A life threatening case of Hiccups | Department of Emergency Medicine

A life threatening case of Hiccups – A Resident Clinical Pearl

Mark McGraw, PGY3 FMEM program, Dalhousie University Saint John

Reviewed by Dr. Luke Taylor

Introduction:

Its mid morning on an acute shift in the emergency department and you hear a familiar but somewhat out of place sound coming from around the corner. You look up to see the triage nurse walking in a middle-aged male patient who is hiccuping constantly. The patient looks unwell and is pale, but he is able to walk into the department without assistance. The triage nurse asks the charge doc where she should place the patient. He has had intractable hiccups for over a week and has been unable to sleep or eat anything. His chief complaint is hiccups and weakness. She notes he also has a small infected cyst on his back that is being treated with Keflex from one of the local surgeons and had a subjective fever at home. Vitals on triage were normal but she was concerned because he just didn’t look right. You suggest he take a trauma bed and state you’ll see him now based on his appearance and wonder to yourself how often a trauma bed is taken up with someone who has a chief complaint of hiccups….

A little background:

Hiccups are a bit of a physiologic anomaly and appear to have no protective effect or evolutionary purpose. Hiccups can be found early in life and are can be found as early as the second trimester of pregnancy. The incidence of hiccups in the general pediatric and adult population is unknown but its fair to say the majority of people have experienced them at some point in their lives. To most, hiccups are nothing more than a brief annoyance or embarrassing distraction but in some cases they can herald sinister pathologies.

Hiccups result from inappropriate closure of the glottis through a reflex arc that consists of the phrenic nerve, vagus nerve, and thoracic sympathetic chain. During inspiration our glottis remains patent allowing unimpeded airflow into the lungs. The hiccup reflex triggers glottis closure, typically triggered during the swallowing to prevent aspiration, about 30 milliseconds after the onset of inspiration resulting in a rush of air against a closed glottis.

The majority of problematic hiccup cases arise from stimulation, inflammation, or injury to nerves of the afferent reflex arc. Two of the most common causes of benign hiccups are gastric distension from eating a large amount of food or consuming carbonated beverages and relaxation of the glottis due to alcohol ingestion.

The differential for hiccups is broad. UpToDate lists over 50 items on its differential for persistent/intractable hiccups grouped as CNS disorders, vagus/phrenic irritation, GI disorders, thoracic disorders, CV disorders, toxic/metabolic causes, postoperative, drug induced, and psychogenic.

Hiccups under 48 hours

In patients with hiccups lasting less than 48 hours and without red flag symptoms or other warning signs it is reasonable to try physical maneuvers to stop hiccups. The goal of all these maneuvers is stimulation/irritation of the afferent reflex arc.

• Breath holding or Valsalva maneuvers (increasing hypercapnia),
• Sipping or gargling cold water (nasopharynx irritation)
• Swallowing a spoonful of dry sugar (nasopharynx irritation),
• Pulling a patient’s knees to his/her chest and having them lean forward (decrease diaphragmatic pressure)

Hiccups over 48 hours

There is little quality evidence on the treatment of hiccups. In general, if an etiology is suggested from the history and physical target treatment, i.e. using a PPI in patients with underlying GERD, should be considered.

A 2015 systematic review suggested the use of baclofen and gabapentin as first line agents in treating hiccups with metoclopramide and chlorpromazine used as second line agents. A follow up systematic review in 2017 published in the journal of emergency medicine found that only baclofen and metoclopramide had randomized control trials supporting their efficacy. Baclofen was found to be particularly effective for treatment of intractable hiccups associated with stroke.

Treatment options:

• Baclofen 5 to 10 mg PO TID,
• Gabapentin 100 to 400mg PO TID,
• Metoclopramide 10mg PO TID or QID,
• Chlorpromazine 25mg PO TID,

A recent case report published in the American Journal of Emergency Medicine (Kocak et al., 2020) demonstrated almost immediate termination of hiccups in a patient following a subdermal injection of lidocaine and thiocolchicoside into the sternocleidomastoid muscle and epigastric region.

Back to our case

Our patient settles into a bed in the trauma bay and his repeat vitals show a declining blood pressure and increasing heart rate. His only complaint at this time continues to be his persistent hiccups. Cardiac, respiratory, abdominal and CNS exams are unremarkable. When you assess the “small lump” on his back you find an area of erythema extending from the superior tip of his scapula to his L1/L2 region inferiorly with a large softball size nodule around the lateral border of his scapula. You initiate empiric therapy with pip/tazo and clindamycin and call for an urgent CT scan and surgical consult.

While prepping for the scan the patient asks about treatment for his hiccups. You decide to try metoclopramide 10mg IV, which does nothing to alleviate his hiccups. His CT scan confirms a massive abscess extending from his deltoid muscle to his obliques with infiltration into the muscle and fascia. He is taken to the OR by a team of 3 surgeons for emergent debridement of his necrotizing fasciitis. After a brief stay in the ICU he is transferred to the surgical floor where you find out his hiccups have resolved.

Summary
The next time you are working in the emergency department and a patient presents with hiccups here are a few helpful points to remember:

• Patients with hiccups lasting less than 48 hours in the absence of red flag / systemic symptoms typically do not require medical workup or treatment.
– Physical maneuvers to terminate hiccups may provide relief for patients in the ED.
• Patients with persistent hiccups over 48 hours warrant a full physical exam and laboratory studies tailored to the patient’s history as hiccups may be the initial manifestation of an underlying neoplasm, infection, or metabolic disorder.
• If no underlying etiology is found there is reasonable evidence to support empiric treatment with metoclopramide 10mg PO TID or baclofen 5 to 10mg PO TID.
• In patients with persistent hiccups secondary to another disease process empiric treatment may be a useful adjunct while the underlying cause is addressed.

References

Polito NB, Fellows SE. Pharmacologic Interventions for Intractable and Persistent Hiccups: A Systematic Review. J Emerg Med. 2017 Oct;53(4):540-549. doi: 10.1016/j.jemermed.2017.05.033. PMID: 29079070.
Steger M, Schneemann M, Fox M. Systemic review: the pathogenesis and pharmacological treatment of hiccups. Aliment Pharmacol Ther. 2015 Nov;42(9):1037-50. doi: 10.1111/apt.13374. Epub 2015 Aug 25. PMID: 26307025.
Kocak AO, Akbas I, Betos Kocak M, Akgol Gur ST, Cakir Z. Intradermal injection for hiccup therapy in the Emergency Department. Am J Emerg Med. 2020 Sep;38(9):1935-1937. doi: 10.1016/j.ajem.2020.03.044. Epub 2020 Mar 25. PMID: 32245702.
Chang, F. Y., & Lu, C. L. (2012). Hiccup: mystery, nature and treatment. Journal of neurogastroenterology and motility, 18(2), 123–130. https://doi.org/10.5056/jnm.2012.18.2.123
Image of reflex arc: http://blog.clinicalmonster.com/2017/03/23/so-bored-i-hiccuped/
Marion, DW. Hiccups. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2020.