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  

– 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  

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  

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,psychogenic%20disorders%2C%20or%20metabolic%20disorders.  
May 2024