Cannot miss / life threats
Cannot miss / life threats
Diagnostic flow β check first
Diagnostic flow β check first
- Anxiety is a diagnosis of exclusion in the ED.
- Vitals + ECG + glucose + SpO2 first β rule out hypoxia, arrhythmia, hypoglycemia.
- Risk-stratify for ACS and PE based on age, risk factors, symptoms.
- Look for tox / withdrawal clues (history, pupils, vitals).
- If organic workup negative + classic panic features β reassure, treat, refer.
Differential diagnosis β checklist
0/17
Check off each diagnosis as you consider it. Tap the name for unique exam, lab/imaging clues, first-line confirmatory test, and management.
Cardiopulmonary mimics0/4
Endocrine / metabolic0/4
Toxic / withdrawal0/5
Primary psychiatric0/4
Initial ED workup
Bedside0/5
- Vitals including SpO2
- POC glucose
- ECG
- Focused exam (cardiac, pulm, neuro, thyroid)
- Pregnancy test if reproductive-age female
Labs0/2
- Targeted: troponin if cardiac sx, D-dimer if PE risk, TSH if hyperthyroid sx, BMP, UDS, EtOH
- Avoid shotgun workup in young low-risk patients with classic panic features
Imaging0/2
- CXR if cardiopulm sx
- CTPA only if PE risk by Wells/PERC
Initial management0/5
- Calm environment, reassurance, slow breathing coaching.
- Treat underlying organic cause if found.
- Acute panic / severe symptoms: lorazepam 0.5β1 mg PO/IV (use sparingly; risk of dependence).
- Avoid benzodiazepines in suspected substance use disorder; consider hydroxyzine 25β50 mg PO.
- Refer to outpatient psychiatry / therapy; start SSRI in coordination with PCP if appropriate.
Pearls / pitfalls
Pearls
- Never label a first-time 'panic attack' in a patient β₯ 40 or with cardiac risk factors without ruling out ACS/PE.
- Tachycardia that doesn't resolve with reassurance is a red flag β recheck for organic cause.
- Hyperventilation can produce paresthesias and carpopedal spasm β coach slow breathing rather than paper bag.
- Discharge with PCP/psych follow-up; benzos should be a bridge, not a long-term plan.