Treatment of Hiccups in the Hospital Setting
For hospitalized patients with hiccups, initiate chlorpromazine 25-50 mg orally three to four times daily as first-line pharmacological treatment, while simultaneously addressing any underlying causes. 1, 2
Initial Assessment and Non-Pharmacological Interventions
Before initiating pharmacological therapy, attempt simple vagal nerve stimulation maneuvers:
- Physical maneuvers such as Larson's maneuver (bilateral pressure on the styloid process behind the earlobes) can effectively terminate hiccups through vagal stimulation. 3
- The HAPI (Hiccup relief using Active Prolonged Inspiration) technique involves maximal inspiration held for 30 seconds with an open glottis, followed by slow expiration, and has demonstrated immediate relief in clinical cases. 4
- For mechanically ventilated patients, adjust ventilator settings to reduce hiccup frequency before escalating to pharmacological interventions. 1
Pharmacological Management Algorithm
First-Line Treatment: Chlorpromazine
Chlorpromazine remains the only FDA-approved medication specifically indicated for intractable hiccups and should be the initial pharmacological choice. 2, 5, 6, 7
Dosing regimen:
- Oral: 25-50 mg three to four times daily; if symptoms persist for 2-3 days, escalate to parenteral therapy. 2
- Intramuscular: 25-50 mg IM; if symptoms persist after 2-3 days of oral therapy, administer 25-50 mg (1-2 mL) in 500-1000 mL saline as slow IV infusion with patient supine. 5
Critical monitoring requirements:
- Monitor blood pressure closely during IV administration, as hypotension is a significant risk; keep patient flat in bed during infusion. 5
- Observe for QT prolongation, sedation, and extrapyramidal symptoms, particularly in elderly patients who are more susceptible to neuromuscular reactions. 1, 5
Alternative Pharmacological Options
If chlorpromazine is contraindicated or ineffective:
- Gabapentin and baclofen have emerged as safe alternatives, with baclofen showing particular efficacy in chronic cases. 8, 7
- Metoclopramide (a prokinetic agent) is widely employed, particularly when gastroesophageal pathology is suspected. 8, 6, 7
Special Clinical Scenarios
Perioperative and Anesthesia-Related Hiccups
For hiccups occurring during anesthesia or in the immediate perioperative period, propofol 1-2 mg/kg IV can be administered, ensuring adequate depth of anesthesia before any airway manipulation. 3
Post-Extubation Hiccups with Stridor
If hiccups occur with post-extubation stridor, administer nebulized epinephrine 1 mg immediately. 1
For patients at risk (low cuff leak volume before extubation), prophylactic corticosteroids (prednisolone 1 mg/kg/day) should be initiated at least 6 hours before planned extubation. 9, 1
Consider high-flow oxygen therapy via nasal cannula after extubation for patients at risk of respiratory complications. 9, 1
Persistent Hiccups Beyond 48 Hours
For hiccups persisting beyond 48 hours, conduct a systematic evaluation for underlying causes including:
- Thoracic pathology (myocardial infarction, mediastinal masses) 8, 7
- Central nervous system disorders (stroke, space-occupying lesions, brain injury) 8, 7
- Gastrointestinal pathology (gastric/duodenal ulcers, gastritis, GERD, esophagitis)—upper GI endoscopy, pH monitoring, and manometry should be included systematically 7
- Medication side effects (anti-parkinsonism drugs, anesthetic agents, steroids, chemotherapy) 8
- Metabolic derangements (renal failure, electrolyte abnormalities) 7
Critical Pitfalls to Avoid
Never use sedative medications that may compromise respiratory function in patients with borderline respiratory status, as this increases morbidity risk. 1
Avoid subcutaneous injection of chlorpromazine; inject slowly and deeply into the upper outer quadrant of the buttock for IM administration. 5
Do not inject undiluted chlorpromazine directly into a vein; IV route is reserved only for severe hiccups, surgery, and tetanus, and must be diluted to at least 1 mg/mL and administered at 1 mg per minute. 5
In elderly or debilitated patients, start with lower chlorpromazine doses and increase gradually, as this population is more susceptible to hypotension and neuromuscular reactions. 2, 5
Keep patient supine for at least 30 minutes after parenteral chlorpromazine administration to prevent orthostatic hypotension. 5