Anxiety

[rling]

I'm a new paramedic and will be starting my accreditation on next week. Quite often, we get calls that end up being anxiety related. However, the conclusion of anxiety is usually deduced after a battery of questions and diagnostics.

What are some of the questions that you ask and things that you look for that gives a quicker indication that anxiety is the problem at hand?

Some things that I notice about the patients after the fact are:

Mental Status: Anxious/Distressed/Crying (obviously)
Tachycardic
Tachypneic with clear lung sounds
Possible tingling in hands, feet, fingers, lips (carpal pedal spasms from hyperventilation)
Chest pain/tightness/pressure, possibly provocable by palpation or respiration
Blood Pressure normal to slightly elevated
(Capnography, but my county doesn't have it)

Things that I would assess:
Airway
Breathing (Rate, Effort, Depth, Lung Sounds)
Circulation (Radials - Rate, Rhythm, Quality), Skin Signs,
Vitals - BP, HR, SPo2
Blood Sugar
EKG, 12 Lead EKG for those over 40 y/o or with cardiac history

Although we tend to dismiss anxiety, I've come to find that to some degree, symptoms of more serious conditions can be similar to anxiety, such as Pulmonary Embolisms, Spontaneous Pneumothoraxs, etc.

Am I missing anything here?

 

[KEVD18]

well, as you've come to the conclusion of, a dx of anxiety is usually arrived at after excluding other possibilities.

once you've eliminated everything else, thats where you land.

im curious as to why you place those limits on your XII leads.

these are the thing you list that you have seen in these types of patients:
Mental Status: Anxious/Distressed/Crying (obviously) so altered mental status
Tachycardic a cardiac complaint right?
Tachypneic with clear lung sounds
Possible tingling in hands, feet, fingers, lips (carpal pedal spasms from hyperventilation)a possible symptom of lots of cardiac complaints
Chest pain/tightness/pressure, possibly provocable by palpation or respirationthis ones a given
Blood Pressure normal to slightly elevatedhypertension is a cardiac complaint, right?
(Capnography, but my county doesn't have it)

so i guess my question is, if a patient of any age or history presents with those symptoms, arent they deserving of the best possible assesment that you can give them?

nobody has a cardiac history until their first event, which could take place at any age.

 

[daedalus]

I battle panic disorder myself. Know that I know what it is, when I get an attack, I know it is an attack and through techniques taught to me from psychotherapy (and with the help of lexapro) I have been able to completely control the disease. Your symptoms are spot on, and if this is the first attack the patient has experienced, remember that they will literally think they are dying.

Hx of anxiety is obviously a huge indicator of a possible attack. Be sure to take a complete and objective medical history. Also, be aware that many people with depression will develop anxiety at some point. These two come in pairs and often the patient is not aware of it. S/S of an attack combined with a history of depression should cause you to consider panic disorder in your differential. Obviously and as you pointed out, a complete physical with 12 lead is usually indicated because the patient will often report feelings of doom, chest discomfort, etc.

In the field, it will be very difficult to distinguish the two. It matters little in prehospital management. Remember, these people feel like they are dying, and its quite an intense feeling. Its an emergency to them, so should it be to you. Do not dismiss any one case as a panic attack. On a call I had not to long ago, we picked up a gentleman complaining of CP. Myself and the paramedic dismissed the case as anxiety, and than later that day got a nurse added to our crew and went code 3 back to that hospital to pick up the same man and deliver to cath.

EDIT: KEVD18 is right. Patient deserves are full workup. Even ACS can occur with no ECG changes initially.

 

[Ridryder911]

Again, medical call assessments should be based upon hx., hx, hx. Ruling out probable calls should a routine procedure. What was the precipitating event? What type of hx. do they have? What previous medications are they prescribed? What does the general appearance and presentation look like?

Then a detailed and eliminating physical assessment should be performed. As mentioned, we should assume the worse even though we may personally have made a hypothetical diagnosis. I have changed diagnosis mid-stream. Thinking or assuming it to be one thing and turns out to be another. There is nothing wrong with that.

I routinely assess most "panic or anxiety" patients on multiple levels. Understanding, that I will not be surprised to see non-contributing ECG changes, benign physical findings.. yet, again who knows unless you assess? Our job in emergency medicine is to assume the worst (within reason) and then eliminate it as much as possible and many times this has to be finished within hospital care. That is why cardiac markers are drawn or anti-anxiety medication is administered and corrects the problem, we have made a diagnosis.

Many medical problems over lap and one has to understand that they actually can have multiple problems as well. Don't just treat accordingly but appropriately.

R/r 911

 

[triemal04]

Although we tend to dismiss anxiety, I've come to find that to some degree, symptoms of more serious conditions can be similar to anxiety, such as Pulmonary Embolisms, Spontaneous Pneumothoraxs, etc.

Am I missing anything here?

Yes. Your symptoms and differential dx are good, but dismissing a panic attack is flat out wrong.

Forget the classic teenager that is hyperventilating because ohmygawdjohnnysaidhedidn'tlikemeandsaidhelikedsusywholikeshimbackandwhatdoido!?!?. That is an easy fix. But someone having an true panic/anxiety attack really does both need and deserve the full treatement that is available for you to give them. As has been said, many in that state do feel like they are about to die, and to some extent, have little voluntary control over what they are doing. First order of buisness should be to try and talk them down, which if you can do it is great, but, in unable, using meds is not wrong, but absolutely appropriate, be it valium, versed, ativan, nitrous oxide, or what have you.

Yes, you should definetly assume the worst until proven otherwise, but once proven, you still need to treat the patient accordingly.