Rosen & Barkin's 5-Minute Emergency Medicine Consult (345 page)

For persistent or intractable hiccups, a thorough history and physical exam dictate further diagnostic testing.

• CBC with differential
  
• Electrolytes, BUN, creatinine
  

• CXR
  
• Further imaging may be indicated depending on clinical suspicion of a particular etiology; this can often be performed on an outpatient basis.
  

Eructation (belching)

TREATMENT

• Treat specific causes when identified:
  
  • Remove foreign bodies from the ear.
    
  • Relieve gastric distention with a nasogastric tube.
    
• Nonpharmacologic maneuvers:
  
  • Catheter stimulation of the posterior pharynx
    
  • Direct stimulation of the uvula with a cotton swab
    
  • Supraorbital pressure
    
  • Carotid sinus massage
    
  • Digital rectal massage
    
  • Suboccipital release
    
    • Gentle traction and pressure applied to the posterior neck, stretching the suboccipital muscles and fascia.
      
• Pharmacologic treatment:
  
  • First line, only FDA approved medication for hiccups: Chlorpromazine
    
• Additional medications:
  
  • Gabapentin
    
  • Metoclopramide
    
  • Baclofen
    
  • Haloperidol
    
  • Nebulized lidocaine
    
  • Amitriptyline
    
  • Phenytoin
    

• Amitriptyline: 10 mg PO TID
  
• Baclofen: 10 mg PO TID
  
• Chlorpromazine: 25–50 mg IV/IM, 25–50 mg PO TID–BID
  
• Gabapentin: 100 mg PO TID–QID
  
• Haloperidol: 2–5 mg IM
  
• Lidocaine (4%): 3 mL nebulized, repeat if necessary
  
• Metoclopramide: 10 mg IV/IM, 10–20 mg PO QID
  
• Phenytoin: 200 mg IV
  

FOLLOW-UP

If hiccups interfere with daily activities and could lead to decreased nutritional or fluid intake, aspirations, insomnia, wound dehiscence

• If hiccups last <48 hr
  
• Workup inconsistent with underlying organic etiology
  

Referral in cases of intractable hiccups for investigation into underlying cause and more definitive therapeutic measures:

• Phrenic nerve block, crush, or transection
  
• Hypnosis
  
• Behavioral modification
  
• Acupuncture
  
• Psychiatric interventions
  

Home remedies in case of recurrence:

• Swallowing a spoonful of sugar
  
• Sucking on a hard candy or swallowing peanut butter
  
• Breath holding/Valsalva maneuver
  
• Biting a lemon
  
• Tongue traction
  
• Lifting the uvula with a cold spoon
  
• Drinking from the far side of a glass
  
• Fright
  
• Noxious stimuli
  
• Rebreathing into a paper bag
  

Protracted hiccups are strongly suggestive of underlying organic disease.

• Calsina-Berna A, García-Gómez G, González-Barboteo J, et al. Treatment of chronic hiccups in cancer patients: A systematic review.
  J Palliat Med
  . 2012;15(10):1142–1150.
  
• Chang FY, Lu CL. Hiccup: Mystery, nature and treatment.
  J Neurogastroenterol Motil.
  2012;18(2):123–130.
  
• Kolodzik PW, Eilers MA. Hiccups (singultus): Review and approach to management.
  Ann Emerg Med
  . 1991;20(5):565–573.
  
• Kwan CS, Worrilow CC, Kovelman I, et al. Using suboccipital release to control singultus: A unique, safe, and effective treatment.
  Am J Emerg Med.
  2012;30(3):514.e5–514.e7.
  
• Launois S, Bizec JL, Whitelaw WA, et al. Hiccup in adults: An overview.
  Eur Respir J
  . 1993;6(4):563–575.
  

CODES

• 306.1 Respiratory malfunction arising from mental factors
  
• 786.8 Hiccough
  

BASICS

• Incidence dependent on:
  
  • Rate of ascent
    
  • Final altitude
    
  • Sleeping altitude
    
  • Duration at altitude
    
• Acute mountain sickness (AMS) incidence:
  
  • Up to 67% incidence with rapid ascent (1–2 days) to >14,000 ft
    
  • 22% incidence for skiers visiting resorts and sleeping at 7,000–9,000 ft, 40% at 10,000 ft
    
• AMS risk factors:
  
  • Previous history of high-altitude illness
    
  • Physical exertion
    
  • Younger persons (<50 yr)
    
  • Physical fitness not protective
    
  • Obesity and existing lung disease increase the risk
    
• High-altitude pulmonary edema (HAPE) incidence:
  
  • <1–2%
    
  • Varies with rate of ascent
    
• High-altitude cerebral edema (HACE) incidence <1%
  
• HACE and HAPE are unusual at altitudes under 13,000 ft (4000 m)
  

• Relationship between pregnancy and high-altitude illness is not clearly established.
  
• Pregnancy-induced hypertension, proteinuria, and peripheral edema are more common at high altitude, which may be related to maternal hypoxemia.
  
• No evidence of increase in spontaneous abortions, placental abruption, or placenta previa at high altitudes
  
• Travel by pregnant women with normal pregnancies to moderate altitudes appears safe, although caution should be exercised when traveling >13,000 ft and for women with complicated pregnancies
  

Although elderly persons are more likely to have underlying health problems that may be affected by altitude, such as HTN, COPD, and coronary artery disease, the risk of development of AMS is less in those older than 55 than in other age groups.

• Rapid ascent to >8,000 ft (about 2,500 m) without proper acclimatization is the most common cause of high-altitude–related illness.
  
• Rapidity of ascent, final altitude reached, sleeping altitude, and individual susceptibility all play a role in development of high-altitude illness as well.
  

DIAGNOSIS

• AMS:
  
  • Headache + at least 1 of the following:
    
    • Nausea/vomiting
      
    • Fatigue/lassitude
      
    • Dizziness
      
    • Difficulty sleeping
      
  • Onset 4–12 hr after ascent
    
  • Generally benign and self-limited
    
  • Symptoms may become debilitating.
    
• HAPE:
  
  • Onset 2–4 days after ascent, most commonly on 2nd night
    
  • Can be life threatening
    
  • Cough (dry at 1st, then productive)
    
  • Dyspnea at rest
    
• HACE:
  
  • Life threatening
    
  • Occurs in the presence of HAPE and/or AMS:
    
    • Seen rarely as isolated entity
      
  • Onset:
    
    • May occur 12 hr after onset of AMS
      
    • Generally requires 2–4 days for development
      
  • Altered mental status
    
  • Severe or increasing headache
    
  • Nausea/vomiting
    

• AMS in infants and young children manifested by:
  
  • Increased fussiness
    
  • Decreased playfulness
    
  • Decreased appetite
    
  • Vomiting
    
  • Sleep disturbances
    
• Incidence of HAPE is greater in younger individuals (<20 yr) than in older adults
  
• No cases of HAPE or HACE have been reported in children <4 yr old