Paralyzing Panic Attack

[LondonJ]

Hi,

Had a passenger flying in the right seat with me yesterday in a 4 seater, we were 20 mins into the flight at low altitude (2500'), he suddenly got very anxious and asked to turn back, which I did. Approximately 30 seconds later he started to experience symptons in the following order:
1) Pins and needles in feet and hands
2) Difficulty breathing (which intensified)
3) Complete inability to move his limbs (paralyzed in effect)
4) Slurred speech - caused by muscles in his face seizing up
5) Tightness in chest

Fortunately I was 4 mins away from another airfield which I was able to divert to.

He is a fit and healthy 22 year old and the paramedic was of the opinion that it was a panic attack so was able to talk him through it without any other treatment. After about 40 mins he was able to walk around and was fine, so I'm inclined to agree with the paramedic's diagnosis.

Has anyone encountered this before? Are there any known ways to prevent it (though I think his light aircraft flying days are over:))?

Best,
J

[Torque2]

There have been similar incidents caused by the stroboscopic effects of props/rotor blades passing through sunlight, a syndrome which I think is called 'flicker vertigo'. It is similar to watching stroboscopic effects on tv and thus a warning is given to viewers, the end product is a seizure-like state with varying depths.

Perhaps your friend may be susceptible to this effect? I'm sure someone with more knowledge of the comparative signs of this and 'panic' will be able to comment. :ok:

[patient]

By my name, I would say I am more eligible to answer this question.

From the face evidence, i suppose your fd/student does suffer from Panic Disorder (a kind of Mood Disorder). It's caused by the chemical in brain out of proportion etc... that false alarm for panic is triggered, i.e. those symptoms for panic while there is NO real danger.

If your fd/student "associated" these symptoms with certain situations/environments (e.g. flying, people etc...), and s/he tries to avoid those situation/environments, then this will become Phobia (with a purpose to avoid the panic).

There is NO prevention to mood disorder (like immune injection) . But it's highly treatable with medicines (SSRI/SNRI etc....) and Cognitive Behavioural Therapy (CBT).

So far as I know, a quick/immediate way to solve it is breathing in a small bag. Your fd/student's shortness of breath would cause him/her hyperventilation (?, can't remember the term). That is too much oxygen in his/her blood that will lower his consciousness etc.. (cannot remember).

Breathing in a bag/mouth & nose covered with hands can increase the Carbon Dioxide content in the blood and to soothe the him/her.

If you are a pilot/instructor, you should know this. This is IN THE SYLLABUS.

[LondonJ]

Thank you for your reply patient. I am indeed familiar with the contents of the syllabus. Hyperventilation was my first thought and I used a paper bag clamped over his nose and mouth and this had no effect. However, given how quickly the symptoms developed and intensified I made it my priority to divert and land the aircraft to get proper medical help.

[bucket_and_spade]

If you are a pilot/instructor, you should know this. This is IN THE SYLLABUS.

Erm, really necessary? A perfectly valid question from the original poster, be they a PPL, an instructor or neither.

[Loose rivets]

All of the above, and thinking laterally, mild anaphylaxis. Never discount this as a possibility when a slew of disabling symptoms appear out of nowhere.

[patient]

LondonJ: You did remember the syllabus by giving your fd/student a bag to breath in. WELL DONE! :ok:!Juz maybe you dunno that hyperventilation can be a consequence of panic attack (wiki hyperventilation) and your fd/student wasn't aware of this as well. After medication and/or CBT and got stabilised (not yet cured), he will know what to do (i.e. use your bag), and say "hey, the attack comes~ wait a while ;)"

By telling that your fd/student recovered in 40mins, I would say the chance of panic attack is here and pretty high. When the disturbance is gone (it can go within less than 5 seconds!), the patient would be simply very normal. Just s/he would become pretty hungry and/or tired (cos' much of the energy has been used to "panic" (to prepare to fight or flight).

If possible, you can ask your fd/student about his feeling during the episode. Was he feeling dying or edgy? i.e. if you didn't divert your flight, he felt vividly that the world would be ending/collapsing or sth very would be happening. This is a very important clue for a panic attack.

Anaphylaxis means "severe" allergy reaction, therefore mild anaphylaxis or "mild severe" allergy reaction seems doesn't make much sense.

Anaphylaxis WON'T come out of nothing. There must be an antigent, be it a bee sting, a pollen grain, a dust mite, or certain food etc. Since there is no evidence that your fd/student had been in contact with such antigent, I can claim that the chance for anaphylaxis is minimal. Also, other symptoms of anaphylaxis include swelling, rashes, suffocation (due to swelling of trachea) etc... these were not found in your fd/student. and if it were really anaphylaxis, 40 mins of anaphylaxis would be enough to KILL him. Lateral thinking doesn't means thinking without logic.

Most replies here just paid too much attention to the symptom seizure overlooking chest tightness, shortness of breath, pins and needls in limbs, and most importantly, he became fine after 40 mins. When taking ALL these symptoms, the chance of panic attack/disorder is quite significant.

Whether his light aircraft flying days are over or not depends the treatment offered to him, his intention to get healed and whether his interest is "scared off" by this episode. Of course, Class 2 medical. This is what I am looking at too~

[telster]

Certainly sounds like the guy was hyperventilating, as diagnosed by the paramedic.

Just a word of warning about using the paper bag treatment. I've used it on people several dozen times and it normally does work, however its pretty frowned upon in medical texts now. The danger is that some of the symptoms of hyperventilation for example tightness of the chest, lightheadedness etc could be from something more sinister than a panic attack, and reducing the amount of oxygen being breathed in might be harmful if for example they are actually having a heart attack.

The advice now is to try and talk the patient into calming down, maybe counting through their breaths trying to slow them down. I've found that this can take longer than a paper bag to work, but is still effective. Difficult I realise if you are trying to fly an aircraft at the same time, and I don't mean any criticism for you giving a paper bag. I realise it is still advised in many first aid books, but it is now pretty outdated.

Pointers towards someone hyperventilating rather than anything more serious include that their colour might be pretty pink rather than pale or grey. Tingling around the mouth, and in the fingers. Hands and feet can tighten up into "carpo-pedal spasm", certainly the hands claw up fairly distinctively and its easily recognised once you've seen it. Skin tends to be drier than the classic heart attack and its profuse sweating (although not always the case).

Its actually the low carbon dioxide level in the blood that causes the symptoms, one thing it does is cause the bloodvessels in the brain to constrict causing lightheadedness and even the patient to eventually pass out. Once passed out, they relax and their breathing will slow and they will come to again. Hopefully they won't be quite so panicky when they come to or else the whole cycle could repeat itself. Oxygen levels have no relevance and it is quite safe, even recommended in some medical books, to give oxygen to someone who is hyperventilating. In the event that it isn't a panic attack then the oxygen might well be beneficial, and since the tissues of the brain are actually short of oxygen because of the blood vessels constricting then the supplemental oxygen might even help in a panic attack (in theory).

Some panic attacks are pretty obvious, other times it is quite hard to be certain about it. I've been pretty certain that people have been having heart attacks who I've eventually found out were just having panic attacks, hopefully I've never been caught out the other way.

Another word of warning is that I would guess that having a heart attack would be a pretty scary thing, so no guarantees that someone with a history of panic attacks is just having another one on this occasion.

So bottom line, rebreathing into a paper bag does help restore the carbon dioxide levels, but you'd better be pretty certain that a panic attck is all they're having.

Regards!

Telster
(Ex UK Paramedic)


Just read through the posts a little better and a couple of points need to be commented on.

Anaphylaxis, although always by definition a severe allergic reaction does come in different degrees. At one extreme the lips could be swelling up without any other real problems breathing, at the other the patient could be in cardiac arrest with a very few minutes. People do have anaphylaxis without any previous history of it and might not know what they are allergic to. After all, everyone with it at some point had their first ever attack. And onset isn't necessarily very rapid, it can be some considerable time after exposure to the allergen, even several hours. I've never seen it, but you even get exercise-induced anaphylaxis but I'm not too sure how that works (I've not been looking at wikipedia).

I wouldn't take feelings that someone is going to die as a pointer towards a panic attack. "Feeling of impending doom" was a symptom of a heart attack drummed into us when training, and there is a medical saying that if someone says they're going to kill themselves they almost certainly won't, and if someone says they're going to die then they very possibly will (and I've found that to be more often than not true).

All in all it sounds like the original poster did the exact right thing in getting down on the ground asap.

[Hawk]

1) Pins and needles in feet and hands
2) Difficulty breathing (which intensified)
3) Complete inability to move his limbs (paralyzed in effect)
4) Slurred speech - caused by muscles in his face seizing up
5) Tightness in chest


The time frame for those symptoms is 20 minutes before the recommended requirement to present to a hospital emergency department.

[LondonJ]

Many thanks for your detailed reply telster! :)

[telster]

No worries!

[patient]

so is it a heart attack or panic attack? I am quite interested to know.





BTW,

DSM-IV Diagnostic Criteria for Panic Attack
A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sensations of shortness of breath or smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded, or faint
Derealization (feelings of unreality) or depersonalization (being detached from oneself)
Fear of losing control or going crazy
Fear of dying
Paresthesias (numbness or tingling sensations)
Chills or hot flashes

[Bad medicine]

In the end, LondonJ did exactly the right thing. Faced with symptoms of a potentially very serious condition, he diverted and got medical attention for his passenger. An aircraft is not the place for untrained people to be making a complicated diagnosis and providing treatment on the basis of that diagnosis.

Yes, breathing into a bag can relieve the symptoms of hyperventilation - if that is the problem. It could also significantly reduce the oxygen supply to a damaged or dying heart or brain. Unless you are very sure (and I'm not sure how you can be in the circumstances), the safe thing to do is to seek rapid, qualified advice.

Cheers,

BM

[telster]

Patient

The fact that the guy was walking round apparently ok after landing and being seen by the paramedic points to it being much more likely it was a panic attack than a heart attack.

As Bad Medicine points out, in the air isn't the place to try and make a diagnosis. If in doubt, assume the worst. As I said, I've been wrong and misdiagnosed a panic attack as a heart attack, probably more than once and thats with the benefit of ECGs etc in the back of an ambulance safely on the ground. All the boxes for a panic attack can be ticked, but all the symptoms are so vague that they could be of anything. Low blood sugar, thats something else that can give panicky symptoms (and before starting another change of direction in the thread, no they haven't got to be diabetic).

Always assume the worst. Sticking a paper bag over someones face probably will help if it is just hyperventilation, but thats assuming the best case diagnosis, not the worst.

[patient]

Yes, landing the plane for paramedics is the best way. and LondonJ did the 100% correct thing. What I tried to say about "breathing in a bag" is just a quick relief the symptom before landing a plane.

Why am I so sure about it's "highly likely" a panic attack - I had this experience. Simple. There had been a number of episodes before I sought medical help. The one I could remember was in the subway, I got panic attack that my mind was filled with my "worries" (family issues to solve at that moment). During that attack, I started to "realise" there "were" so many people around me on the train.

This episode lasted for ~15 mins and went away very quickly (really within 1-2 seconds). Then I feel very tired and hungry. As a paramedic, I guess you know why.

After it, I got depersonalisation and derealisation. So, I decided to see a psychiatrist.


Can I get Class 1 or 2 Medical after recovery?!!

[Loose rivets]

Patient says:

Anaphylaxis WON'T come out of nothing. There must be an antigent, be it a bee sting, a pollen grain, a dust mite, or certain food etc. Since there is no evidence that your fd/student had been in contact with such antigent, I can claim that the chance for anaphylaxis is minimal. Also, other symptoms of anaphylaxis include swelling, rashes, suffocation (due to swelling of trachea) etc... these were not found in your fd/student. and if it were really anaphylaxis, 40 mins of anaphylaxis would be enough to KILL him.

To be pedantic, I said, Nowhere. This is clearly an everyday expression.

There is no doubt that horrendous symptoms can suddenly appear after many hours with no food intake of any kind. Some of the symptoms can be so like our aircrew first aid training for a heart attack, that it would take an expert to detect the difference. As mentioned in a later post, the severity can cover a wide range.

Lateral thinking doesn't means thinking without logic.

Thank you for the lesson in philosophy, I bear that in mind when I'm next trying to make sense of bewildering symptoms.



The thing is, so many places on the planet have considerable aviation activity. A great number of these places have little or no medical support. Everything we can take on board during emergency training and forums like this, becomes very important when days away from help.

Heaven knows, so many Americans have no medical cover whatsoever, and their fear of going to a hospital - and then getting a bill that will cost them their house - is so great that many will abandon their treatment the second they can walk.

[patient]

Anaphylaxis won't come from nowhere as well. It needs (an) allergen(s).

As from the above, panic attack is very likely and anaphylaxis can basically be ruled out, and the incident happened in UK, not USA~

[telster]

Patient

Anaphylaxis doesn't come from nowhere, as you quite rightly pointed out.

It might come from an antigen, several hours previously, that the patient doesn't know that he's allergic to. It might come from some crumbs of peanut left on the aircraft seat, or some pollen left by a previous passenger, that again he has no knowledge of.

In hindsight, in this situation, after the guy recovered after landing, it sounds like it was a panic attack.

At the time the guy was taken ill, without the benefit of a crystal ball and prior knowledge that he was going to recover, such a diagnosis was impossible.

Not wishing to needlessly carry on a thread past its usefullness, and accepting that you have personal knowledge of panic attacks, but the diagnosis of panic attack is a dangerous one to make. Panic attacks in themselves and associated hyperventilation are physically harmless, although frightening (unless they open a door and jump out the aircraft!), unlike the alternaltive conditions that might be going on.

As a paramedic I would have to be very very certain that was all that was going on before leaving someone without taking them to hospital. Normally we'd take them in just to cover ourselves.

Anaphylaxis, heart attack, low blood sugar, stroke...etc etc are all things that certainly couldn't have been ruled out by the original poster whilst trying to fly an aircraft, or even by an experienced doctor travelling as a passenger alongside the sick guy.

Once again, LondonJ did the right thing.

[patient]

telster: thanks for the post. I also agree that LondonJ's decision (to land the plane) is a 100% well-done, and it's no use to diagnose onboard. Even if I were the pilot, I would have done the same.

But after reading the post (as everyone does here), the chance of anaphylaxis can really be ruled out, not inflight, but afterwards. Everyone made their guess after reading the post, not inflight. So, if reading the whole pic (esp that patient became fine after 40 mins), I wouldn't propose anaphylaxis.

Anyway and again, J has done a good job! :ok: