What is the appropriate ER workup and treatment for a patient who had an abrasion on Monday and began having hiccups on Tuesday?

Emergency Workup and Treatment for Post-Aquablation Hiccups

Chlorpromazine is the recommended first-line medication for treating intractable hiccups in a patient who developed hiccups following aquablation. 1, 2

Initial Assessment

• Evaluate airway patency and respiratory status immediately, as hiccups can sometimes indicate or lead to airway compromise 3
• Assess vital signs including oxygen saturation to rule out hypoxemia 3
• Check for signs of gastroesophageal reflux, which is a common cause of hiccups following procedures 4
• Evaluate for post-procedural complications such as bleeding, infection, or perforation that may be triggering the hiccups 3

Diagnostic Workup

• Perform contrast-enhanced CT of the chest and abdomen to evaluate for:

  • Esophageal perforation or injury 3
  • Mediastinitis (presenting with severe sore throat, deep cervical pain, chest pain, dysphagia) 3
  • Pleural effusion or hemothorax 3
  • Diaphragmatic irritation 5

• Consider upper endoscopy if:

  • Symptoms persist beyond 24 hours 3
  • There are signs of esophageal injury or gastroesophageal reflux 4, 5

Treatment Approach

First-line Pharmacologic Treatment:

• Chlorpromazine 25-50 mg PO or IM three to four times daily 1, 2
  • FDA-approved specifically for intractable hiccups
  • Monitor for hypotension, particularly with parenteral administration
  • Keep patient lying down for at least 30 minutes after IM injection 2
  • Watch for QT prolongation, especially if combined with other medications 3

Alternative Pharmacologic Options:

• Metoclopramide if gastroesophageal reflux is suspected 6, 5
• Baclofen for persistent hiccups not responding to chlorpromazine 5

Non-pharmacologic Interventions:

• Physical maneuvers to disrupt diaphragmatic rhythm 6:
  • Stimulation of the uvula or pharynx
  • Breath holding techniques
  • Vagal stimulation (carotid massage, if no contraindications)

For Refractory Cases:

• Consider positive pressure ventilation under controlled settings if hiccups are severe and persistent 7
• Evaluate for possible phrenic nerve block if hiccups persist beyond 48 hours despite treatment 7

Monitoring and Follow-up

• Continuous monitoring of vital signs and oxygen saturation during initial treatment 3
• Capnography if available, especially if respiratory compromise is suspected 3
• Monitor for QT prolongation if using chlorpromazine, particularly with other QT-prolonging medications 3
• Observe for at least 6 hours after initial treatment to ensure resolution or improvement 3

Special Considerations

• Hiccups following urologic procedures may be related to diaphragmatic irritation, gastroesophageal reflux, or vagus/phrenic nerve stimulation 4, 5
• Post-procedural hiccups that persist beyond 48 hours should prompt evaluation for serious underlying causes 5
• Consider herpes zoster as a rare but possible cause if hiccups are accompanied by unilateral pain or vesicular lesions 8