What are the treatment options for hiccups in the Emergency Department (ED)?

Treatment Options for Hiccups in the Emergency Department

Chlorpromazine is the most effective first-line pharmacological treatment for persistent hiccups in the ED setting, with recommended dosing of 25-50 mg IM or IV for adults with intractable hiccups. 1, 2

First-Line Approaches: Non-Pharmacological

Before moving to medications, try these physical interventions:

1. Physical maneuvers (attempt for 1-2 minutes each):

   • Nasopharyngeal stimulation using a PCR swab or similar device (most recent evidence shows rapid resolution) 3
   • Stimulation of the uvula or pharynx
   • Disruption of diaphragmatic rhythm (holding breath, breathing into paper bag)
   • Traditional vagal maneuvers (drinking cold water, swallowing granulated sugar)

2. Address underlying causes if quickly identifiable:

   • Gastric distention (most common cause)
   • Alcohol intake
   • Gastroesophageal reflux

Pharmacological Management Algorithm

If non-pharmacological approaches fail after 5-10 minutes of attempts:

For Adults:

1. First-line medication: Chlorpromazine

   • Dosing: 25-50 mg IM for most patients 2
   • Alternative: 25-50 mg IV (dilute to 1 mg/mL and administer at 1 mg/minute) for intractable cases 2
   • Oral option: 25 mg PO q6h if less urgent 1

   Caution: Monitor for hypotension; keep patient lying down for 30 minutes after injection

2. Second-line medications (if chlorpromazine unavailable or contraindicated):

   • Metoclopramide (especially if GI-related) 4, 5
   • Baclofen (particularly effective for persistent cases) 5
   • Gabapentin 6

For Pediatric Patients (6 months to 12 years):

• Chlorpromazine: 0.25 mg/kg IM q6-8h PRN 2
• Maximum dosage:
  • Ages 6 months to 5 years (or ≤50 lbs): not over 40 mg/day
  • Ages 5-12 years (or 50-100 lbs): not over 75 mg/day except in severe cases

Special Considerations

• Elderly patients: Use lower doses of medications; they are more susceptible to hypotension and neuromuscular reactions 1, 2
• Persistent hiccups (>48 hours): Consider underlying pathology requiring further workup 7
• Intractable hiccups (>2 months): May require specialty consultation and advanced interventions 6

Common Pitfalls to Avoid

1. Failure to recognize serious underlying causes: While most hiccups are benign, persistent hiccups can indicate serious pathology (myocardial infarction, brain tumors, renal failure)
2. Underdosing chlorpromazine: The full recommended dose is often needed for effect
3. Not monitoring for hypotension: Always keep patients lying down for at least 30 minutes after parenteral chlorpromazine
4. Overlooking GERD: The most common cause of persistent hiccups is gastroesophageal reflux disease 7
5. Blind finger sweeps: Never perform these in cases of suspected foreign body as they may worsen obstruction 8

The treatment approach should be escalated based on duration and severity of symptoms, with prompt recognition of cases requiring further investigation beyond symptomatic management.