Acute anxietyMANAGEMENT

PSYCHIATRIC PRESENTATIONS · 12 SECTIONS

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578 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Acute anxiety Acute psychosis Agitation:behavioral emergency Anorexia Nervosa (Medical Complications)Bipolar disorder Bipolar Disorder (Depressive Episode)Bipolar Disorder (Manic Episode)Bulimia Nervosa (Medical Complications)Catatonia Conversion disorder Factitious Disorder Failure to Cope (Social)Failure to Thrive Generalized Anxiety Disorder Homicidal Ideation Major Depressive Disorder Major depressive episode Malingering Neuroleptic malignant syndrome Panic Attack Post-Traumatic Stress Disorder (Acute)Schizophrenia Exacerbation Suicidal Ideation Suicidal ideation and attempt Suicide Attempt

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp57

Immediate stabilization

›Initial priorities

›Airway compromise signs

›Stridor

›Inability to speak full sentences

›Breathing compromise signs

›SpO2 < 94% on room air

›Severe work of breathing

›Circulatory compromise signs

›SBP < 90 mm Hg

›Altered mental status

›If any instability, escalate to resuscitation bay

›Continuous cardiac monitoring

›Pulse oximetry

›IV access

›Immediate exclusions before labeling panic

›Hypoglycemia

›POC glucose

›If < 3.9 mmol/l, treat per hypoglycemia protocol

›Hypoxia

›SpO2 trend

›Supplemental oxygen if needed

›Cardiac ischemia or arrhythmia

›12-lead ECG within 10 minutes for chest pain or palpitations

›Telemetry for recurrent symptoms

›Pulmonary embolism or asthma exacerbation

›Respiratory rate

›Wheeze

›Toxicologic or withdrawal syndromes

›Stimulant exposure

›Alcohol or benzodiazepine withdrawal risk

High-risk symptom pattern triggers

›Red flag triggers

›New focal neurologic deficit

›Stroke pathway activation

›CT head pathway if indicated

›Syncope or near syncope

›Cardiac syncope evaluation pathway

›Orthostatic vitals if appropriate

›Chest pain with exertion

›ACS evaluation pathway

›Troponin pathway

›Persistent tachycardia > 130 beats/min

›Sepsis, PE, arrhythmia evaluation

›IV fluid consideration if dehydration

›Fever

›Infection evaluation

›Substance induced hyperthermia evaluation

Key concepts

›Panic attack framing

›Abrupt surge of intense fear or discomfort

›Peak within minutes

›Prominent autonomic symptoms

›Diagnosis of exclusion in first presentation

›Medical mimics prioritized when atypical or high risk

›Recurrent stereotyped episodes with prior workup increases likelihood

›Hyperventilation physiology

›Respiratory alkalosis

›Paresthesias and carpopedal spasm

›Chest tightness and lightheadedness

02History/hx90

Symptom characterization

›Episode features

›Onset pattern

›Sudden onset

›Gradual onset

›Duration

›< 30 minutes typical

›Prolonged symptoms suggests mimic or ongoing trigger

›Peak intensity timing

›Peak within 10 minutes supports panic attack

›Progressive worsening supports alternate diagnosis

›Primary symptoms

›Dyspnea or air hunger

›Chest pain or pressure

›Palpitations

›Tremor

›Diaphoresis

›Nausea or abdominal distress

›Dizziness or presyncope

›Paresthesias

›Chills or heat sensations

›Derealization or depersonalization

›Fear of dying

›Fear of losing control

Triggers and context

›Psychosocial context

›Recent stressor

›Loss

›Conflict

›Academic or work pressure

›Trauma exposure

›Recent assault

›Recent accident

›Environment

›Crowds

›Enclosed spaces

›Sleep and fatigue

›Sleep deprivation

›Shift work

›Substance and medication factors

›Stimulants

›Caffeine

›Amphetamines

›Cocaine

›Cannabis exposure

›High potency products

›First time use

›Alcohol use

›Recent heavy use

›Recent cessation

›Medication contributors

›β-agonists

›Thyroid hormone excess

›Steroids

›Decongestants

Risk factors for medical mimics

›Cardiac risk

›Prior CAD

›Diabetes

›Smoking

›Family history sudden death

›Thromboembolism risk

›Recent surgery

›Recent immobilization

›Prior DVT or PE

›Estrogen therapy

›Active malignancy

›Endocrine risk

›Hyperthyroid symptoms

›Adrenal tumor history

›Respiratory risk

›Asthma

›COPD

›Prior pneumothorax

Psychiatric history and safety

›Prior episodes

›Similar stereotyped episodes

›Prior ED evaluations and results

›Prior response to specific interventions

›Baseline mental health

›Panic disorder history

›Generalized anxiety history

›Depression history

›PTSD symptoms

›Safety screen

›Suicidal ideation screen

›Current thoughts of self-harm

›Intent or plan presence

›Homicidal ideation screen

›Current thoughts of harming others

›Specific target

›Psychosis screen

›Hallucinations

›Delusions

03Physical Exam/exam68

Vital signs and general appearance

›Physiologic status

›Heart rate

›Persistent tachycardia pattern

›Paroxysmal tachycardia pattern

›Blood pressure

›Severe hypertension

›Hypotension

›Respiratory rate

›Hyperventilation

›Bradypnea after sedatives

›Temperature

›Fever

›Hypothermia

›SpO2

›Desaturation with exertion

›Normal saturation with air hunger

›General appearance

›Severe agitation

›Unable to participate in exam

›Unsafe behavior

›Tremor

›Fine tremor

›Coarse tremor suggesting withdrawal

›Diaphoresis

›Profuse diaphoresis suggesting catecholamine excess

›Mild diaphoresis with anxiety

Focused cardiopulmonary and neurologic exam

›Cardiovascular findings

›Rhythm

›Irregularly irregular

›Regular narrow complex tachycardia

›Murmur

›New murmur

›Loud systolic murmur

›Perfusion

›Delayed capillary refill

›Cool extremities

›Respiratory findings

›Work of breathing

›Accessory muscle use

›Speaking in full sentences

›Auscultation

›Wheeze

›Crackles

›Unilateral diminished breath sounds

›Neurologic findings

›Mental status

›Alert and oriented pattern

›Confusion or delirium

›Focal deficits

›Weakness

›Aphasia

›Visual field deficit

›Tetany features

›Carpopedal spasm

›Perioral paresthesias

PITFALLS

›Common pitfalls

›Panic label with first presentation and no evaluation

›Mimic risk higher in older patients

›Mimic risk higher with cardiopulmonary red flags

›Sedation before excluding hypoglycemia or hypoxia

›POC glucose prior to benzodiazepine when feasible

›SpO2 assessment prior to benzodiazepine

›Missed stimulant intoxication

›Persistent mydriasis

›Severe hypertension

›Missed withdrawal syndrome

›Autonomic hyperactivity

›Tremor and agitation

04Differential Diagnosis/ddx48

Life-threatening mimics

›High acuity conditions

›Acute coronary syndrome

›ICD-10 I20.0

›ICD-10 I21.x

›Clinically significant arrhythmia

›ICD-10 I47.1

›ICD-10 I48.x

›Pulmonary embolism

›ICD-10 I26.x

›Pneumothorax

›ICD-10 J93.x

›Asthma exacerbation

›ICD-10 J45.901

›Anaphylaxis

›ICD-10 T78.2xxA

›Sepsis

›ICD-10 A41.x

›Thyrotoxicosis

›ICD-10 E05.x

›Hypoglycemia

›ICD-10 E16.2

›Stroke or TIA

›ICD-10 I63.x

›ICD-10 G45.9

Common non-life-threatening mimics

›Lower acuity conditions

›GERD or esophagitis

›ICD-10 K21.9

›Costochondritis or chest wall pain

›ICD-10 M94.0

›Vestibular syndrome

›ICD-10 H81.x

›Anemia

›ICD-10 D64.9

›Medication side effects

›β-agonist induced tremor and tachycardia

›Steroid induced mood symptoms

Primary psychiatric diagnoses

›Anxiety spectrum

›Panic attack

›SNOMED CT Panic attack

›ICD-10 F41.0 panic disorder

›Generalized anxiety disorder

›ICD-10 F41.1

›Acute stress reaction

›ICD-10 F43.0

›PTSD

›ICD-10 F43.10

›Somatic symptom disorder

›ICD-10 F45.1

05Laboratory Tests/lt42

Core tests by presentation

›Baseline labs when indicated

›POC glucose

›Indication first presentation or altered mental status

›Hypoglycemia treatment trigger < 3.9 mmol/l

›Electrolytes

›Indication palpitations, weakness, diuretic use, vomiting

›Potassium abnormalities and arrhythmia risk

›CBC

›Indication dyspnea, pallor, bleeding concern, infection concern

›Anemia contribution to tachycardia and dyspnea

›Beta hCG

›Indication pregnancy possibility

›Ectopic pregnancy consideration with abdominal pain

Targeted tests

›Focused labs for specific mimics

›Troponin

›Indication chest pain, ischemic ECG changes, high cardiac risk

›Serial strategy per chest pain pathway

›TSH and free T4

›Indication weight loss, heat intolerance, tremor, persistent tachycardia

›Non-urgent in low-risk recurrent panic pattern

›D-dimer

›Indication PE workup in low to intermediate pretest probability

›Age-adjusted threshold use when validated locally

›Venous blood gas

›Indication severe hyperventilation with concern for metabolic process

›Respiratory alkalosis pattern in hyperventilation syndrome

›Serum ketones

›Indication diabetes with tachypnea

›DKA exclusion support

Toxicology and exposure testing

›Substance evaluation

›Urine toxicology screen

›Indication suspected stimulant intoxication or unclear presentation

›Limited role in immediate management

›Blood alcohol level

›Indication altered mental status or withdrawal concern

›Withdrawal risk increases as level falls

›Acetaminophen level

›Indication suspected ingestion or unclear altered mental status

›Time since ingestion critical for interpretation

›Salicylate level

›Indication tachypnea with mixed acid base concern

›Tinnitus or nausea supportive

06Diagnostic Tests/dt46

Scoring Systems

›Structured assessment tools

›GAD-7

›Screening for generalized anxiety symptoms

›Score 10 or greater suggests clinically significant anxiety

›PHQ-9

›Screening for depression symptoms

›Positive responses trigger safety assessment

›Panic Disorder Severity Scale

›Baseline severity assessment when diagnosing panic disorder

›Use for outpatient tracking more than ED decision making

›HEART score

›Chest pain risk stratification support

›Use only when chest pain pathway applies

›Wells criteria and PERC

›PE pretest probability estimation

›PERC use only in low risk patients

MRI

›MRI role

›Brain MRI indications

›Persistent focal neurologic deficit with nondiagnostic CT

›Concern for posterior circulation stroke

›Cardiac MRI considerations

›Not first-line in acute ED evaluation of panic-like symptoms

›Consider in outpatient evaluation of cardiomyopathy if indicated

›Limitations

›Time and availability constraints in acute setting

›Motion artifact in agitated patients

›CT role

›CT pulmonary angiography

›Indication PE suspicion with positive decision rule pathway

›Contrast allergy and renal considerations

›CT head

›Indication new severe headache with neurologic features

›Indication altered mental status without clear cause

›CT aorta

›Indication tearing chest pain with pulse deficit or neurologic findings

›Severe hypertension plus chest pain risk pattern

Ultrasound

›POCUS applications

›Lung ultrasound

›Pneumothorax pattern

›B-lines pattern for pulmonary edema

›Cardiac ultrasound

›Pericardial effusion screening in hypotension

›Gross LV function assessment in shock

›IVC assessment

›Volume status support when dehydration suspected

›Limited accuracy in isolation

07Disposition/dispo28

Level of care decisions

›Admission or observation indications

›Persistent abnormal vital signs

›Hypoxia

›Hypotension

›Persistent tachycardia

›Positive diagnostic evaluation

›Abnormal ECG requiring monitoring

›Elevated troponin pattern

›PE confirmed or strongly suspected

›Inability to function safely at home

›Severe agitation requiring repeated parenteral sedation

›Inability to maintain hydration

›Safety concerns

›Active suicidal intent

›Active psychosis

Discharge criteria

›ED discharge readiness

›Resolution or near resolution of acute symptoms

›Stable respiratory status

›Stable hemodynamics

›Medical mimics reasonably excluded for risk level

›Normal ECG when indicated

›Appropriate labs or imaging when indicated

›Clear outpatient plan

›Primary care follow-up

›Mental health follow-up

›Reliable support and safe environment

›Trusted contact aware of plan

›Transportation plan

08Treatment/t86

Nonpharmacologic measures

›First-line de-escalation

›Environment

›Quiet room

›Reduce stimulation

›Reassurance

›Brief explanation of physiologic anxiety response

›Normalization of symptoms after exclusion of dangerous causes

›Breathing retraining

›Slow diaphragmatic breathing

›Avoid paper bag breathing

›Grounding techniques

›5-4-3-2-1 sensory technique

›Muscle relaxation

Pharmacologic symptom relief

›Benzodiazepines

›Lorazepam

›0.5 mg to 1 mg PO or SL

›Repeat 0.5 mg to 1 mg after 20 to 30 minutes if needed

›Typical total 1 mg to 2 mg

›0.5 mg to 1 mg IV

›Repeat 0.5 mg to 1 mg after 10 to 15 minutes if needed

›Respiratory depression monitoring

›Midazolam

›2.5 mg IM

›Repeat 2.5 mg to 5 mg IM after 10 to 15 minutes if needed

›Continuous monitoring until awake and stable

›1 mg to 2 mg IV

›Repeat 1 mg to 2 mg IV after 5 to 10 minutes if needed

›Higher risk with opioids or alcohol

›Diazepam

›2 mg to 5 mg PO

›Repeat 2 mg to 5 mg after 30 to 60 minutes if needed

›Long half-life caution in older adults

›2 mg to 5 mg IV

›Repeat 2 mg to 5 mg after 10 to 15 minutes if needed

›Avoid rapid IV push

›Precautions

›Avoid in suspected intoxication with CNS depressants

›Alcohol co-use

›Opioid co-use

›Lower doses in older adults

›Increased fall risk

›Delirium risk

›Antihistamines

›Hydroxyzine

›25 mg PO

›Repeat 25 mg PO after 6 hours if needed

›Sedation counseling

›50 mg PO

›Use in larger adults or severe symptoms

›Anticholinergic burden caution

›Diphenhydramine

›25 mg PO or IM

›Alternative when hydroxyzine unavailable

›Avoid in delirium prone patients

›Beta blockers

›Propranolol

›10 mg PO

›Use for prominent tremor or performance anxiety pattern

›Onset slower than benzodiazepines

›Precautions

›Avoid in asthma with active bronchospasm

›Avoid in bradycardia or heart block

Longer-term initiation and referral

›Ongoing management planning

›CBT referral

›First-line for panic disorder

›Effective for recurrence prevention

›SSRI initiation considerations

›Best started with follow-up capacity

›Early activation anxiety possible

›Example SSRI regimens

›Sertraline 25 mg PO daily

›Increase to 50 mg PO daily after 1 week if tolerated

›Reassess at 4 to 6 weeks

›Escitalopram 5 mg PO daily

›Increase to 10 mg PO daily after 1 week if tolerated

›QT risk awareness in higher doses

›Avoid chronic benzodiazepines

›Dependence risk

›Withdrawal risk

Evidence notes

›Evidence and guideline alignment

›Benzodiazepines provide rapid symptom relief for acute panic in ED practice

›Evidence base includes clinical experience and observational data

›Use lowest effective dose and shortest duration

›CBT and SSRIs improve long-term outcomes in panic disorder

›Lower relapse rates than benzodiazepine-only strategies

›Requires outpatient follow-up infrastructure

09Special Populations/sp35

Pregnancy

›Pregnancy considerations

›Evaluation adjustments

›PE risk increased in pregnancy

›Beta hCG early in workup when pregnancy possible

›Medication safety

›Prefer nonpharmacologic measures first

›Benzodiazepines only if benefits outweigh risks

›Obstetric consultation triggers

›Abdominal pain with pregnancy

›Vaginal bleeding

Geriatric

›Older adult considerations

›Higher mimic prevalence

›ACS risk higher

›Arrhythmia risk higher

›Medication sensitivity

›Benzodiazepine dose reduction

›Fall risk precautions

›Delirium risk

›Avoid anticholinergics when possible

›Evaluate for infection and metabolic causes

Pediatrics

›Pediatric considerations

›Medical mimic emphasis

›Asthma exacerbation

›Ingestion

›Dosing strategy

›Weight-based benzodiazepine dosing when needed

›Lorazepam 0.05 mg/kg IV

›Maximum single dose 2 mg

›Repeat interval 10 to 15 minutes if needed

›Family involvement

›Caregiver calming presence

›Simple breathing coaching

›School and social triggers

›Bullying

›Academic pressure

10Background/b30

Epidemiology

›Frequency and patterns

›Panic attacks common in general population

›Many episodes occur without panic disorder diagnosis

›Recurrent attacks increase likelihood of panic disorder

›Typical age distribution

›Often begins in adolescence or early adulthood

›New onset later in life increases concern for medical mimic

›Comorbidity

›Depression common

›Substance use common

Pathophysiology

›Mechanisms

›Autonomic activation

›Sympathetic surge

›Tachycardia and tremor

›Respiratory patterns

›Hyperventilation induced hypocapnia

›Cerebral vasoconstriction and lightheadedness

›Cognitive components

›Catastrophic misinterpretation of benign bodily sensations

›Feedback loop increasing symptoms

Therapeutic Considerations

›Treatment rationale

›Nonpharmacologic measures target feedback loop

›Breathing reduces hypocapnia

›Grounding reduces catastrophic appraisal

›Benzodiazepines target acute autonomic distress

›Rapid onset

›Sedation and dependence risks

›SSRIs and CBT target recurrence and functional impairment

›SSRIs modulate serotonergic circuits over weeks

›CBT retrains misinterpretation and avoidance behaviors

11Patient Discharge Instructions/pdi25

copy discharge instructions

›Discharge plan

›Today assessment

›Symptoms consistent with panic attack after evaluation

›No dangerous cause found based on today testing when performed

›What to do during another episode

›Sit down in a safe place

›Slow breathing

›Inhale 4 seconds

›Exhale 6 seconds

›Grounding using 5-4-3-2-1 senses

›Avoid triggers for the next 24 hours

›Caffeine

›Energy drinks

›Recreational drugs

›Alcohol binge use

›Follow-up

›Primary care within 3 to 7 days

›Mental health or CBT referral

›Return to ED now for

›Chest pain that is new, severe, or with exertion

›Trouble breathing not improving with rest

›Fainting or near fainting

›New weakness, numbness, trouble speaking, or severe headache

›Fever with worsening symptoms

›Any safety concern including thoughts of self-harm

12References/r23

Clinical guidelines and evidence sources

›Key references

›AHA ACC chest pain evaluation guideline

›ECG and troponin based risk stratification framework

›High sensitivity troponin pathways where available

›ACEP clinical policy for suspected pulmonary embolism

›PERC and D-dimer use in low risk patients

›Imaging thresholds based on pretest probability

›APA guideline and evidence base for panic disorder

›CBT effectiveness for panic disorder

›SSRI effectiveness for panic disorder

Decision support tools

›Tools

›GAD-7

›Anxiety symptom severity screening

›Supports outpatient monitoring

›PHQ-9

›Depression symptom screening

›Safety screen trigger when positive

›Wells and PERC

›PE pretest probability estimation

›Avoid unnecessary CT imaging in low risk patients

›HEART score

›Chest pain risk stratification support

›Not for isolated anxiety without chest pain features

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.