Chief complaint: Hiccups (i.e. “singultus”).

Timing: 3 days.

Diagnosis: Persistent hiccups.

Etiology: Unknown.

Who cares? You care. Why? Because persistent hiccups (>48 hours) and intractable hiccups (>1 month!) is likely indicative of an underlying illness that needs work-up/diagnosis.

1. What is the difference between a “bout,” “persistent,” and “intractable” hiccups?

2. What’s an ED-ready trick to treat the symptom?


1. A bout of hiccups is anything under 48 hours! Persistent hiccups=48hours-1 month! Longer than 1 month=intractable.

Persistent or intractable hiccups common causes include:

  • CNS (vascular lesions or infection).
  • Peripheral nerve irritation (phrenic nerve). Look for recent surgeries and assess for any space occupying lesion in the neck or thorax.
  • Electrolyte abnormality.
  • Toxins/Drugs.

Some even consider hiccups an anginal equivalent!

In other words: investigate the cause for patients with hiccups >48 hours, especially with any abnormal vital sign.

2. Valsalva or other vagal maneuvers have been proposed. No data exists on efficacy. A very good way to get patients to correctly perform a Valsalva maneuver is to have them forcefully exhale into the fat end of a 10cc syringe (See the Academic Life in EM post)



Krysiak W et al. Hiccups as a myocardial ischemia symptom. Pol Arch Med Wewn. 2008 Mar;118(3):148-51.

Smith G, Boyle MJ. The 10 mL syringe is useful in generating the recommended standard of 40 mmHg intrathoracic pressure for the Valsalva manoeuvre. Emerg Med Australas. 2009 Dec;21(6):449-54. Pubmed .

Up-to-date article on hiccups.