’) or situational (usually where attacks have occurred previously).
Symptoms/signs • Tremor • Tachycardia • Tachypnoea, • Sweating • Concerns of death from cardiac or respiratory problems
They may complain of dizziness, circumoral paraesthesia, carpopedal spasm, and occasionally sharp or stabbing chest pain. Initial examination would reveal tachypnoea with equal air entry over both lung fields, and no wheeze or evidence of airway obstruction. It is important to consider secondary causes (such as PE or DKA). Therefore, perform the following investigations:
• SpO2 • ECG • ABG if SpO 2 ↓ , or if symptoms do not completely settle in a few minutes • BMG
If symptoms do not completely settle in a few minutes, obtain: • CXR • U&E, blood glucose, FBC
Treatment Do not sedate a patient who is hyperventilating. Once serious diagnoses have been excluded, use this information to help reassure the patient with primary hyperventilation. Often this is all that is required, but it may be helpful to try simple breathing exercises (e.g. breathe in through nose)