Hiccups Bout: <48 hours of hiccups
Persistent hiccups: 48 hours – 1 month
Intractable Hiccups: >1 month
Why is this important? You should workup PERSISTENT AND INTRACTABLE hiccups.
CNS: stroke, mass, infection, increased ICP
Diaphragm Irritation: Pneuomonia, cholecystitis, pericarditis, Myocardial Infarction
Stomach wall irritation: ileus, fullness, ulcer, obstruction
Phrenic nerve, Vagus Nerve, Recurrent Laryngeal Irritation: Infection, mass, trauma (recent surgery), etc.
Metabolic/Electrolyte abnormality: Uremia, etc
Toxins/Drugs: alcohol, etc
Remember, can possibly an angina equivalent.
Psychogenic
Other Infectious Etiologies (Ebola)
History, Physical Exam, Treatment should center around these causes.
History: Alcohol use, medication changes, recent surgeries
Physical:
HEENT exam including otoscope and throat exam: r/o infection, mass, lymphadenopathy, foreign body etc
Neuro exam
Abdominal exam
Lung exam
Workup:
EKG, CBC, electrolytes, blood urea nitrogen (BUN), creatinine, calcium, liver function tests, and amylase/lipase, ecg, consider cxr.
Treatment: Most therapies are based on case reports or small studies and are focused on treating the underlying cause.
Physical Maneuvers (try first): Breatholding, Valsalva (against syringe), ice water gargle, pressing eyeballs, knee to chest to compress chest.
Pharmacological therapy
o These aim to resolve the physiological causes of hiccups
Chlorpromazine 25 mg three times daily PO/IV (if given IV give with bolus).
Only FDA approved drug based on case series
Phenothiazine; dopamine antagonist
Metoclopramide 10 mg three or four times daily orally
Dopamine antagonist and gastric motility agent
Baclofen 5-20mg three times daily orally
Skeletal muscle relaxant
Haldol 5-10mg PO or IV
Included is a table of pharmacologic treatments based on possible cause:
Gastric Distenstion GERD Diaphragmatic Irritation Central Acting Agents Dopamine Antagonist GABA Agonist Simethicone 25mg (antiflatulant) Metoclopramide 10mg QDS PO (prokinetic) Haloperidol 1.5-3mg qhs Chlorpromazine 10-25mg PO or IV Baclofen Metoclopramide 10mg (prokinetic) PO H2 blocker or PPI Baclofen 5-20mg three times daily orally Haloperidol 5-10mg PO or IV Sodium valproate 200-500mg PO Nifedipine 10-20mg three times daily orally Metoclopramide Midazolam 10-60mg/24h (really for terminal hiccups)! Sodium valproate, aim for 15mg/kg/24h in divided doses
Others: Carvedilol, Gabapentin, Lidocaine oral soln, Olanzapine, amitryptiline, Cisapride, marijuana
*If intractable hiccups remain resistant to non-pharmacological techniques, the strongest evidence to date supports the use of chlorpromazine 25 to 50 mg administered intravenously, with a second dose within 2 to 4 hours intravenously or intramuscularly
Sources:
Uptodate
Palliative Care Medicine Information Service
Life In The Fast Lane