| Intro |
| For the first pearl during our reign, I wanted to teach about the most dangerous thing I could think of. Hiccups. There are some dangerous etiologies out there so stay tuned. |
| TR Pearls – <5 minutes |
| – Often benign and self-limiting, but if persistent may be due to a medication, GERD, stroke, ACS or cancer/chemo – Common in pediatrics and more likely to be benign. In adults has a male predominance – First line try maneuvers that increase CO2 like breath holding – If s/s >48 consider workup based on hx and exam – Check ears for foreign body – Get a good history: dysphagia, chest pain/SOB, headaches, GERD, focal deficit – DC offending agents like dexamethasone – If >48 hours of s/s may start PPI. Nearly 80% of persistent hiccups are 2/2 GERD |
| Extended Pearls – >5 minutes |
| Duration of hiccups: – Hiccup Bout: Less than 48 hours – Persistent Hiccups: 48 hours – 1 month – Intractable Hiccups: Greater than 1 month Epidemiology – Intractable hiccups have a male predominance in non-CNS causes with odds ratio of 2.42 – Younger ages, affects females more often – Less likely organic causes in children and full-term infants Differential: primarily central vs peripheral (vagal nerve stim/irritation or lytes) (***not all inclusive list. The differential is extensive!) – CNS: Stroke, tumors, injury, seizure, aneurysms, encephalitis/meningitis, MS – Cardiac: ACS, atrial pacing, aortic aneurysm, ablation of afib, pericarditis – GI: GERD, esophageal tumors – ENT: cough, ear foreign body – Drugs: chemotherapeutic agents, steroids, psychiatric medications – Electrolyte abnormality: Hyponatremia, hypokalemia – Procedures (vagal nerve stimulation/irritation): intubation, bronchoscopy, esophagogastroduodenoscopy, central venous catheter – Other benign causes: stomach distention from large meal or air swallowing (eg panic attacks), carbonated beverages, spicy foods, etoh Clinical Presentation/History: – Normally self-resolving by 48 hours and intractable if greater than 1 month – Headaches, dysphagia, GERD, weight loss, abdominal pain – Recent surgery, instrumentation, or intubation – Known cancer or chemoMedication review and consider DC of offending agents – Persistence during sleep may suggest organic cause – Precipitating causes: large meals, stress, or excitement, spicy foods, carbonated beverages Evaluation Generally conservative unless history or physical suggest otherwise – Ear exam: looking for foreign body or hair against TM – CN, lungs, abdominal exam Consider workup based on exam, history, and duration of signs/symptoms – CMP: sodium most common electrolyte responsible – CBC: if infection suspected – CXR: mass vs structural abnormality – ACS: ECG, troponin, BNP – CNS: CTH vs CTA head/neck vs MR brain, LP Treatment Conservative treatment: – Elevation in CO2 which can inhibit the reflex: Breath holding, large gulps of water, drinking water upside-down – Vagal maneuvers – Pharyngeal vs nasopharyngeal stimulation with NG tube Pharmacologic – Reserved for >48 hours – DC offending agents or switching dexamethasone for methylprednisolone – PPI – often first line, GERD – Other medications – similar in efficacy – Metoclopramide – Chlorpromazine – Gabapentin – Baclofen Referral to GI for EGD, pulmonology, ENT, neurology based on findings |
| Further Resources |
| http://www.emdocs.net/em3am-hiccups/ https://www.ncbi.nlm.nih.gov/books/NBK538225/#:~:text=In%20particular%2C%20hiccups%20are%20often,psychogenic%20disorders%2C%20or%20metabolic%20disorders. |
