Ignoring Hiccups Lasting >48 Hours is a Bad Idea. Here’s Why and What to Do…

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    Ignoring Hiccups Lasting >48 Hours is a Bad Idea. Here’s Why and What to Do…

    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)

     

    References:

    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 .

    http://www.aliem.com/tricks-of-the-trade-valsalva-maneuver-by-using-a-10-cc-syringe/

    Up-to-date article on hiccups. http://eresources.library.mssm.edu:2226/contents/overview-of-hiccups?source=preview&search=%2Fcontents%2Fsearch&anchor=H1213673819

     

     

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