›Cardiac monitor when chest pain, palpitations, syncope, or abnormal vitals
›Pulse oximetry
›IV access if abnormal vitals or significant distress
›If SpO2 < 92%, oxygen and alternate diagnosis workup
›Rapid rule out triggers
›If chest pain concerning for ischemia, ECG within 10 minutes
›If hypoglycemia suspected, point of care glucose immediately
›If severe agitation with hyperthermia, toxidrome pathway
Symptom control
›Non pharmacologic measures
›Quiet room and reduced stimulation
›Coached slow breathing
›Grounding technique prompt
›Pharmacologic options when needed
›Hydroxyzine PO 25 mg
›Repeat 25 mg in 6 hours as needed
›Avoid with significant QT prolongation
›Lorazepam PO or SL 0.5 mg
›Repeat 0.5 mg in 30 to 60 minutes as needed
›Avoid in intoxication with other sedatives
›Lorazepam IV 0.5 mg
›Indication
›Severe panic with inability to take PO
›Severe agitation without toxidrome features
›Monitoring
›Respiratory rate
›Sedation level
Diagnostic plan and sequencing
›Targeted testing
›ECG based on triggers
›Glucose based on triggers
›Pregnancy test when applicable
›Avoid overtesting when low risk
›Normal vitals and classic panic features
›No cardiopulmonary red flags
Reassessment loop
›Time window reassessment
›Recheck vitals in 15 to 30 minutes after intervention
›Repeat focused cardiopulmonary exam if dyspnea or chest symptoms persist
›Escalation logic
›If symptoms persist with abnormal vitals, broaden medical workup
›If new neurologic findings, neuro pathway
17Disposition/dispo19
Level of care criteria
›ICU criteria
›Persistent hypoxia
›Hemodynamic instability
›Severe toxidrome features
›Inpatient admission criteria
›Medical etiology identified requiring treatment
›Persistent inability to function with ongoing severe symptoms
›Observation criteria
›Chest pain workup pathway
›Persistent tachycardia needing serial evaluation
›Discharge criteria
›Symptoms improved
›Normalized vital signs
›Medical mimics addressed as indicated
›Safe supervision and follow up plan
Follow up timing
›Outpatient follow up
›Primary care within 1 to 2 weeks
›Mental health follow up within 1 week when available
›Same week follow up for new medication initiation
18Discharge Instructions/di22
Copy discharge instructions
›Summary
›Today your symptoms fit best with anxiety or a panic attack after testing and exam did not show an emergency medical cause.
›Symptoms can feel intense and scary but are not usually dangerous when serious causes have been ruled out.
›Medications
›Take medications only as prescribed.
›Avoid alcohol, cannabis, and other drugs that can worsen anxiety.
›Avoid caffeine and energy drinks for the next 48 hours.
›Self care
›Use slow breathing during symptoms.
›Use grounding techniques during symptoms.
›Maintain hydration and regular meals.
›Follow up
›Arrange follow up with your clinician within 1 to 2 weeks.
›Arrange mental health follow up within 1 week if available.
›Return to emergency care now if
›Chest pain that is new or severe
›Trouble breathing
›Fainting
›New weakness
›New confusion
›Fever with worsening symptoms
›You feel unsafe at home
19References/r6
Guidelines and evidence
›Guideline references
›NICE guideline, Generalised anxiety disorder and panic disorder in adults, 2011, updated
›American Psychiatric Association, Practice guideline for the treatment of patients with panic disorder, updated
›World Health Organization, mhGAP Intervention Guide, anxiety disorders section, updated
›American Heart Association and American College of Cardiology, chest pain guideline, 2021
›ACEP clinical policies and decision tools for suspected pulmonary embolism, local protocol dependent
Evidence & Review
Reviewed by SymptomDx Medical Team·Last reviewed
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.