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
