# Panic attack/PTSD/seizures



## bigbaldguy (Apr 14, 2011)

Is it possible for a severe panic attack caused by PTSD to result in loss of consciousness and seizure? Has anyone seen this in the field? Recently had a case where patient appeared to be having a massive panic attack. Patient would pass out then seize then rouse then it would repeat. Could this be caused by hyperventilation. I'm 99.9 percent certain this individual was not faking the loss of consciousness or seizures.


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## CUjays34 (Apr 15, 2011)

*Panic Attacks*

You bet they can!  I've actually had one.  It's different for everyone but it is an involuntary activation of the sympathetic nervous system and can cause profound dizziness, shaking, tachypnea, sweating, tachycardia, feeling of impending doom, etc. etc.


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## mycrofft (Apr 15, 2011)

*Anytime you recover from vasovagal or hypervent syncope you can do Funky Chicken.*

There is also the possibility of a psychological component.


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## Aidey (Apr 15, 2011)

After a similar situation the explination I got was "kind of". 

The MD said that since my patient didn't have a notable postictal period that most likely the pt lost consciousness from the hyperventilation and was having significant carpal-pedal spasms that were mimicking seizure like activity.


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## DesertMedic66 (Apr 15, 2011)

Aidey said:


> After a similar situation the explination I got was "kind of".
> 
> The MD said that since my patient didn't have a notable postictal period that most likely the pt lost consciousness from the hyperventilation and was having significant carpal-pedal spasms that were mimicking seizure like activity.



My mother had a pulmonary embolism and had all those symptoms. The medic said it was probably just a panic attack then the doctor tested and confirmed the embolism.


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## Aidey (Apr 15, 2011)

Mine pt was a 12yo female with a psych history. Her CO2 got down to 7 right before the last time she passed out. Resp rate went way down, CO2 came up, she woke up. With some serious coaching I was able to keep her resp rate at a decent level and she stayed conscious after that, with a CO2 in the mid 20s I think.


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## Melclin (Apr 15, 2011)

Google 'conversion disorder'. I'm not making a dx of your pt, just suggesting it as a possibility. 

These are complex patients that are often difficult to manage even at the highest levels and it is a class of pts that are not at all well understood. The best treatment from us is the rest and reassurance we offer most pts and to quell the underlying judgement that often surrounds the more (oft named) _dubious_ psychiatric pts.


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## CAOX3 (Apr 15, 2011)

bigbaldguy said:


> Is it possible for a severe panic attack caused by PTSD to result in loss of consciousness and seizure? Has anyone seen this in the field? Recently had a case where patient appeared to be having a massive panic attack. Patient would pass out then seize then rouse then it would repeat. Could this be caused by hyperventilation. I'm 99.9 percent certain this individual was not faking the loss of consciousness or seizures.



You need to be careful with this.

Sometimes providers see hyperventilation, one of the family members  may mention anxiety and everybody runs with panic attack when it actually can be something more sinister, these people need to be assessed thoroughly.

Sounds complicated, maybe more them one thing going on, what was her history like?


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## medichopeful (Apr 15, 2011)

bigbaldguy said:


> Is it possible for a severe panic attack caused by PTSD to result in loss of consciousness and seizure? Has anyone seen this in the field? Recently had a case where patient appeared to be having a massive panic attack. Patient would pass out then seize then rouse then it would repeat. Could this be caused by hyperventilation. I'm 99.9 percent certain this individual was not faking the loss of consciousness or seizures.



Yes, severe hyperventilation can result in loss of consciousness.  Remember, hypocapnia (which is many times the result of hyperventilation) causes cerebral vasoconstriction, which can in turn cause a loss of consciousness.


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## MrBrown (Apr 15, 2011)

medichopeful said:


> Yes, severe hyperventilation can result in loss of consciousness.  Remember, hypocapnia (which is many times the result of hyperventilation) causes cerebral vasoconstriction, which can in turn cause a loss of consciousness.



Exactly what Brown was going to say.


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## bigbaldguy (Apr 15, 2011)

Male adult patient, confirmed history of anxiety related to a traumatic event. 
Pulse variable
Resp 75 (hard to tell on this one)
BP 140/90

One additional note, something I forgot about till I sat down and thought about it. Every time the patient went unconscious his heart rate would drop 30+ beats a minute even during seizure, and even when he was awake it was all over the place from 90 to 160's. I initially though this was a drug issue but my ICP took over the questioning and I started talking to witnesses. From, the info I got from witnesses it is very unlikely this was a drug issue.


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## MrBrown (Apr 15, 2011)

What was the rest of this blokes presentation like? Was he anxious? hyperactive? flushed? sweaty?  Did you get a temperature or a GCS? What was he doing before this "panic attack" happened? What meds was he on? 

Brown is thinking you are probably right but Brown's differentials also include something metabolic or neurogenic.


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## CAOX3 (Apr 15, 2011)

There is some correlation between panic attacks and focal seizure activity, but I need a nap and my brain is mush, maybe someone else could chime in I don't believe its common, but it does happen on occasion.


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## bigbaldguy (Apr 15, 2011)

MrBrown said:


> What was the rest of this blokes presentation like? Was he anxious? hyperactive? flushed? sweaty?  Did you get a temperature or a GCS? What was he doing before this "panic attack" happened? What meds was he on?
> 
> Brown is thinking you are probably right but Brown's differentials also include something metabolic or neurogenic.



Patient broke down in a stairwell in a building. No one else was around and he was found by a security guard. Might have been there for a bit. Very pale, clammy, eyes were glazed, patient was only vaguely responsive to verbal instructions while conscious. His over all appearance was that of someone having a panic attack plus the added symptoms of loss of consciousness and seizure. When he did come around he did not appear altered other than being very anxious. He also complained at one point of his chest hurting but I think it was from the hyperventilation as it went away when we got his breathing to slow a bit. He definitely wasn't hyperactive. Temp was normal, GCS was also normal, sinus rhythm was normal other than the wild swings in heart rate. I spoke with several people on scene and at the hospital that know the kid well and they all said it was unlikely he was using any drugs or at least any drugs that would cause this kind of reaction. Patient did have a history of these attacks but as near as I could tell this was the worst one yet. There was a major event that had just occurred involving his family life that may have triggered this. I won't get into details on the cause for his PTSD but lets just say he had a really really bad childhood. My main concern is that if I had been on my own I would have treated this as a drug issue, luckily my ICP spotted it as a true panic attack and reined me in before I started giving the kid 20 questions on what drugs he had taken and made the situation worse.


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## medichopeful (Apr 15, 2011)

MrBrown said:


> Exactly what Brown was going to say.



Glad to help!


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## mycrofft (Apr 16, 2011)

*Absence of post-ictal state is indicative of.....*

......anyone....?:unsure:


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## Zodiac (Apr 16, 2011)

mycrofft said:


> ......anyone....?:unsure:



Psychogenic non-epileptic seizures. There are also several forms of epileptic seizures that don't generally include a postictical state but with the information provided, I don't think that's the problem the patient was having.


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## bigbaldguy (Apr 16, 2011)

Zodiac said:


> Psychogenic non-epileptic seizures.



Just spent an hour reading up on this and yes it does fit very well with what was happening to the patient. It also fits with the patients history. 

Thank you for your help on this one


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## MSDeltaFlt (Apr 17, 2011)

When you hear hooves, look for horses and not zebras.  History of anxiety and hyperventilation that passes out, wakes up and does it again is an anxiety attack.  It's psychological. Remove from stressful environment and enhance calm.


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## Trevor (Apr 17, 2011)

Anxiety is a diagnosis of exclusion and SHOULD NOT be made in the field! My Gestalt says that many patients are having "Panic Attacks", however you ABSOLUTELY can not diagnosis this in the field. These patients get a full work up and transported for further evaluation of whatever symptoms they are having. 

Signs/Symptoms of *"Anxiety"*- Shortness of breath, anxiousness, hyperventilation, hypocapnea, dyspnea, "sharp" chest pain with sudden onset, Tachycardia, clear lung sounds. dizziness/syncope. Clammy or diaphoretic skin. 

Signs/Symptoms of *Pulmonary Embolism*- Shortness of breath, anxiousness, hyperventilation, hypocapnea, dyspnea, "sharp" chest pain with sudden onset, Tachycardia, clear lung sounds. Dizziness/syncope. Clammy or  diarphoretic skin.

Understand?


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## Zodiac (Apr 17, 2011)

MSDeltaFlt said:


> When you hear hooves, look for horses and not zebras.  History of anxiety and hyperventilation that passes out, wakes up and does it again is an anxiety attack.  It's psychological. Remove from stressful environment and enhance calm.



It's a psychogenic seizure (previously referred to as pseudoseizures but there's nothing false about them). They're brought on by psychological problems...including anxiety.


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## Zodiac (Apr 17, 2011)

***In addition to my previous comment

Psychogenic non-epileptic seizures (previously referred to as pseudoseizures but there's nothing false about them) go a far step beyond a simple anxiety attack. Although they are brought on by psychological problems and have nothing to do with abnormal electrical discharges in the brain, they are just as dangerous, uncontrollable, and unpredictable and they don't always have a trigger. The OP stated that the patient would lose consciousness and seize, rinse and repeat. Assuming that a physiological explanation for these episodes did not exist (history of epilepsy, head trauma, etc.) and given the patient's history of PTSD then the only plausible conclusion that could be made would be that this patient was experiencing psychogenic seizures. To dismiss it as just an anxiety attack would be detrimental as people who with histories of psychogenic seizures have been known to cause motor vehicle accidents and severely sever their tongues/cheeks. For his safety and that of others, transporting for a psychological evaluation would be beneficial so that he could begin receiving proper treatment for his condition and perhaps evade injuring himself.


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## usalsfyre (Apr 17, 2011)

Trevor said:


> Anxiety is a diagnosis of exclusion and SHOULD NOT be made in the field! My Gestalt says that many patients are having "Panic Attacks", however you ABSOLUTELY can not diagnosis this in the field. These patients get a full work up and transported for further evaluation of whatever symptoms they are having.
> 
> Signs/Symptoms of *"Anxiety"*- Shortness of breath, anxiousness, hyperventilation, hypocapnea, dyspnea, "sharp" chest pain with sudden onset, Tachycardia, clear lung sounds. dizziness/syncope. Clammy or diaphoretic skin.
> 
> ...



Ehhh, I see what your saying...but their presentation is more different than simply listing the symptoms suggest. I've yet to see an anxiety disorder that presented as being truly in extremis. Granted, there's probably a lot of PE's that don't present that way either, but how many of these deteriorate? Some understanding of risk stratification is important as well. I'd be much less concerned about PE in an otherwise healthy 14 year old than a 70 year old with cardiac history being treated for prostate cancer.

At some point these are the type of distinctions EMS is going to have to start making to advance and prove value in the healthcare system.


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## mycrofft (Apr 17, 2011)

*Trevor, of course. Good point*

Having seen scores of all sorts of presentations in the field, we "understand". Get it, got it, good?

A "field diagnosis", however, is necessary, unless you are working strictly from a set of protocols which dictate treatment without an idea of the problem and based solely upon field assessment findings...i.e., "cook-booking".

Without some sort of field diagnosis, you either run like heck for the nearest faclity with _every_ call because you cannot make a differenteial to guide you to start any particular treatment, or you start treating *everything* with the symptoms and signs you have elicited so far... which as you pointed out indirectly would result in a lot of very sick and anxious  people being given benzos when they needed oxygen, or t-shirt rebreathing, or  rapid tranport and a receiving facility equipped to handle a PE, or a psychiatric admit, or intravenous cardiac meds, or whatever.

I got good at spotting pseudoseizures, but I always had ACLS materials and 
O2 on hand and called for suction JIC (just in case). The tough ones were those with a psych component. And just because they are exhibiting a clinically unlikely seizureform activity, doesn't mean there isn't something wrong with them anyway.


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## Trevor (Apr 18, 2011)

mycrofft said:


> Having seen scores of all sorts of presentations in the field, we "understand". Get it, got it, good?
> 
> A "field diagnosis", however, is necessary, unless you are working strictly from a set of protocols which dictate treatment without an idea of the problem and based solely upon field assessment findings...i.e., "cook-booking".
> 
> Without some sort of field diagnosis, you either run like heck for the nearest faclity with _every_ call because you cannot make a differenteial to guide you to start any particular treatment, or you start treating *everything* with the symptoms and signs you have elicited so far... which as you pointed out indirectly would result in a lot of very sick and anxious  people being given benzos when they needed oxygen, or t-shirt rebreathing, or  rapid tranport and a receiving facility equipped to handle a PE, or a psychiatric admit, or intravenous cardiac meds, or whatever.[FONT]





Absolutely, i just find it absurd that EMS providers *THINK* we can diagnosis Anxiety.


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## Aidey (Apr 18, 2011)

Do you honestly think that MDs order a d-dimer on every single patient that presents to the ER with anxiety?


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## Trevor (Apr 18, 2011)

Aidey said:


> Do you honestly think that MDs order a d-dimer on every single patient that presents to the ER with anxiety?



Nope, i dont, especially since they have a really, really, REALLY low specificity....


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## Aidey (Apr 18, 2011)

Sure it has a low specificity, but it has a high sensitivity, and a negative test is considered conclusive in proving there is no thrombus. So, if you don't think they are running d-dimers on everyone how do you think they are differentiating between anxiety and PE?


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## Trevor (Apr 19, 2011)

by getting a better history then what the OP posted... Look, all Im saying is that you CAN NOT absolutely differentiate this difference between PE/Anxiety everytime prehospitally... Can you sometimes? Sure. But most of the time you need more diagnostics... (d-dimer ,if you want. Spiral CT, etc.) But most of all, education is important. There's a reason Physicians have as much education as they do... They learn about things like the PERC rule (which i would be willing to bet the majority of pre hospital responders dont know about). They have better clinical Gestalt, and that knowledge and skills help guide their decision on whether or not to do something like a ddimer... 

And as a side note, high sensitivity doesnt mean that the test points to a certain (*read specific*) diagnosis. In order for a test to be valuable it should have a relatively high specificity *as well*...


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## systemet (Apr 19, 2011)

> And as a side note, high sensitivity doesnt mean that the test points to a certain (*read specific*) diagnosis. In order for a test to be valuable it should have a relatively high specificity *as well*...



Agreed - an ideal test is minimally invasive, inexpensive, with no risk to the patient, quick, and has 100% sensitivity and 100% specificity, but that's rarely the way it works.

Usually you end up in a situation where you have to trade sensitivity for specificity.  If you want to catch every patient with condition X (100% sensitivity), you end up getting a few false positives (<100% specificity).  If you want to be highly specific, you end up becoming less sensitive.

I don't have a source at hand, but I was under the impression that a d-dimer is 90-95% sensitive, and 50% specific for detecting PE.


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## CAOX3 (Apr 19, 2011)

Perc  rule we covered that in a respiratory ed class I took a few years back, quick and to the point and if I'm not mistaken almost 100% correct at diagnosing PE.

Lets see I believe its eight criteria based on age, vitals, history, edema and I believe steroid use, but I'm not positive on that.

Time go find the book.


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## bigbaldguy (Apr 19, 2011)

I'm really digging the info you guys are providing on this topic. D dimer and perc are both new to me but I looked them up and applying what I know about patient to these tests says low probability of PE. Just to be clear we transported this patient priority and my ICP was able to stay with patient during initial patient evaluation at ER. We were also given patients paperwork regarding previous medical issues and psych evals at pickup.


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## Aidey (Apr 19, 2011)

Trevor said:


> And as a side note, high sensitivity doesnt mean that the test points to a certain (*read specific*) diagnosis. In order for a test to be valuable it should have a relatively high specificity *as well*...



I understand the difference between sensitivity and specificity, and in the case of the d-dimer I believe the value is because it is accurate at ruling out a PE, not because it can rule in a PE. The test is ~95% accurate by itself, and if a patient has a negative d-dimer along with the absence of other clinical indications of a PE the chance of a patient having a PE gets about as close to zero as it can. 

My point still stands that not every patient who goes to the ED with a complaint of anxiety gets a d-dimer, and they most definitely don't get a CT or a pulmonary angiogram. It is also entierly possible for the well educated provider to use and apply the various assessment tools to determine the probability of a PE.


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## CAOX3 (Apr 19, 2011)

CAOX3 said:


> Perc  rule we covered that in a respiratory ed class I took a few years back, quick and to the point and if I'm not mistaken almost 100% correct at diagnosing PE.
> 
> Lets see I believe its eight criteria based on age, vitals, history, edema and I believe steroid use, but I'm not positive on that.
> 
> Time go find the book.



Let me clean this up a little, sorry I was a bit rusty.

If they meet the criteria then they rule out for PE and I believe the percentages are near 100%

Ok, its  hormones not steroids.


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## Trevor (Apr 25, 2011)

Aidey, 

Youre absolutely correct, thats where clinical Gestalt comes in. The point Im trying to make (albeit, apparently not well) is that EMTs (as a whole, AND AT ALL LEVELS) have a habit of "not knowing what we dont know". WE have a habit of calling something the least dangerous thing it could be without knowing, or evaluating, for the more life threatening things first...


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## Patria O Muerte (Apr 28, 2011)

As far as I know, from personal experience, these can be very murky waters. I had an extremely bad anxiety attack last year (in my EMT class!) due to an anxiety disorder that was undiagnosed at the time, and because I wasn't even considering anxiety the medic and EMT who were treating me took my word for it that it was a heart problem. Fortunately, after a few minutes of my pulse jumping around and my breathing going out of control, they realized it could indeed be stress, and started calming me down. That did the trick.

Point is, at least in my experience on the road, we're used to looking at things from a very medical perspective in certain scenarios. Its cases like these that we should take a step back and try to view any psychological problems that may be contributing to it. I know that, as emergency providers, we're used to assessing patients in a humanistic and comforting way, but sometimes tunnel vision occurs, and we have to be sure that we are being rational. Unfortunately these days psychological problems and neuroses are more common than not. 

For someone who has never actually personally experienced an anxiety/panic attack, it is very hard to describe. I'd imagine that on the outside looking in it seems like someone is being overdramatic and needs to calm themselves down. But to the person suffering through it, it is one of the most terrorizing feelings in the world. It is like that sinking feeling you get in your stomach when you realize you've done something wrong or have lost something- it's like that but about 10x worse, there is no identifiable cause to it in the moment, and it lasts longer than you can bear it. I implore any providers dealing with a patient in this state to realize how serious of a condition it really is.


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