Hiccups

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

Drug Rashes

• Unsurprisingly key in diagnosis is a good history.

• Most commonly caused by antibiotics.

• 90% are morbilliform: widespread erythematous macules or papules

• Common timeframe is 1-2 weeks after starting drug (however some can take up to three weeks).

Rash Presenting Symptoms Onset After Drug Causes Treatment Erythema Multiforme Target like lesions symmetric on trunk and extremities (generally distributed acrally) Mucous membrane involvement in multiforme major.

3-14 days HSV primarily; also NSAIDS, sulfa drugs, antibiotics, anti-epileptics. Stop offending agent. Drug Rash with Eosinophilia and Systemic Symptoms Syndrome (DRESS)

Fever and rash. Must be organ involvement: hapatic (60-80%), renal, lung. 2-8 weeks Anticonvulsants and allopurinol, additionally sulfa medications, antibiotics, CCB, NSAIDs, and anti-retrovirals (LFTs and BMP should be trended). Topical corticosteroids for rash. Systemic corticosteroids (for interstitial lung disease or nephritis); supportive care/withdrawl of causative agent for organ involvement

Stevens-Johnsons

Sydrome

Blisters with mucous membrane involvement

SJS involves less than 10% of the skin surface.

+Nikolsy

4-28 days Allopurinol, sulfa drugs, anti-epileptics, nevirapine and oxicam NSAIDs Range from observation to ICU level care (consider burn unit for approaching >30% BSA)

IV-IG and systemic corticosteroids are controversial.

Stop drug. Supportive.

Toxic Epidermal Necrolysis Similar to above, however involves >30% of skin.

4-28 days Same as above, however >80% are due to drug. Same as above. Burn Unit/ ICU setting. Serum Sickness-Like Reaction* Rash: urticarial polycyclic wheals on trunk, limbs, face. Fever. Arthralgias in >2/3 patients. 1-2 weeks Penicillin, amoxicillin, cefaclor, bactrim Stop drug. Supportive

Note: True sereum sickness-- protein antigen from a nonhuman species (antitoxin for snake bites, rabies). 

Intranasal Analgesia and Anxiolysis

Today we will be discussing IN anxiolysis and analgesia, especially useful in our pediatric population.  An appendix with a BAN administration outline is also attached. Indications

Perfect for kids coming in with acute trauma (laceration, need for x-rays, etc) or patients undergoing procedures such as I&D of an abscess.

May be used prior to obtaining x-rays for pain control in children not necessarily needing a line for reduction (or even in those needing a line as this may be a faster way to reduce pain, and may help provider in obtaining IV line).

Routine Medications – Analgesia/Anxiolysis Dose

• Analgesia: Fentanyl (1-1.5mcg/kg), Ketamine (0.5mg/kg)

• Anxiolysis: Midazolam (0.2mg/kg)

Other IN Medications: Midazolam, Precedex (dexmedotomidine), flumazenil, naloxone

Pearls of Administration

Have patients blow their nose first if possible.

Try to limit dose to 0.3mL per nostril (certainly no more than 1 mL per nostril), using concentrated solutions. 

Divide larger volumes over two nostrils.

May deliver in aliquots 10-15 minutes apart if larger.

Remember, it’s a good idea to put patients on a pulse ox prior to administration.

Account for “dead space” of atomizer (~1mL).  

APPENDIX

BAN Dosing

Remember, there is also the BAN (breath actuated nebulizer) for medication administration which is a an alternative to intranasal medications when tolerated.  Only use BAN in Breath Actuated Mode in ED.

Here is the dosing for BAN:

• Fentanyl:

  • Adults: 4mcg/kg dose titrated q 10 min up to three doses

  • Pediatrics: 2-4 mcg/kg titrated q 10 min up to three doses

• Morphine:

  • Adults: 10-20 mg titrate q 10-15 min up to three doses

  • Pediatrics: 0.2 mg/kg q15 min up to three doses