# Panic Attack?  That isn't supposed to happen.



## MMiz

This wasn't my call, but something I heard a few days ago from a friend.  It makes sense to me, but I'm still a bit confused.

Woman uses unmanned FD station phone to call 911.  Her boyfriend didn't think they'd make it to the hospital.

EMS ATF 19 y/o distraught female.

S: Pt complaining of abdominal pain and tingling in both arms and hands.  Patient's fingers are bent in awkward claw-like positions.
A: NKDA
M: Denies
P: No pertinent medical hx
L: Ate mean a couple of hours prior
E: Patient had rough day at work, doesn't want to talk about it, came home, and now experiencing symptoms

O: 30 minutes prior to arrival
P: Nothing makes it better or worse, symptoms are consistent
Q: Tingling in arms and hands
R: No radiation
S: 4-5
T: 30 minutes prior, no change in pt's condition

Vitals: I don't have vitals, but here is a guess:
R: 22
P: 110
....

Pt was placed on O2 @ 2LPM via NC.  After talking with pt for only minutes, pt's condition completely normalized.  Pt was transported without incident or change in condition.

*Hospital dx was a panic attack.  What was with the fingers?*  Friend explained it due to lack of O2 and blood perfusion to extremities, but I've never seen or heard of it.  My first thoughts were ectopic pregnancy or neuro.


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## Guardian

Sounds like classic hyperventilation.  Swallowing too much air causes bloating and stomach ache.  A drop in co2 causes a wide variety of nervous system symptoms and a drop in calcium causes muscle cramps and spasms, especially in the extremities.  I usually have to deal with one of these basket cases every week or so.


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## akflightmedic

Guardian pretty much summed it up.

That is classic presentation of hyperventialtion.

When you get these patients, ask if their lips or face is numb. Ask if their toes are cramped. The curled up hands are a huge ding ding ding!!!!

These patients need to be talked down usually. Remove all extra personel, any stimuli, lights/sirens, shut them off. Get in front of the patient and talk quietly and slowly and encourage them to focus on you while you get them to regain control of their breathing. Talk slow and steady, everything is ok, in your nose out your mouth..nice and slow. You do this over and over until they start to breathe normal and then their hands uuncramp and their body quits tingling. Then you get a refusal and go back to bed...LOL.

If done properly, you can have them back to normal and able to leave within 20 mins or so. For me, that is worth it instead of transporting them, waiting at the ER forever and then doing a report while tying up the unit that could be needed elsewhere.

It takes a patient provider to do all of this. A lot of people I work with just rather throw them in the truck and dump them as soon as possible.


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## MMiz

Thanks for the additional information.  After reading your responses, and confirmed by a quick google, it seems as though I truly missed the classic case of hyperventilation.  I missed it, and I mean I *really *missed it.

Thanks!


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## Guardian

akflightmedic said:


> It takes a patient provider to do all of this. A lot of people I work with just rather throw them in the truck and dump them as soon as possible.




Lack of patience in an issue I’ve been seeing a lot lately.  I might even start a thread on it soon.  

MMiz, I guess you're just a mere mortal like the rest of us.


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## emtkelley

My hands do the same thing when I get a panic attack. In fact that is one of the first signs with me and then I feel like my throat is closing. I have never been to the dr. about them but my husband, who is a Paramedic, can usually talk me through it with no problem. And yes, it takes a very patient person to talk someone down.


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## HorseHauler

especially his wife h34r:


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## BossyCow

Why was the pt put on O2?


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## emtwannabe

To give them something to focus on. If they are wearing a nasal cannula, they have to stop and concentrate on the O2.

Jeff


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## Ridryder911

I treat panic attacks as a psychological event, in which it is. It is the reflection of the psyche that is being presented in a physical form. 

I usually use reaffirmation, and allowing them to vent and discuss the feelings. I do however; may become firm and directive on some dependent on the situation. Many, feel that they have no control of the situation and need guidance. 

Unfortunately, I believe a lot of the rise of "panic attacks" is increasing due to the "acceptance" of the inability coping skills. In severe cases, I will discuss with medical control and administer sedative or relaxants. 

R/r 911


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## Tincanfireman

Many times I've had hyperventilation/panic attack pt's complain of "not getting enough air".  Some providers (not me) will put a NRB on the pt's face and crimp the O2 line, with the idea of fooling the person into thinking they are getting O2. Problem is, if the person realizes what has occurred, all credibility is lost.  I agree, it's better to spend a few minutes trying to talk them down than to transport. But, if they really want to go it's their right. I just provide the means.


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## VentMedic

Tincanfireman said:


> Some providers (not me) will put a NRB on the pt's face and crimp the O2 line, with the idea of fooling the person into thinking they are getting O2.



That is not accepted practice and should not be done at any time!!

Hypoxia and hypercapnia will occur quickly and may result in a progression of unexpected events. In simple terms, suffocation by plastic. 

The nasal cannula works much better until you can assess the patient. There may be more causing the rapid breathing then what you see initially. Assuming it is hyperventilation syndrome due to anxiety or hysteria may cause you to miss very valuable information.


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## Tincanfireman

Agree, x 1000.  Poor practice and I don't condone it, however, what others do is out of my hands.  Kind of goes along with the hoary brown paper bag routine.  It's shortcuts like this that end up in subpoenas!


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## bstone

BossyCow said:


> Why was the pt put on O2?



It never hurts to oxygenate. Hyperventilation is short, fasts breaths. Some believe that this doesnt allow for proper oxygenation. Increasing the amount of oxygen may help with symptoms.


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## jmaccauley

There is an obvious psychological effect when administering oxygen to a patient suffering from panic or anxiety. Sometimes, putting anything around the face adds to the stress. In my profession (LEO), I often deal with folks who are stressed, panicked or just plain scared. I have them perform the same breathing exercises (combat breathing we call it) that I teach officers to perform when they find themselves getting too excited. Softly tell them to breathe in deeply for a count of 4, hold for a count of 4 and exhale on a count of 4. It works well as a temporary solution.


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## Ridryder911

bstone said:


> It never hurts to oxygenate. Hyperventilation is short, fasts breaths. Some believe that this doesnt allow for proper oxygenation. Increasing the amount of oxygen may help with symptoms.


I totally disagree with you. True hyperventillation symptoms is produced by respiratory alkalosis, (too much oxygenation) and thus applying oxygen on the patient actually potentates and may worsen the symptoms. (The carpopedal spasms, H/A, paresthesia around the lips, fingers, is caused by the pH level in the blood stream (review blood gases). The patient needs to rebuild the Co2 and yes, if one places a NRBM at 4 LPM or so, one can increase the Co2 level. 

R/r 911


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## bstone

Ridryder911 said:


> I totally disagree with you. True hyperventillation symptoms is produced by respiratory alkalosis, (too much oxygenation) and thus applying oxygen on the patient actually potentates and may worsen the symptoms. (The carpopedal spasms, H/A, paresthesia around the lips, fingers, is caused by the pH level in the blood stream (review blood gases). The patient needs to rebuild the Co2 and yes, if one places a NRBM at 4 LPM or so, one can increase the Co2 level.
> 
> R/r 911



You disagree with placing the pt on a NRB at 4lpm? That's what I tried to say. Guess I wasn't clear. This is technically oxygenating, afterall, even tho it builds up CO2.


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## BossyCow

Ridryder911 said:


> I totally disagree with you. True hyperventillation symptoms is produced by respiratory alkalosis, (too much oxygenation) and thus applying oxygen on the patient actually potentates and may worsen the symptoms. (The carpopedal spasms, H/A, paresthesia around the lips, fingers, is caused by the pH level in the blood stream (review blood gases). The patient needs to rebuild the Co2 and yes, if one places a NRBM at 4 LPM or so, one can increase the Co2 level.
> 
> R/r 911



That's what I thought.  I also agree with your comment that the best treatment for anxiety is one on one patient interaction.  Playing that fine line between showing that you take their symptoms seriously and being an authority figure in control of the scene is what works best in the calls I've been on.  If the patient gets even the slightest inkling that you think this is 'only psychological' things get a lot worse.  I've had some luck with some patients in showing them the Pulse Ox reading and telling them the symptoms are from too much air instead of too little.. then the "Breathe with me... In.... Out... In... Out" routine.  Keep them concentrating, eye contact on you while you coach them into slowing the breath down.  
There are always going to be those so locked into it that they won't or can't work with you, but I've found these to be the exception rather than the rule.


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## MMiz

Did I ever tell you the time when I was on an airplane, the guy has symptoms of an AMI, I put him on O2, and the bag didn't inflate?  Yeah, no bag inflation = no O2.  They tell passengers not to worry if the bag doesn't inflate only to falsely reassure them.  I assure you, if the bag does not inflate, you are *not* getting O2.


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## Guardian

yikes, remind me to never have a mi on an airplane


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## TheDoll

Guardian said:


> yikes, remind me to get on an airplane


fixed:blush:


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## VentMedic

Ridryder911 said:


> I totally disagree with you. True hyperventillation symptoms is produced by respiratory alkalosis, (too much oxygenation) and thus applying oxygen on the patient actually potentates and may worsen the symptoms.



Too much ventilation hence the term "hyper_ventilation_".  In many causes of hyperventilation and respiratory alkalosis, one may not have enough _oxygenation_.    example; pulmonary emboli, pneumonia esp. PCP

Cases where we do have to take the PaCO2 levels down by a ventilator, we closely monitor the cerebral oxygenation by jugular oximetry to maintain adequate oxygentation. (traumatic brain injury, PPHN of newborn-but not with jugular ox)




> (The carpopedal spasms, H/A, paresthesia around the lips, fingers, is caused by the pH level in the blood stream (review blood gases). The patient needs to rebuild the Co2 and yes, if one places a NRBM at 4 LPM or so, one can increase the Co2 level.



Many of the physical symptoms are associated with the calcium drop in the blood.  The "NRBM at 4 LPM" is a throw back to the 1980s (yes Rid the 80s were good) and the hospital version of a quick paper bag.  Can be very dangerous if unsupervised as must be 1:1 observation. That is a rare staffing thing in a busy ER.  It can also cause a mega increase in anxiety if pt senses the 4 LPM as not meeting their 18 LPM minute volume demand.  Imagine finishing a foot race on a hot day and the water drinking fountain is on "trickle".

During the past five years we have been cautioned on the "anxiety" hyperventilation assumption in teen-agers and some adults. Diabetes that has not be diagnosed may present as hyperventilating, NO hx of DM, and anxious because they don't know what's wrong with them. They become more anxious when well meaning caregivers keep telling them to "slow down your breathing" and they can not control their breathing. Glucose levels are not always in the protocols for <18 y/o.  What a surprise when the ABG is drawn and the pH is <7.0.   I actually see this quite frequently now with the obesity issues. If it is psychogenic hyperventilation, the arterial stick may make or break that.<_< 

There are also the Dive Masters who are too afraid to admit they took one too many dives. Between the fear of losing their jobs, career and disability, they can present pretty hysterical with classic hyperventilation signs. I've had to calm a few experienced divers down for the HBO chamber. The novice diver usually does not present as anxious. They usually don't know the seriousness like the experienced divers. 

Let us not forget the people who are diagnosed with chroncic hyperventilation syndrome.

Acute and Chronic HVS
http://www.emedicine.com/emerg/topic270.htm
Quote from this article;
"*Prehospital Care:* 

Because respiratory distress or chest pain has many potentially serious causes, this diagnosis should never be made in the field. Even when a patient carries a prior diagnosis of HVS, transporting patients with these complaints for a more complete evaluation than is available in the field is prudent.

Rebreathing into a paper bag is not recommended in the field. Rebreathing should not be initiated in the ED until after more serious etiologies have been excluded. Deaths have occurred in patients with acute myocardial infarction (MI), pneumothorax, or pulmonary embolism misdiagnosed as HVS and treated with paper bag rebreathing."

Good general articles on causes of respiratory alkalosis.
http://www.anaesthesiamcq.com/AcidBaseBook/ab6_2.php

Good e-Medicine article on respiratory alkalosis- although I disagree with the brown bag, it is used only after confirmation of psychogenic hyperventilation and other causes are excluded. 
http://www.emedicine.com/med/topic2009.htm

quote from above article;
"The diagnosis of hyperventilation syndrome should be a diagnosis of exclusion. Rule out all organic medical conditions, including pulmonary embolism, cardiac ischemia, and hyperthyroidism, before establishing a diagnosis of hyperventilation syndrome."

Supportive care may not necessarily mean running a NRBM at 15 LPM but oxygen will not have a profound short term effect on acid/base. Rebreathing CO2 will have an immediate effect on pH.  Lowering the pH by raising the CO2 may not be what the body wants at that particular time. (ex. DKA)


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## Guardian

TheDoll said:


> fixed:blush:



if by fixed you mean you totally screwed it up and changed the meaning, then yea, it's fixed :sad:


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