Chief complaint: Hiccups (i.e. “singultus”).
Timing: 3 days.
Diagnosis: Persistent hiccups.
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.
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)
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. http://eresources.library.mssm.edu:2226/contents/overview-of-hiccups?source=preview&search=%2Fcontents%2Fsearch&anchor=H1213673819